Acute Medicine Flashcards
(29 cards)
Explain the management process for anaphylaxis?
- ABCDE approach
- A = maintain patency, if GCS < 8 –> intubate
- B = 100% O2 on 15 L, Salbutamol if bronchospasm (indicated by wheeze)
- C = IV access (14-18gauge cannula), Fluids if hypo (500ml of warm crystalloid or 0.9% saline),
- IM Adrenaline 0.5-1mg (repeat until HR and BP stabilise)
- Alternatives: Prochloperazine (anti-histamine 10mg IV) or dexamethasone (steroid 200mg IV)
- Mast Cell Tryptase (MCT) measure at time of incident, 4hrs after and 24hrs after
- Monitor NP, HR, RR, O2 sats, temperature
Explain the management of paracetamol overdose?
- ABCDE assessment
- Assess risk of toxicity, if < 75mg/kg then unlikely, if >150mg/kg then significant risk
3a. if <1hr –> Activated charcoal
4. 4hrs later measure PPC also FBC, INR, U+Es. LFTs
- if still at risk (assess using PPC)? –> then N-acetylcysteine
3b. if > 8hrs –> N-acetylcysteine then measure PPC (assess risk)
3c. if > 24hrs - measure PPC (assess risk), other test results (late): raised bilirubin + creatinine; low albumin; hypoglycaemia; acidosis;
Why do patients get paracetamol toxicity?
OD causes stores of glutathione to run out –> inability to metabolise excessive amount of paracetamol
What is the treatment of paracetamol toxicity post 8hrs? Explain the dosing regimen?
N-Acetylcysteine
- 150mg over 1 hr
- 500mg over 4hr
- 100mg over 16hrs
What are the key investigations for paracetamol toxicity?
- Plasma paracetamol concentration - determine level in relation to weight to determine risk
- INR (NAC) affects levels
- U+E and LFTs
What is the key investigation for anaphylaxis?
Mast cell tryptase
What are the symptoms of paracetamol toxicity (sequelae)?
- Early = N+V
- 24-72 hrs = RUQ pain and tenderness
- 3-5 days = jaundice, coagulaopthy (bruising), hypoglycaemia
What are the effects of amphetamines?
Increased energy, talkativeness; decreased need for food; hallucinations; dilated pupils
What are the OD effects of amphetamines?
- Lack of energy
- Psychosis (hallucinations, delusions, paranoid thoughts, agitation)
- Others: increased RR, HR, hyper-reflexia, tremor etc
- Severe: cardiogenic shock, AKI, fever
What is the general treatment for amphetamines (think immediate treatment and 6 complications, be logical and keep it brief)
- <1hr Activated charcoal
- Metabolic acidosis - IV bicarb
- HTN - IV GTN
- Hypotension - Vasopressor and IV glucagon
- Agitation or Seizure - IV loraz, midaz, benzo
- Hyperthermia - cooling measures e.g. tepid sponge, cold saline, dantrolene
What are the mild and severe effects of opioid toxicity
Mild - pin point pupils, nausea and vomiting, sweating, agitation, euphoria, drowsy, confused
Severe - Hallucinations, respiratory depression, decreased HR, RR, GCS, myoclonic jerks
What is the management for opioid toxicity (no excuse for not getting this)
- Naloxone - 0.4mg injection - repeat in 60 s with 0.8mg if no improvement (max dose 2mg)
What are the toxic effect of TCAs and at what doses are its effects worrying? What is the main worrying complications?
> 10mg is significant toxicity
30mg is high chance of seizures and coma
- Mild - blurred vision, urinary retention, dry mouth, agitation, confusion, hallucinations
- Severe - hypoxia, resp depression, metabolic acidosis, seizures and coma
- Oesophageal burns
What are the ECG findings of TCA overdose?
- Prolonged QTC - if >100mms then significant risk of seizure and coma
- Dominant R wave in AVR
- Sinus tachycardia
What is the treatment for TCA overdose.
- Long QTC - IV bicarbonate
- Seizures - IV lorezepam/diazepam
- Resistant hypo - IV glucagon or vasopressor e.g. noradrenaline
- Arrhythmia - IV Magnesium
What are the features of alcohol withdrawal?
- Nausea, vomiting, shaking, fever, pale, tonic-clonic, raised HR/RR
- peaks at 12-24hrs, usually relieves within 48hrs - Severe i.e. DT
- temperature,
- Delusions + Hallucinations (lilliputian or wenicke-korsakoff)
- coarse tremor, acutely confused
- CV collapse
What is the treatment of alcohol withdrawal?
- IV pabrinex (thiamine)
- Chlodizepoxide reducing regimen
- 20mg/6hrly
- Then reduce over 1 week - Vitamin supplements
- IV vitamin B/C - Fluid resuscitation
- can require around 10L
- do not give saline if known chronic liver disease, give dextrose 5% as often hypoglycaemic
What is the major complications of alcohol withdrawal
- Delirium tremens
2. Wernicke-Korsakoff syndrome
What are the symptoms of DVT?
Moderate leg pain and swelling (>65%)
Distended superficial veins
Erythema
Hot
Homan’s sign - pain in calf on dorsiflexion of foot
Acute breathless and chest pain (if PE has developed)
what are the key investigations for DVT?
- Two level Well’s score (if ≥ 2 DVT likely –> USS, if < 2 DVT unlikely = D-dimer)
- Venous compression USS of leg vein (if +ve = anticoagulate; if -ve do D-Dimer)
- Also abdo and rectal/pelvic exam
- Bloods - FBC, INR, clotting, U+Es, APTT
What are the key symptoms of PE?
Sudden onset chest pain and dyspnoea Haemoptysis Acute desaturation (low O2%), increased HR, RR, JVP Dizzy and Syncope DVT signs Mild fever
What are the investigative findings/ladder for PE?
- Bloods - FBC, U+Es, Clotting, INR, APTT
- ABG - hypoxia
- ECG - Sinus tachycardia, S1Q3T3, RBBB. RAD (latter two suggest massive emboli)
- Two level Well’s score (≥5 PE likely –> CTPA, < 5 PE unlikely –> D-Dimer)
- CTPA (+ve –> anticoagulate; -ve –> D-dimer)
5b. V/Q mismatch
5c. Pulmonary angiography
What is the treatment pathway for PE?
- Oxygen - 15L/min via NRBM
- LMWH, Fondaparinoux or UFH (if severely renal impaired) give for at least 5d
- PO NSAIDs for pain (opiate will likely exacerbate respiratory depression)
- Warfarin - have overlap, continue LMWH until INR 2-4, then stop LMWH, continue warfarin for 4-6 weeks mod, 3-6 months for all others
- Thrombolysis if haemodynamic unstable
- Alteplase or Streptokinase - Embelectomy if massive
- IVC filter
What is the treatment pathway for DVT?
- LMWH, Fondaparinoux or UFH (if severely renal impaired) give for at least 5d
- Warfarin - have overlap, continue LMWH until INR 2-4, then stop LMWH, continue warfarin for 3 months
- Thrombolysis if patient has symptomatic iliofemoral DVT, good fun status, survival > 1 year and low bleed risk
- Alteplase or Streptokinase - IVC filter
