Acute and Emergency medicine Flashcards
(318 cards)
1
Q
When does Troponin rise and peak in ACS?
What does this tell you?
A
Within 3-12 hours
Peak 24-48 hours
Angina will have no trop rise; STEMI/NSTEMI will
2
Q
When is myoglobin useful in ACS
A
Early rise at 1-4 hours
3
Q
When is CK useful in ACS
A
Rise 3-12 hours
Peak 24 hours
4
Q
Hyperacute (hours) and Acute (hours to days) changes on an ECG in ACS
A
Hyperacute- Tall T, ST elevation
Acute- T wave inversion, Pathological Q waves
5
Q
Leads 11,111,avf on an ECG are…
A
Inferior heart
6
Q
Leads 1,avl, V5, V6 on an ECG are…
A
Lateral heart
7
Q
Leads V1, V2 on an ECG are…
A
Septal
8
Q
Leads V3, V4 on an ECG are…
A
Anterior
9
Q
Indications for primary percutaneous coronary intervention
A
ST rise >1mm (2 small squares) in 2 limb leads
ST rise of >2mm in 2 contralateral chest leads
LBBB
Must be within 120 minutes
10
Q
What if a STEMI presents >120 minutes, how do you treat it?
A
Thrombolyse
If no effect then PCI
11
Q
What does MONAT stand for in STEMI treatment?
A
Morphine 2.5-10mg slow IV bolus + Metoclopramide Oxygen 15L NRBM Nitrates GTN spray Aspirin 300mg PO Ticagrelor or clopidogrel
12
Q
Treating an acute NSTEMI/Unstable angina
A
300mg Aspirin Nitrates Morphine Anti-thrombin therapy: 1- Fondaparinux 2- Ticagrelor (12 months)
13
Q
What is the GRACE score
A
6 month future CV AE risk
if >3% then coronary angiography within 96 hours
14
Q
What is the TIMI score
A
Mortality AE predictor post-MI
15
Q
What can give a falsely high troponin
A
HF PE CKD Dialysis Arrhythmia SAH Seziure
16
Q
What medications should someone be on post-MI
A
Beta blocker, aspirin, 12 month ticagrelor, ACEi
17
Q
ECG signs for angina
A
ST depression, Flat/inverted T waves
Signs of past MI
18
Q
When do you refer an anigina to a specialist
A
New angina of sudden onset
Recurrent and Hx of MI/CABG
Uncontrolled by drugs
19
Q
What is the Well’s score; what action do you take if >4?
A
Likelihood of PE
> 4= High risk therefore CTPA
< 4= Low risk -> D-dimer= +ve = CTPA
20
Q
What is a PERC score? Explain ‘HAD CLOTS’
A
Any of the criteria in this score are met then PE not ruled out
Hormone, Age >50, DVT/PE Hx, Cough blood Leg swelling, O2 neded, Tachycardia >100BPM, Surgery/Trauma
21
Q
D-dimer has good sensitivity, what does this mean?
A
SNOUT
-VE= UNLIKELY TO BE PE
22
Q
PE associated ECG changes
A
S1Q3T3
Large S wave in lead 1
Pathological Q wave in lead 3 (> 1 small box duration)
Inverted T wave in lead 3
Right axis deviation
23
Q
What is the gold standard for PE Dx?
When can the above not be done?
A
CTPA
If renal impairment or pregnant therefore use V/Q scan
24
Q
How do you identify a massive PE?
What do you treat this with?
A
Hypotension +/- Cardiac arrest
Alteplase (Thrombolysis)
25
How do you treat sub-massive or non-massive PEs
LMWH or fondaparinux for 5 days or until INR >2
Warfarin should be started within 24 hours
26
What are type A and Type B aortic dissections?
Type A- Ascending Aorta (MAJORITY) and highest mortality, caused by tamponade, interrupted flow, valve incompetence
Type B- Not in the ascending aorta
27
General features of Aortic dissection
Abrupt sharp tearing chest pain that is maximal at onset
| Paraplegia, limb ischaemia, neuro deficit, syncope
28
Signs of Type A dissection vs type B
What are the pulses like? Any murmurs?
Type A- Hypotension
Type B- Hypertension
Asymmetry and absence of peripheral pulses
Aortic regurg murmur (Early diastolic decrescendo)
29
How do you confirm a Dx of Aortic dissection
BP both arms
CT angiography is gold standard
Transoes echo if haemodynamic instability
30
How do you treat aortic dissection
Type A= surgery
| Type B= Iv labetalol to control HTN, conservative if uncomplicated
31
Presentation of pericarditis
Non prod cough, chest pain worse on lying flat, radiates to neck
32
ECG changes in pericarditis
Wide spread saddle shaped ST elevation
PR depression
T wave inversion
33
Treating pericarditis
NSAIDS (Naproxen) + PPI and cease phenytoin
| Avoid antimicrobials
34
How gets primary and secondary pneumothorax?
Primary- young thin men
| Secondary- Old with pre-existing lung disease
35
Criteria for chest drain in pneumothorax
>2cm + SOB +/- > 50yrs
| < 2cm + no SOB and primary ?Discharge
36
Which way is the mediastinum pushed in a tension pneumothorax
Contralaterally
37
How do you treat a tension pneumothorax?
Large bore needle 2nd ICS MCL
Syringe and saline- allow air to bubble through
Then chest drain
38
How does a tension pneumothorax cause cardiorespiratory arrest?
What are the signs of this
Great vein compression
Hypotension, neck vein distension, Cont. Tracheal deviation
39
What is a low/Int and high risk CURB-65 score?
Low- 0-1
Int- 2
High= 3-5
40
When would you consider an ICU admission for pneumonia?
Shock
Hypercapnia
Uncorrected hypoxia
41
Most common cause of an infective COPD exacerbation
H.Influenzae
| + S.Pneum, Morazella Catarrhalis
30% Viruses (Like Rhino virus)
42
Indications for admission of an infective COPD exacerbation
```
Cannot cope at home
Deterioration
Severe SOB/Cyanosis/Oedema
LTOT
Rapid onset
Acidotic
Sp02<90%
Hypoxic
CXR changes (Acute)
```
43
Treatment of an infective COPD exacerbation
Neb bronchodilators- Salbutamol and Ipratropium
30mg Pred
Amox/Tetra/Clarithro
44
Indications for Abx in a COPD exacerbation
Pyrexia
Purulent sputum
Consolidation on CXR
45
What would indicate a COPD exacerbation is needing NIV?
