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Acute care Flashcards

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1
Q

Diarrhoea followed by widespread non blanching red rash and what to check

A

Vasculitis

Check renal function, proteinuria

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2
Q

Classification of post op haemorrhage e

A

Primary - continuous, starting during surgery, replace blood loss, treat shock, may return to theatre for haemostasis
Reactive - bleeding starts in response to blood pressure increase (anaesthetic wears off and stress reaction)
Secondary - infection 1-2w post op

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3
Q

Causes of sinus bradycardia

A 
Drugs - b blockers, digoxin, amiodarone, verapamil
Acute MI (inferior)
Sick sinus syndrome
Vasovagal
Hypothyroid
Hypothermia
RICP
Cholestasis
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4
Q

Manage bradycardia

A

Treat if under 40 or symptomatic
Atropine 0.6-1.2mg IV
Pacing - wire or external
Isoprenaline infusion

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5
Q

Red flags for headache

A

Thunderclap - SAH
Worse leaning forward, in morning and coughing - RICP, venous thrombus
Unilateral and eye pain - acute glaucoma, cluster headache
Scalp tenderness, over 50 - giant cell arteritis
Fever or neck stiffness - meningitis
Reduced consciousness
Pregnant - pre eclampsia
Travelling - malaria

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6
Q

3 signs elicited on exam for meningitis

A

Kernig’s sign - pain and resistance on extension of knee when hip flexed
Brudzinski sign - hip and knee flex when neck flexed
Tripod - stand up in tripod position to avoid bending neck

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7
Q

Immediate managements for coma

A

Hypoglycaemia - 50ml 50% dextrose iv stat
Wernicke’s encephalopathy - thiamine
Opiate OD - naloxone (0.4-2mg iv), IM or NGT
Benzo OD - flumazenil only if airway compromise
Septic - abx, acyclovir (herpes simples)

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8
Q

Causes of coma

A

V - stroke, subdural/subarachnoid hypertensive encephalopathy
I - meningitis, encephalitis (herpes simples, malaria
T - trauma
M - hypoglycaemia, dka, honk, hypoxia, co2 narcosis, hypothermia, addisonian crisis, myxoedema (hypothyroid), hepatic/uraemic encephalopathy
I - tricyclics, alcohol, carbon monoxide
N - tumour
C - epilepsy non-convulsive or post ictal state

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9
Q

GCS make up

A 
Motor:
6 fully responsive
5 localised response to pain
4 withdraws from pain
3 flex to pain
2 extend to pain
1 no response 
Verbal:
5 orientated
4 confused conversation
3 inappropriate speech
2 incomprehensible speech
1 none
Eye opening:
4 spontaneous
3 in response to speech
2 in response to pain
1 none
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10
Q

Grades of hypertensive retinopathy

A

Grade 1 - twisting of retinal arteries with silver wiring (reflective)
Grade 2 - with AV napping - arteries thickened over veins
Grade 3 - with flame shaped haemorrhages and cotton wool exudates (infarcts)
Grade 4 - with papilloedema

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11
Q

Bell’s palsy senses findings

A

Hyperacusis
Midriasis
Altered/metallic taste
Non forehead sparing

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12
Q

Types of shock

A

Pump failure: cardiogenic, or secondary to PE, tamponade, tension pneumothorax
Circulatory failure:
- anaphylaxis
- hypovolaemia including heat exhaustion, fluid (diarrhoea etc) and bleeding (incl third spacing)
- sepsis
- hypothyroid, addisons
- neurogenic - spinal surgery
- drugs - antihypertensives, anaesthetics

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13
Q

Doses of 2 abx for sepsis

A

Meropenem 1g/8h

Co amoxiclav 1.2g/8h

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14
Q

Manage heat exhaustion causing shock

A

Cooling
0.9% saline
Hydrocortisone

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15
Q

What is anaphylaxis

A

Type 1 IgE mediated hypersensitivity reaction
Causes: urticaria, capillary leak, wheeze, cyanosis, oedema due to histamine
Other sx: diarrhoea, vomiting, itchy, sweating

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16
Q

Management for anaphylaxis

A

Adrenaline IM 0.5mg of 1:1000 every 5m
Chlorphenamine 10mg iv
Hydrocortisone 200mg iv

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17
Q

ECG criteria for thrombolysis

A

ST elevation of 1mm or more in 2 or more limb leads
ST elevation of 2mm or more in 2 or more chest leads
New LBBB
Deep ST depression and tall R waves in V1-3

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18
Q

Contraindications to thrombolysis

A 
Internal bleeding
Suspected aortic dissection
Oesophageal varices
Recent haemorrhagic stroke 
Recent trauma or surgery within 2w
Acute pancreatitis
Severe liver disease
Active lung disease with cavitation
Cerebral neoplasm
Severe hypertension
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19
Q

Possible ECG signs for NSTEMI

A

Normal
Inverted or flat t waves
St depression

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20
Q

Poor prognostic factors in NSTEMI

A

Over 70yo
Raised troponin
History of unstable angina
Comorbidities - previous mi, poor lv function, diabetes