```
Previous admin in 12 months
DNACRP
RR>30
PH<7.35
Hx NIV
Abx/Steroids in last 12 months
Decreased exercise tolerance
Wx loss
```
46
Criteria for a Moderate Asthma exacerbation
PEFR 50-75%
RR<25
HR<110
Speech normal
47
Criteria for a severe Asthma exacerbation
PEFR 33-50%
Cannot complete sentences without taking a breath
RR>25/HR>110
48
Criteria for a life threatening Asthma exacerbation
```
PEFR <33%
Sats <92%
Rising PaCO2
Silent chest/Exhaustion
Dysrhythmia/Bradycardia
Hypotension
Confusion
```
49
Managing acute asthma
```
Salbutamol- 5mg Neb w/o2 back to back
Ipratropium- 500mcg- Neb w/o2- 4 hourly
Hydrocortisone 200mg IV OR 40mg Pred orally
Magnesium sulphate 2g IV over 20 mins
IV Aminophylline 5mg/kg over 20 mins
```
50
Causes of cardiogenic pulmonary oedema
LHF leads to inc LV-end diastolic pressure; causes inc pulmonary hydrostatic pressure
MI/IHD/Arrhythmia/Cardiomegaly/-ve Inotropic drugs/Failed prosthetic valve
51
Causes of non-cardiogenic pulmonary oedema
ARDS, IV fluid overload, Hypoalbuminaemia, Toxins, Smoke inhalation
52
Signs of Pulmonary oedema on CXR
Batwing Hilar shadows
Kerley B lines (Interstitial space expansion)
Upper lobe diversion because of increased flow- upper lobe pulmonary veins resemble a stag's antlers
Cardiomegaly
53
Treating an acute pulmonary oedema
```
IV furosemide 50mg
Morphine
GTN if BP<90 sys
ICU if cardiogenic shock
?NIV
```
54
What type of crackles are heard upon auscultation in pulmonary oedema
Fine inspiratory crackles
55
Upon leg examination in ?DVT what signs are you looking for (3)?
Deep vein tenderness
Swelling 10cm distal to tibial tuberosity; Must be >3cm bigger than unaffected calf
Oedema- MAY BE PITTING
56
How do you interpret Well's score for DVT?
2+= Likely= Proximal leg vein USS within 4 hours
D-Dimer +LMWH if cannot do above but get USS within 24 hours
=1 = Unlikely D-dimer; if +ve then USS within 4 hours
57
Treating DVT
1) LMWH/Fondaparinux until 5 days or INR>2
2) Warfarin within 24 hours continue for 6 months
3) Safety net- SOB/PAIN
58
In unprovoked DVT what should you check for?
Cancer
CR/FBC/Calcium/LFTs/Urinalysis
?Thrombophilia
59
Features of cellulitis
Red, warm, tender, swollen
| Poorly defined margins
60
What is the Eron classification?
Classifies cellulitis
1- Afebrile
2- Febrile but no unstable cormobidities
3- Toxic appearance, unstable comorbids
4- Sepsis syndrome- Organ dysfunction, Not responding to fluid challenge
Admit for IV Abx if 3/4
61
How do you treat...
Localised cellulitis with no systemic upset
Cellulitis + Systemically unwell
Cellulitis of the face
Localised cellulitis with no systemic upset- Oral flucloxacillin or macrolide/Clinda if allergic
Cellulitis + Systemically unwell- IV Fluclox or Benzyl or Co-Amox
Cellulitis of the face- IV Abx + Optham referral
62
Define severe sepsis and septic shock
Severe sepsis= SIRS + Organ dysfunction
Septic Shock= SIRS + Hypotension despite fluid resus
63
What criteria are considered for SIRS
Temp, WCC, HR, RR, PAO2
64
What is the sepsis six
BUFALO
| Complete within 1 hour
65
Signs of an acutely ischaemia limb (6 P's)
Pale, Pulseless, Pain, Paralysis, Perishingly cold, Paraesthesia
66
Signs of critical limb ischaemia
```
Hangs leg out of bed
Ulceration/Gangrene
Intermittent claudication
ABPI <0.5
Mottled
```
67
RF for gout
```
Diet
Diuretics
Renal failure
Cytotoxics
Myeloproliferative disease
Chemo
Aspirin
```
68
How do you confirm a Dx of gout
Diagnostic: Monosodium urate crystals in the synovial fluid or tophi
Therefore: 1) Joint aspiration 2) X-ray
Serum uric acid >360 u/mol is suggestive but not diagnostic
69
X-ray signs of gout
Punched out lesions in peri-articular bone
Preservation of joint space
No peri-articular osteopenia
70
Treatment of acute gout
Rest + NSAIDS +/- Colchine (+ PPI)
Prednisolone 15mg/day if above CI
If already on allopurinol do not alter!
71
Preventative drugs for gout
Allopurinol (May cause an initial acute attack)
72
Typical presentation of septic arthritis?