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21
Q

Causes of cardiogenic shock

A 
MI
Arrhythmia
PE
Tamponade
Tension pneumothorax 
Myocarditis
Aortic dissection
Endocarditis
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22
Q

Manage cardiogenic shock

A

Pulmonary capillary wedge pressure low = plasma expander
High = inotropic support dobutamine
Dopamine

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23
Q

Severe asthma and life threatening asthma features

A

Severe: rr>25, pulse >110, PEFR <50%, unable to complete sentences
Life threatening: silent chest, cyanosis, bradycardia, hypotension, PEFR <33%, exhaustion, normal/high pCO2, pOw <8, low pH

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24
Q

Manage life threatening asthma

A

Salbutamol 5mg and ipratropium 0.5mg nebs
Hydrocortisone/prednisolone
Magnesium sulphate 1.2-2g iv
Aminophylline

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25
Causes of pneumothorax
``` Pneumonia, TB, abscess Trauma CT disorders Cystic fibrosis, asthma, copd, fibrosis Carcinoma Iatrogenic ```
26
Complications of pneumonia
``` Abscess Pleural effusion Empyema Resp failure Septicaemia Pericarditis Myocarditis Cholestatic jaundice Renal failure ```
27
Examination findings for PE
``` Gallop rhythm Loud P2 Pleural rub AF Raised JVP RV heave Cyanosis, tachypnoea, hypotension ```
28
Initial antibiotics for meningitis and other drug for meningitic
Benzylpenicillin 1.2g iv/im then cefotaxime 2g (trust guidelines) Dexamethasone
29
Normal LP opening pressure
18-20cm
30
CSF in pyogenic meningitis, TB and viral
Pyogenic - Turbid, polymorphs, high cell count, low glucose, high protein TB - fibrin web, mononuclear, medium cell count, low glucose medium protein Viral - clear, mononuclear, medium cell count, high glucose, low protein
31
Causes of encephalitis
Viral - HSV, CMV, arbovirus, EBV, VZV, measles, mumps | Non-viral - bacterial meningitis, TB, listeria, malaria
32
Bloods and LP and treatment for encephalitis
Blood cultures Blood film for malaria parasites PCR of serum, throat swab and MSU Toxoplasma IgM titre LP - moderate protein and lymphocytes, low glucose Acyclovir 10mg/kg/8h within 1h for HSV empirical
33
Causes of cerebral abscess
``` Infection - ear, sinus, dental, periodontal Skull fracture Congenital heart disease Endocarditis Bronchiectasis ```
34
Manage status epilepticus
``` Lorazepam IV 2-4mg over 30 seconds Rectal diazepam Buccal midazolam Phenytoin infusion Diazepam infusion Dexamethasone if cerebral oedema/vasculitis ```
35
CI to phenytoin in status epilepticus
Bradycardia or heart block
36
Indications for CT head after head injury
``` Vomiting Reduced GCS Focal neuro deficit Suspected skull fracture Seizure post trauma Loss of consciousness and over 65yo, coagulopathy, anterograde amnesia or high impact injury ```
37
Long term complications of head injury
``` Subdural haematoma Seizures Parkinsonism Diabetes insipidus Dementia ```
38
Bad prognostic factors in head injury
``` Old age Decerebrate rigidity Extensor spasms Increased blood pressure Low pO2 Temperature high ```
39
Normal ICP and pathophysiology of RICP
0-10mmHg Vasogenic - increased cap permeability from infection, trauma, ischaemia, tumour Cytotoxic - cell death from hypoxia Interstitial - obstructive hydrocephalus
40
What is Cushing's response in RICP
Falling hr and increasing bp
41
Management of ventilation in RICP
Cause hyperventilation to decrease pCO2 and cause vasoconstriction
42
Management of RICP
Hyperventilate Mannitol but cautious of rebound increase in ICP Dexamethasone if cerebral oedema around tumour Fluid restriction to under 1.5l /d
43
Triggers for DKA
``` Surgery Infection MI Pancreatitis Chemotherapy Antipsychotics ```
44
Electrolyte abnormality in DKA
Hyponatraemia due to osmolar compensation for hyperglycaemia | Normal or high sodium = severe water loss
45
Manage DKA
Soluble insulin IV novorapid 4-8u, change to sc when ketones under 1 and eating 5% dextrose when glucose under 10 Fluids and potassium replacement
46
DKA complications
Cerebral oedema Aspiration pneumonia VTE Low electrolytes - phosphate, magnesium, potassium
47
Manage hypoglycaemia
200-300ml of 10% dextrose | Or glucagon 1mg IM
48
Diabetic emergencies
DKA Hypoglycaemia HONK - hyperglycaemic hyperosmolar non-ketotic Hyperlactataemia - with metformin or sepsis
49
What is HONK and how to treat and cause
Dehydration and high BM for a week with hyperosmolarity and no ketone production, from drugs, MI or bowel infarct Give saline and K once urine flowing, may need insulin but wait for 1h to check