```
Inflammed joint with sudden fast onset
>50% knee
No movement
Joint held in position of most comfort- usually flexion
Fever, shaking, rigors
```
73
What would a septic arthritis X-ray look like
Initially may be normal
Later on there is a loss of landmarks and soft tissue swelling with displacement of the capsular flat planes
74
Diagnosis of septic arthritis
Clinical Hx/Exam +/- X-ray
Joint aspiration (MOST RELIABLE) -> Culture
?CT/MRI
75
Treatment of septic arthritis
STAT IV flucloxacillin or clindamycin
+ Orthopaedic referral
(VANCOMYCIN IF MRSA)
76
What are the 4 I's of DKA
Infection, Infarction, Insufficient insulin, Intercurrent illness
77
DKA presentation
Osmotic diuresis (Polyuria) leads to hypoperfusion, hypotension, and shock
Polydipsia
SOB
KUSSMAL breathing
Dehydration- Cap refill, dry mouth, dec skin turgor, weak pulse
78
3 Diagnostic criteria for DKA
Acidaemia PH<7.3 HCO3<16mmol/L
Ketonaemia/uria Urine ketones ++ or Cap ketones >3 mmol/L
Hyperglycaemia (or known T1DM) CBG >11mmol/L
79
Treatment of DKA
IV insulin 0.1 units/kg/hr
0.9% Saline 1L over 1 hr > 2 hrs > 2hrs > 4 hrs> 4 hrs> 6 hrs
Treat Hypokalaemia 20mmols if <5 + 40mmols <4.5
Hourly CBG/ketones/bicarb/K+
80
Indications of DKA resolution
PH >7.3 ketones <0.3 mmol/L
Stop IV
? Start SC insulin
81
When would you consider giving glucose in DKA
Once Glucose <14mmol/L
5% Dextrose
or add 10% glucose 125ml/hr
82
Indications for Critical care in DKA
```
Bicarb < 5
Pregnancy (Big DKA RF)
Drowsy
HF
Anuria/Oliguria
K+ <3.5 on admin
Sats <92%
```
83
Potential complications of DKA
```
Arrhythmias
Gastric stasis
Thromboembolism
Cerebral oedema
ARDS
AKI
```
84
What is Whipple's triad of hypoglycaemia
Plasma hypoglycaemia
Concurrent symptoms
Resolution with correction of low glucose
85
Treating hypoglycaemia
Quick acting carbohyrate/Glucose 10-20g orally
If unconscious/uncooperative then IV glucose 10-20% E.G 150mls 10% Dextrose/15 mins
If no IV then IM Glucagon
Prolonged hypoglycaemic coma- IV Mannitol + Dexamethasone + Iv glucose
86
What is HHS?
Sevre uncorrected hyperglycaemia causes osmotic diuresis and volume depletion resulting in blood hyperviscosity
87
Presentation of HHS
How do you distinguish this from DKA?
Onset is days- weeks
WATERY= Poluria, thirsty, dehydrated, urgdency
WEAK= Fatigue, LoC
PAIN- Headaches, Papilloedema
HHS- Slower onset, Elderly, likely T2DM, Hyperglycaemia is more pronounced, Ketacidosis less pronounced
88
Dx criteria of HHS
Hypovolaemia
Plasma osmolarity >320 mOsmol/kg
Hyperglycaemia > 30mmol/L
89
Management of HHS
IV 0.9% saline aim for +ve balance of 3-6L by 12 hours
Once hydrated then give insulin, if given too soon this can precipitate CV collapse; 0.05 units/KG/Hr if ketonaemia
TARGET GLUCOSE 10-15mmol/L
90
Complications of HHS
Higher mortality than DKA...
Ischaemia, Infarction, VTE, DIC, ARDS, Multi-organ failure, Rhabdomyolysis, Cerebral oedema, Central Pontine Myelinolysis,Over-administration of insulin
91
ECG findings on 1st degree AV block
PR consistently prolonged
92
ECG findings on 2nd degree MOBITZ 1 AV block
Progressive PR prolongation then a QRS block
93
ECG findings on 2nd degree MOBITZ 2 AV block
Normal PR
P wave not followed by QRS at a constant ratio
+? Wide QRS
94
ECG findings on 3rd degree AV block
No PR interval
| P wave does not relate to QRS
95
Heart block pharmacological interventions?
| When would you use this?
0.5mg Atropine IV can repeat 3 times
Adrenaline
Syncope, Shock, MI, Ischaemia, HF (ADVERSE FEATURES)
96
Cerebral perfusion pressure formula
CPP= MAP - ICP
97
Initial features of increased ICP post-head injury?
What does this progress to?
Decreased consciousness
Ipsilateral pupillary dilatation as temporal lobe herniation causes occulomotor compression
Contralateral hemiparesis, Cardio-respiratory arrest, Cushing's response
98
What is cushing response following head injury
Reflex increase in BP with bradycardia
| + irregular breathing
99
Signs of a basal skull fracture
```
Bilateral orbital bruising (Panda eyes)
Subconjunctival haemorrhage
Haemotypanum
CSF rhinorrhea/otorrhoea
Battle's sign (Brusing over mastoid process over days)
```
100
Indications for an immediate CT scan post-head injury
```
GCS<13 (or < 15 in the ED)
Basal skull fracture
Seizure
Focal neurological deficit
>1 episode of vomiting
```
101
Normal sequlae of head injury
Mild headache
Nausea
Cannot concentrate
Anxiety
102
Indications for non-urgent CT post-head injury (8 hours)
Some LoC/Amnesia
+(65+, Clotting problems, Dangerous mechanism, > 30 mins retrograde amnesia)
ALWAYS IF ON WARFARIN
103
How is recovery in Syncope Vs seizure
Syncope is likely to be a rapid full recovery
104
What is Todd's paresis?
May follow seizures
| focal deficit or hemiparesis lasting 24 hours
105
What do all new onset seizures need?
BRAIN IMAGING
106
Indications for an emergency CT post-seizure
```
Focal signs
Head injury
HIV
?Intracranial infection
No improvement in consciousness
```
107
When is it appropriate to discharge a seizure presentation?
Normal neuro/cardio exams
ECG/electrolytes normal
Single seizure
Refer to epilepsy clinic
If already an epileptic then discharge if no change in seizure pattern
108
What is status epilepticus?
> 30 mins
Generalised seizure
Doesn't regain consciousness
109
Treating Status epilepticus
Lorazepam 1-2mg IV slow bolus repeat 5 mins (or 10mg Diazepam) Buccal midazolam if no IV
Then if they continue... 20 mg/kg IV Phenytoin
Get ICU help. RSI if continued seizures.
110
3 features of vasovagal syncope
Sudden
LoC
Spont.Recovery
111
When would you consider a cardiac referral for syncope?
When would you consider a neurology referral?
Abnormal ECG, LoC on exertion, HF, >65 with no prodrome, murmur
Bitten tongue, Amnesia, Unresponsive, Unusual psoturing, Prodrome, Post-ictal confusion
112
Examples of...