50
Myxoedema coma features
Hypothyroid, hypothermia, hypoglycaemia, hyporeflexia, bradycardia, seizures, coma Exam - goitre, cyanosis, low BP, HF, signs of precipitants
51
Treat myxoedema coma
T3 slow infusion then levothyroxine Hydrocortisone, especially if pituitary hypothyroidism Saline, abx, oxygen, warm etc
52
Features of hyperthyroid (thyrotoxic storm)
Agitated, confusion, coma D&V Goitre, bruit, Raised temperature, AF, tachycardia Acute abdo, heart failure, CVS collapse
53
Causes of thyrotoxic storm
``` Thyroid surgery Radioiodine MI Infection Trauma ```
54
Confirm diagnosis of thyrotoxic storm
Technetium uptake
55
Manage thyrotoxic storm
Stabilise: Saline, NGT if vomiting, Sedate if necessary with chlorpromazine Peripheral effects: Propranolol if cardiac output OK, High dose digoxin to slow heart Suppress thyroid: carbimazole PO or NGT Hydrocortisone or dexamethasone Treat infection, cool incl paracetemol
56
Presentation of addisonian crisis
Shock - high pulse, vasoconstriction, postural hypotension, oliguria, weak, confused, coma Hypoglycaemia History of addisons with infection but no increase in steroids, or forgotten to take steroids
57
What investigaions and treatment for addisonian crisis
Cortisol and ACTH with heparin and straight to lab Monitor for low BM Find infection Hydrocortisone 100mg IV stat then change to oral after 72h Antibiotics May need glucose Saline
58
Presentation of hypopituitary coma
Hypothermia, refractory hypotension, septic signs without fever = chronic hypophyseal failure Short stature, loss of axillary hair, gonadal atrophy Headache, meningism, opthalmoplegia, reduced consciousness, hypoglycaemia
59
Investigate and treat hypopituitary coma
``` Cortisol T4, TSH ACTH Glucose Pituitary fossa CT/MRI ``` Treat: hydrocortisone 100mg IV, T3, surgery if apoplexy
60
Features and causes of hypertensive crisis in phaeochromocytoma
Pallor, feel about to die, pulsating headache Raised temperature, LVF, cardiogenic shock, VT, ST elevation Caused by stress, GA, parturition, abdo palpation
61
Treat phaeochromocytoma emergency
Phentolamine to maintain safe BP Phenoxybenzamine = alpha blockers
62
Indications for urgent dialysis
``` Persistently high potassium over 7 Pulmonary oedema and no diuresis Highly catabolic state with rapidly progressing renal failure Acidosis with pH under 7.2 Pericarditis ```
63
ECG changes of high potassium
``` Tall tented t waves Flat p waves Increasing PR interval Wide qrs VF/VT ```
64
Drug Management of hyperkalaemia
Calcium gluconate 10ml of 10% IV over 2mins, repeat as necessary Novorapid insulin and glucose IV Nebulised salbutamol Calcium resonium orally or enema
65
Drugs that can cause metabolic acidosis
Alcohol Antifreeze ethylene glycol Paracetamol Carbon monoxide
66
Symptoms of digoxin toxicity and treatment
``` Cognition decreased Nausea, anorexia Arrhythmia Yellow/green halos Correct hypokalaemia, give digoxin-specific antibody fragments ```
67
Opiate overdose treatment and it’s side effects
Naloxone 0.4-2mg every 2 mins until breathing adequate, max 10mg Can cause diarrhoea and cramps
68
Features of aspirin toxicity and pH change
Vomiting, dehydration, hyperventilation, sweating Tinnitus, vertigo Lethargy and coma, seizures Reduced bp, heart block, pulmonary oedema, hyperthermia Initially respiratory alkalosis due to resp centre stimulation, then metabolic acidosis
69
Manage metabolic acidosis in aspirin toxicity
Bicarbonate | Bicarbonate and KCl to alkalinise urine, monitor for hypokalaemia
70
Dose of paracetamol that is toxic and treatment, and ADR
150mg/kg or 12g in adults, less if malnourished Give N-Ac if over treatment line, or over 8h and suspect high dose, at 150mg/kg in 5% dextrose 200ml in 15mins Can cause rash - treat with chlorphenamine
71
When is paracetamol treatment graph not accurate
Long acting paracetamol HIV positive as hepatic glutathione is reduced Pre-existing liver disease or enzyme induction
72
Things to monitor in paracetamol overdose
Encephalopathy or RICP (oedema) - high BP, bradycardia, decerebrate, extensor spasms INR (peaks at 48-72h) Renal impairment - creatinine and urine flow pH Severe hypotension (<80)
73
Causes of lactic acidosis in paracetamol OD
1) metabolite of paracetamol inhibits aerobic respiration | 2) liver failure causes lactate build up and shock which causes tissue hypoperfusion
74
Complications of hypothermia
``` Arrhythmia Pneumonia Pancreatitis Acute renal failure Intravascular coagulation ```

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