Reflex mediated syncope
Orthostatic hypotension related syncope
Cardiac syncope
Vasovagal, Situational, Cardiac sinus syncope
Primary or secondary AN failure, Alcohol, diuretics, AD, Volume depletion
Bradycardia, SVT, Cardiomyopathy, MI, Valvular, PE, Aortic dissection
113
3 main classifications of syncope
Reflex mediated
Orthostatic hypotension
Cardiac
114
What scores you 1 point in the Rosier Stroke score? What scores -2 points?
+1= Asymmetrical Arm, face or leg weakness, speech disturbance or visual field defects
-2= LoC, Syncope, Seizure
UNLIKELY IF 0 or less
115
Indications for an urgent CT scan in ?Stroke
```
Presents within 4 hours of onset
On anticoagulation
GCS <13
Progressive/Fluctuating symptoms
Papilloedema
Neck stiffness
Fever
```
116
Main Categories of symptoms to ask about in ?Stroke (7)
```
Motor
Sensory
Meningism
Pain
Speech
Cognition/Consciousness
Sight
```
117
Does a normal CT rule out an ischaemic stroke?
No
Initial CT may be normal
Do CT angiogram
118
Managment of an ischaemic stroke
300mg Aspirin
Thrombolyse if within 4.5 hours of onset
Mechanical thrombectomy if within 6 hours
STROKE WARD
119
On the HUNT & HESS scale for SAH severity what would indicate a more severe event?
Stupor, Hemiparesis
120
What do you do in suspected SAH?
Emergency CT scan (detects >90%)
| Then admit for lumbar puncture (typically regardless of CT result) as it takes 12 hours for xanthochromia to develop
121
Once an SAH is confirmed what can be done to investigate causative pathology
Aniogram
122
How do you control BP in SAH and what is the target?
BP<160
| Nimodepine (also prevents vasospasm)
123
How do you treat raised ICP in SAH
```
IV Mannitol
(Increases blood plasma osmolarity, driving water into plasma from the cerebral tissues)
```
124
If an ?SAH is unconscious what do you do?
ET tube
Arterial line
Catheter
Neurosurgical team
125
Complications of SAH
```
30% Rebleed
Vasospasms
Hyponatraemia
Seizures
Hydrocephalus
Death
```
126
Key 'later' features of meningitis
```
Meningism
Kernig's and Brudzinski's signs
Decreased consciousness
Seizures
Focal CNS
Petechial or purpuric non-blanching rash
```
127
Signs of meningococcal septicaemia
Later features of meningitis +
Slow cap refill
Hypotension
Unusual skin colour
128
Signs of septicaemia without meningitis
Hypotensive + infective signs
NO KERNIG'S BRUDZINSKI'S NOR FOCAL NEURO DEFICITS
129
Gold standard Dx for meningitis
Lumbar puncture with CSF culture
130
Lumbar puncture signs suggesting bacterial meningitis
>1.5g of proteins
CSF glucose <50% Plasma glucose (SAME IN VIRAL)
Cloudy fluid (CLEAR IN VIRAL)
RELEASE PROTEINS, USE GLUCOSE, NEUTROPHILLIC
131
Treatment of bacterial mengingits in secondary care
IV ceftriaxone immediately + IV Amox/Ampicillin if >60/Immunocomp/<3 months
Analgesia, Antipyretics, Hydration
IV Dexamethasone 10mg/4Xday
132
Best Abx for strep.Pneum meningitis
Benzylpenicillin + Vanco/Ceph/Rifampicin
Dependent on local sensitivities
133
Key signs of a space occupying lesion
```
Headche worse on lying/Bending/Coughing
Vomiting, papilloedema, Dec GCS
Focal neurology
Blackout, personality change, Amnesia
Seizures
```
134
4 features indicating a secondary headache (SAH, Lesion) vs a primary (Tension, Migraine)
Sudden onset
Focal neurology
Systemic features
>50
135
Key diagnostic criteria for temporal arteritis
```
> 50
New pain
Temporal artery abnormality
ESR>50mm/hour
Abnormal artery biopsy
```
NEED 3/5
136
What visual signs can you get in temporal arteritis
Rapid + profound
| diplopia Amaurosis fugax
137
What does the optic disc look like in temporal arteritis
Pale, Waxy, Elevated disc, Splinter haemorrhages
138
Treatment of temporal arteritis
High dose prednisolone
IV mehtylpred if visual symptoms
+ Osteoporosis prophylaxis
Low dose aspirin
139
Onset of venous sinus thrombosis?
Onset is days-weeks NOT SUDDEN
140
What must you exclude in venous sinus thrombosis
SAH and Meningitis
141
What can be used to Dx venous sinus thrombosis
MRI T2 weighted to visualise thrombus
| CT/MRI/Venography
142
What are the features of cavernous sinus thrombosis
periorbital oedema
| 6th CN palsy
143
Transverse sinus thrombosis
Headache mastoid pain, focal neurology, papilloedema
144
Saggital sinus thrombosis
Seizures, Hemiplegia, Papilloedema
145
Sigmoid sinus thrombosis causes lots of what
Opthalmic symptoms- oedema, proptosis pain
146
What size defines an arterial enlargement as aneurysmal?
| When is said aneurysm at low chance of rupture?
>3cm
<5cm
147
What imaging technique composes the initial assessment of AAA?
What then shows anatomical details?
USS 3mm accuracy (initial assessment and follow up)
CT
148
Signs of AAA rupture?
```
Sudden abd pain/back pain -> Loin groin
sudden collapse
Expansile mass
Shock
Hypotension
Absent pulses
PEA
```
149
Management of a ruptured AAA
```
STABILISE
High flow O2
2X large bore cannulas
Emergency cross match
IV analgesia
Cyclizine
Vascular surgeon
```
150
When would preventative AAA surgery be considered
>5.5cm
151
USS monitoring for AAA
```
3-4.4cm= Annual USS
4.5+= 3 monthly USS
```
152
What is Rovsing's signs
Pain in RIF when pressing LIF
153
McBurney's point
1/3rd from ASIS to umb
| Pain and guarding when ?Appendicitis
154
Key investigations to do if ?Appendicitis
Urinalysis +/- pregnancy test- RULE OUT UTI
USS (FAST) can exclude pelvis pathology and show free fluid
CT has high sensitivity and specificity
155
Pre-surgical Abx for appendicitis
Metronidazole and cefuroxime
156
Appendicitis complications
```
Perforation
Wound infection
Mass
Abscess
paralytic ileus
Adhesion
Maternal mortality in pregnancy
```
157
Best imaging for gall stones
USS
158
What is acute cholecystitis?
Inflammation of the gallbladder wall likely because of Impaction of the neck of the gallbladder
Murphy's sign (2 fingers, pain on insp, not on LUQ)
RUQ pain
Fever
N&V
159
Treating Acute cholecystitis
```
NBM
Analgesia
Fluids
IV cefuroxime
Laparoscopic cholecystectomy
```
160
What is Ascending cholangitis?
Infection and stasis of the biliary tree
161
What is Charcot's triad?
| What is Reynold's pentad?
RUQ pain, Fever/Rigors/ Jaundice
Pentad= Above + CNS distrubance and Hypotension
BOTH SEEN IN ASC CHOLANGITIS
162
4 F's of biliary colic
Female, Fat, Forty, Foetus
163
Classificiation of bowel obstruction
Extrinsic
Intramural
Intraluminal
164
Important bowel obs Qs
```
Any bowel disease
Recent surgery
Hernias
RT
Cancers
```
165
From a Hx how do you distinguish SBO from LBO
In SBO...
| Faeculent vomiting is earlier, colicky pain is worse, constipation is later, and distension is central
166
What are haustra
Do not cross full diameter of LB
167
What are valvulae conniventes
Cross full diameter of small bowel
168
What is the 3, 6, 9 rule for bowel obstruction?
Abnormal if...
SB= >3cm
LB= >6cm
Caecum= >9cm
169
SBO vs LBO on an AXR
SBO= Central gas shadows, valvulae conniventes, no gas in LB
LBO= Constant pain. Peripheral gas shadows, not in rectum, Coffee bean sign if volvulus.
170
What does a barium swallow + x-ray determine
Level of obstruction in SBO
171
Classic presentation of diverticulitis
```
Tender colon with peritonism
+ Change in bowel habit
+ Older
+ LUTS
+ N&V
```
172
CXR sign of perforated bowel
Pneumoperitoneum
173
4 major complications of diverticuliutis
Abscess (use CT with contrast) then USS guided drainage
Perforation
Haemorrhage
Fistulae
174
When would you admit diverticulitis
Cannot tolerate oral fluids
Pain intolerable
Not improved for 72 hours
175
Basic treatment principles of diverticulitis
```
Analgesia
NBM
IV fluids
+/- Abx
Avoid colonscopy as may cause perforation
```
176
Best imaging for an ovarian cyst
Transabdominal/vaginal USS
Then MRI if >7cm
Always rule out UTI and pregnancy
177
When must you always consider ectopic pregnancy as a DDx?
```
Young women
Abdomen pain
Vaginal bleeding
Syncope
Look for hypovolaemic shock!
```
178
Diagnosis of Ectopic pregnancy
USS (Vaginal>Abdominal)
| Pregnancy test
179
What are Cullen's and Grey Turner's signs?
Periumbillical bruising= Cullen's
Flank bruising= Grey Turner's
180
I GET SMASHED
Idiopathic
Gallstones
Ethanol
Trauma
```
Surgery
Mumps
AI
Scorpion sting
Hypercalcaemia/Lipidaemia/Hypothermia
ERCP
Drugs
```
181
By how much is serum amylase raised in acute pancreatitis?
3x (or more)
Serum lipase better
182
Best imaging for pancreatitis
CT least ambiguous and good for severity and Px (post-72 hours)
USS can see gallstones
MRI good for severity
183
How does glucose and calcium change in pancreatitis?
Hypocalcaemia
| Hyperglycaemia
184
What is the Ranson/Glasgow score
Pancreatitis severity- PANCREAS
```
Pao2 <8kpa
Age >55
Neutrophils/WCC >15 x 10^9
Calcium <2mmol/L
Renal urea >16 mmol/L
Enzymes= LDH >600 IU AST >200 IU/L
Albumin <32 g/L
Blood sugars >10
```
>3 points in the 1st 48 hours means severe pancreatitis
185
Systemic complications of pancreatitis
```
Respiratory oedema, effusion, consolidation, ARDS
Hypovolaemia and shock
DIC
Low calcium, High glucose, Low Mg
Haemorrhage, Ileus
Renal dysfunction
```
186
What effect does eating have on duodenal ulcers
Pain relief upon eating (Gastric is worse after eating)
187
Most common type of peptic ulcer
Duodenal ulcer
188
Indications for endoscopy if ? Peptic ulcer
> 55 + 1st presentation
Anaemia/Wx loss/Chronic blood loss/Bleeding/Progressive dysphagia/Persistent vomiting/Mass
189
```
What are...
Melaena
Haematemesis
Coffee ground-vomit
Haematochezia
```
Melaena- Black tarry stools= UGIB
Haematemesis= Bright red indicates active haemorrhage
Coffee ground-vomit= Bleeding ceased
Haematochezia= Fresh blood, LGIB
190
What happens to urea in a GI bleed
Increases
191
In what time frame do you do an endoscopy for UGIB
Within 24 hours
If unstable then immediately
192
What is the Blatchford score?
Informs whether someone needs an endoscopy
193
What is the Rockall score?
Predicts outcomes in GI bleed
194
Key investigations for renal colic
CT KUB within 14 hours
| Urinalysis and MSU- LOOK FOR BLOOD
195
What analgesia is best for renal stones?
IV opioids with oral NSAID like diclofenac or Ketorolac
196
When would you give immediate Abx for otitis media?
Perforation or discharge
Systemically unwell
> 4 days of symptoms
< 2 yrs and bilateral
AMOXICILLIN
197
Signs of a Quinsy? What do you do?
Unilateral pain
Deviated uvula
Cannot open mouth
Contact ENT + IV benzylpenicillin
198
Criteria for oral Abx in Tonsillitis
Fever
Exudative
Tender Ant.Cervical lympthadenopathy
Absent cough
PENICILLIN
199
What is croup
Viral URTI that causes inflammatory spread to the larynx/trachea
URTI symptoms lead to stridor/resp distress/hoarseness
Give Dex +/- Adrenaline
200
Westley clinical scoring of croup
```
Insp stridor
Intercostal recession
Air entry
Cyanosis
Consciousness
```
>6 severe
201
Sepsis criteria considers...
Infection + 2 or more of:
TEMP, CAP REFILL, HR, RR, WCC, LACTATE
202
In ALS when do you assess the rhythm?
After every 2 min cycle of CPR
203
What do you do if the rhythm is shockable (VF, Pulseless VT)
1 shock
| Resume CPR for 2 min
204
What do you do if the rhythm is non-shockable (PEA/Asystole)
Resume CPR for 2 mins
205
When do you give adrenaline during CRP?
1mg every 3-5mins IV/IM
206
When do you give amiodarone during CPR?
300Mg after 3 shocks
207
The reversible causes of Cardiac arrest
Hypoxia
Hypothermia
Hypovolaemia
Hypo/perkalaemia
Tension Pneumo
Thrombosis
Tamponade
Toxins
208
What are adverse features in an tachycardic adult with a pulse?
Shock
MI
Syncope
HF
209
In a tachycardic adult who is unstable what do you do?
Synchronised DC shock up to 3 attempts
300mg amiodarone/10-20mins
Expert help
Repeat shock then 900mg amiodarone over 24 hours
210
Broad complex tachycardia?
VT
211
Narrow complex tachycardia?
SVT
AF
Flutter
Re-entry paroxysmal SVT
212
Treating Fast AF <48 hours onset
Heparinise
| Cardioversion
213
Treating AF >48 hours onset
Beta blocker or CCB
| CHADVAS2 >2= Anticoagulation
214
Indications for emergency electrical cardioversion in AF?
Shock, syncope, Acute HF, Ischaemia
215
Agents used for chemical cardioversion
Flecainide if no structural disease
Otherwise: Amiodarone
216
ECG signs of Flutter
Regular atrial beat
| Sawtooth pattern as constant atrial depolarisation
217
Treating Flutter
Cardioversion (even if >48 hours)
Radiofrequency ablation
Carotid sinus massage and adenosine
218
SVT ECG findings
Narrow QRS <3 small Sq
| Rate >100 BPM
219
Treating SVT
Vagal maneouvres
IV adenosine or DC cardioversion
Cardiology referral
220
ECG findings in VT
Rate >100BPM
Broad QRS >3 small squares
Precordial leads unlikely to have both R + S
221
Treating VT
If BP<90, CHEST PAIN OR HF THEN...
Immediate synchronised cardioversion, shock if acutely unwell
If not then can use Amiodarone via central line
222
Treating VF
ALS algorithm
223
Causes of Hyponatraemia
Hypovolaemic- D+V, Diuretics, renal failure, adrenocortical suppression
Euvolaemic- SIADH, Acute water load
Hypervolaemic- CCF, Cirrhosis, Nephrotic syn, Renal failure
224
SIADH Criteria
Serum hypo-osmolarity <275
Urine osmo >100
Urine Na+ > 30
225
Causes of SIADH
Malignancy, Diuretics, PPIs, SSRIs, ACEi, Loop diuretics
226
How do you treat Hyponatraemia
If Hypovolaemic then 0.9% Saline
| If Euvolaemic/SIADH then fluid restrict +/- Demeclocycline
227
Hypernatraemia causes
Dehydration, GI loss, Urinary loss, Hyperaldosteronism, Diabetes insipidus
228
Treatment of hypernatraemia
Isotonic 0.9% saline
229
Causes of hyperkalaemia
1) Renal
2) Extracellular shift
Renal- AKI/CKD/Amiloride/Spiro/ACEi,/NSAIDS/Addison's
Extracellular shift- DKA, Digoxin, Theophylline
230
Hyperkalaemia ECG changes
Tall Tented T waves
Small P waves
Polonged PR
Wide QRS
231
When do you treat hyperkalaemia
> 6 + ECG changes
| >6.5
232
In hyperkalaemia how do you...
1) Stabilise the cardiac membrane
2) Shift K+ into cells
3) Remove K+ from body
1) 10% 10mls IV Calcium gluconate every 10 min
2) 50mls 50% glcuose with 10 units soluble insulin +/- 5mg Sal back to back
3) 15g calcium resonium
233
Hypokalaemia causes
```
Diuretics
Conn's
D+V
Laxatives
CUSHINGS
ALKALOSIS
Salbutamol/Ins/Glucose
```
234
Causes of hypocalcaemia with
Low PTH
High PTH
Other
Low PTH- Iatrogenic, PT destruction, AI
High PTH- Vit D deficiency
Other- Pancreatitis, Bisphosphonates, Malignancy
235
Chvostek's and Trousseau's sign?
Chvostek's- Tap facial nerve to elicit muscle spasm
Trousseau's- Inflating BP cuff elicits Carpopedal spasm
HYPOCALCAEMIA
236
What is severe hypocalcaemia
<1.9
237
Signs of hypocalcaemia
Tetant, Seizures, Carpopedal spasm, Inc QT, Paraesthesia
238
3 key diseases to exclude with hypocalcaemia
Acute pancreatitis, CKD, Rhabdomyolysis
239
When do you treat hypocalcaemia; what with?
Tetany/Seizures <1.9
Calcium gluconate slow IV
240
Hypercalcaemia
Primary hyperPTH
Maligancy
Thiazides
Primary adrenal insufficiency
241
Hypercalcaemia symptoms
BONE STONES MOANS GROANS
| Pain, vomiting, polyuria, Polydipsia, weakness, constipation, Dec QT, Pancreatitis, Fatigue, Depression, cog impairment
242
Hypercalcaemia + Inc Alk Phos could indicate pain
Bony mets
243
Hypercalcaemia treatment
Fluids and bisphosphonates
244
Key Q in paracetamol OD
```
Number of tablets
Dose
When and how long over
Taken with anything else
Psych Hx
```
245
Biochemistry seen in Paracetamol OD
```
Deranged LFTs ALT>1000
Acidaemia
Inc INR
Inc creatinine ?Renal failure
Hypoglycaemia
Tachycardia
```
246
Risk factors for severe liver damage in paracetamol OD
>150 mg/kg
> 12 g (24 tabs)
Inducers of P45O (CBZ, Pheny, Rif, Barbit)
247
```
Treating Paracetamol OD...
<1 hour
<4 hours
<4-8 hours
>8 hours
Staggered OD
```
<1 hour- Charcoal
<4 hours- Wait until 4 hours for paracetamol level
4-8 hours- Use level and if above line give NAC
>8 hours- Give NAC and review with curve
Staggered OD- Give NAC, Graph useless
248
How is NAC given in Paracetamol OD
IV infusion in 5% glucose 3 consecutive doses/24 hours
```
150 mg/kg in 200ml glu over 1 hour
50mg/kg in 500ml glu/4 hrs
100mg/kg in 1L /16 hours
(1hr-> 4hr-> 16hr)
Stop if INR <1.3 ir ALT<2X upper limit of normal
```
249
Common side effect of NAC?
Anaphalactoid reaction therefore give antihistamine
250
When would you admit a patient with acute alcohol withdrawal?
```
Safeguarding
Delirium Tremens (or Hx of this)
Seizures
<18yrs
AN over-activity
Wernicke's
```
251
What is pabrinex?
Prophylactic treatment of thiamine deficiency
252
Opiate OD causes what result on an ABG
Respiratory acidosis
253
Treatment of Opiate OD
Naloxone
400mcg
short half life so may need to repeat
254
ABG result caused by TCA OD
metabolic acidosis
255
ECG changes on TCA OD
Prolonged QT
Widening of QRS PR
Polymorphic VT Torsades de pontes
Broad complex tachy
256
Treating TCA OD
IV Bicarb
| IV lipid emulsion
257
Amphetamine OD presentation
```
Hyperreflexia
Tachycardia
Dilated pupils
Delirium
Agitation
MDMA- Polydipsia, hyponatraemia, Convulsions
```
258
Treating Amphetamine OD
Activated charcoal
| Benzo to treat convulsions
259
3 Diagnostic criteria for anaphylaxis
Sudden onset/Rapid progression
Life threatening airway/breathing/circulatory compromise
Skin and mucosal changes
260
Key enzyme test for anaphylaxis Dx
Triptase
| Once stable, 4 hour level and then 24 hour for baseline
261
Most important drug to give first in anaphylaxis
Adrenaline
Reverses vasodilation and bronchoconstriction but more importantly ameliorates mast cell degranulation
Adrn-> Repeat -> Fluids -> Chlor + Hydro
262
3 drugs to give in anaphylaxis
0.5mls 1:1000 Adrenaline IM; repeat every 5 mins
10mg Chlorpenamine IV
200mg Hydrocortisone IV
(Watch for biphasic/prolonged reaction therefore admit)
263
4 key complications of AKI
Hyperkalaemia
Pulmonary oedema
Pericarditis
Metabolic acidosis
264
Indications for RRT in AKI
Pulmonary oedema
Persistently high K+
PH <7.15
Ecephalopathy, OD, Pericarditis
265
How do you use serum creatinine and urine output to detect AKI?
26umol rise in SC in 48 hours (or 50% in 7/7)
Urine output <0.5ml/kg/hr in 6 hrs (or 8 hrs in children)
266
What are the 3 stages of AKI?
1) Creatinine inc 1.5x or UO<0.5 for 6 hrs
2) Creatinine inc 2-2.9 baseline or UO<0.5 for >12 hrs
3) Creatinine inc 3x baseline or UO <0.3 for > 12 hours or Anuria for > 12 hours
267
What is STOP AKI
Sepsis- BUFALO
Toxins- DIAMOND HAL
Optimise BP
Prevent harm (Hyperkalaemia, Pul oedema, Acidosis, Pericarditis)
268
Key symptoms distinguishing delirium from confusion
Delirium will have fluctuations in consciousness and a short attention span therefore they cannot concentrate
Thinking is also disordered
USE 4AT
269
Key aetiologies of delirium
Systemic infection, intracranial infection, Drugs, Withdrawal, Metabolic, Hypoxia, Vascular, Head injury, Epilepsy, Nutritional
270
Common causes of unconsciousness
```
Hypoglycaemia
Drug OD
Head injury
Stroke
SAH
Convulsion
Alcohol intoxication
```
271
Key causes not to miss in a patient with collapse/syncope
PE
GI bleed
Ectopic pregnancy
Ruptured AAA
272
The San Francisco Syncope rule says to admit a patient with syncope if they have...THINK CHESS
[CHESS= CHF, Haematocrit<30%, ECG, SOB, SBP<90]
CHF
Haematocrit <30% (Total red blood cells as % of total volume)
Abnormal ECG
SoB
Sys BP <90
273
Indications for an MRI in a patient with back pain
```
>55
Systemically unwell
Hx trauma or malignancy
Infection
Fracture
Cauda equina
```
274
Back pain red flags
```
<20 or >50
Hx malignancy
Night pain
Fever
Hx trauma
Systemically unwell
```
275
Ottawa ankle rules of x-ray
Aim is to exclude a fracture
Cannot Wx bear for 4 steps post injury and NOW
Tenderness over posterior surface or malleoli
Lower threshold if extremes of age or intoxicated
Remember a crack or snap does not mean there was a fracture
276
Advice for ankle injury
RICE
Crutches if cannot Wx bear
Encourage mobilisation
If X-ray not needed then come back in 5 days if you still cannot Wx bear
277
Describe a Colle's and Smith's wrist fracture
Colle's is FOSH 'dinner fork' with the radius displaced downwards and hand displaced dorsally
Smith's is fall onto flexed wrist, Palmar angulation of distal bone fragment 'Garden spade'
278
What is a Galeazzi fracture
Wrist fall on outstretched arm with elbow flexed
| Distal radius fracture with disolaction of distal radioulnar joint
279
What is a Barton's fracture
Dislocation of the radial-carpal joint
280
Important X-ray advice for fractures
Always get 2 views!
281
What causes an acromioclavicular dislocation
Direct blow to top of the shoulder in young athletes
Adduction= pain
Tender over AC joint
282
Most common form of glenohumeral dislocation
Anterior
| Look for military badge numbness
283
What is 'light bulb' sign on an X-ray
Loss of normal half moon overlap (Humerus and scapula)
Suggests posterior dislocation
LOOK FOR LOSS OF EXT.Rotation
284
Sign of a fractured neck of femur
Shortened leg and externally rotated
285
In a ?Hip fracture when are you most concerned about infringement on blood supply?
Score 3-4 on Garden system
Complete fracture + Either partially displaced or bony disruption
(2= Complete + non displaced)
(1= Incomplete)
286
How do you confirm a Dx of urinary retention
USS of bladder
| >300cc
287
Classic presentation of testicular torsion
```
Sudden severe pain radiating to lower abdomen
Vomiting
Red, tender and swollen
Upwards retraction
No cremasteric reflex
Pain NOT eased by elevation
```
288
Causes of airway obstruction
```
CNS depression
Foreign body
Trauma
Swelling
Laryngospasm/Bronchospasm
Blocked tracheostomy
```
289
Causes of breathing problems
CNS depression
Muscle weakness
Disorders of lung function
PE, ARDS, Oedema
290
Causes of circulatory problems
Primary cardiac- MI, Arrhythmia, Tamponade, HF, Myocarditis, HOCM
Secondary cardiac- Asphyxia, Tension Pneumo, Blood loss, Hypoxia, Hypothermia, Septic shock, Hyperthermia, Rhabdomyolysis
291
Trauma triad of death
Coagulopathy
Metabolic acidosis
Hypothermia
292
What injury severity score indicates major trauma
>15
293
Sign of an obstructed airway
Quiet
| No movement
294
Injuries causing Airway compromise
| ATOMFC
```
Airway obstruction
Tension pneumothorax
Open pneumothorax (defect 1/3rd diameter of trachea)
Massive haemothorax (>1500mls)
Flail chest
Cardiac tamponade
```
295
Assessing circulation/End organ perfusion with HEP B
Hands- Temp, sweating, CRT
End organ perfusion- UO, Conscious level
Pulse- Rate quality, regular
BP- Hypotension?
296
What does on the floor and 4 more refer to?
Blood loss...
External wound
Chest cavity
Abd.Cavity
Pelvic cavity
Long bone fracture
297
What are the 4 types of shock
Hypovolaemic/Haemorrhagic
Obstructive (Tamponade)
Cardiogenic
Distributive (Sepsis, Anaphylaxis, Neurogenic)
298
Define Hypotension
>40 decrease in baseline MAP
SYS<90
MAP<60
299
Eye opening in GCS (4)
4- Spontaneous
3- To speech
2- To pain
1- None
300
Verbal response in GCS (5)
```
5- Orientated
4- Confused
3- Inappropriate words
2- Sounds
1- None
```
301
Motor response in GCS (6)
```
6- Obeys commands
5- Localises to pain
4- Withdraws from pain
3- Abn. Flexion
2- Abn.Extension
1- None
```
302
What GCS scores is minor, moderate and severe
Minor 13-15
Moderate 9-12
Severe 3-8
(<8 always intubate)
303
What are the Canadian C-Spine rules?
Trauma criteria for whether someone needs imaging
| If they meet any of the low risk factors they do not need imaging
304
What low risk factors are considered in the Canadian C-spine rules?
```
Comfortable sitting
Ambulatory
Rear-end motor collision
Delayed onset neck pain
No midline cervical spine tenderness
```
305
High risk criteria for a ?C-spine injury
>65 Years
Dangerous mechanism (Fall>1m, High speed collision, horse riding injury etc)
Paraesthesia in extremities
306
Signs of a trauma induced spinal injury
```
Diaphramatic breathing
Neurogenic shock
Priapsim
Responds only to pain above clavicles
Fixed position of upper limb
Flacid areflexia
LoS/Function
Tender/Swelling on leg roll
```
307
When is a trauma induced spinal injury unlikely? When do you decide whether there is a spinal injury?
No Neuro deficit + No pain along spine
1 week post-injury
308
What is the Monro-Kellie doctrine?
Compensatory mechanisms maintain normal ICP for change in volume <100-120ml
After this ICP inc and you can get coning
309
Shape of a subdural haematoma?
| What vessel system is likely involved?
Crescent moon shaped
| Venous
310
Shape of a extradural haematoma?
| What vessel system is likely involved?
Lemon shaped/Lens shaped
| Arterial
311
Key principles in preventing secondary brain injury
```
Prevent hypoxia and hypercapnia
Maintain BP
Look for decompensation
Prevent hypoglycaemia
CT early
Senior input
```
312
Venous saturation and pressure targets in Sepsis
CVP= >8mmhg
| SVO2>70%
313
In septic shock (or lactate >4) what is it important to do within 6 hours (think veins)?
CVP and central venous oxygenation
314
Rule of 15% in collapse
```
PE
Aortic dissection
ACS
Ectopic
Ruptured AAA
SAH
```
315
What 4 key themes must be explored in collapse Hx?
HEAD- Hypoxia, Hypoglyc, Epilepsy
HEART- IHD, Emboli (AF?), Arrhythmia, AS
VESSELS- Vasovagal, situaitonal, Ectopic
DRUGS- Anti-HTN, Beta-blockers
316
What is the OESIL RISK score?
Assesses risk of cardiac death post-syncope/collapse
| >65, Hx CVD, No prodrome, Abn ECG
317
What are the 6 parameters of a NEWS SCORE
```
RR
02 sats
Temp
Sys BP
HR
Consciousness
```
318
Explain how different NEWS Scores impact management
0= Min 12 hour obs
1-4= Min 4-6 hourly obs, Assess by Reg.Nurse
>5 or 3 in one parameter= Min 1 hour obs, inform Med team, clinical assessment
>7= Vital sign monitoring continuously, assessed by team with critical care competencies
