Clinical Interview COPY Flashcards
(203 cards)
1
Q
Hyperkalaemia?
A
K+ > 5.2
Mild 5.3 - 6.0
Moderate 6.0 - 7.0
Severe > 7.0
2
Q
ECG changes in hyperkalaemia?
A
- peaked t-wave
- flat p-waves
- PR prolongated
- Wide QRS
- Pulled up from the t-wave *
3
Q
ECG changes in hypokalaemia?
A
t-wave inversion
ST depression
prominent U-waves
pushed down on T-segment
4
Q
Clinical manifestation of hyperkalaemia? Pathophysiology?
A
Bradycardia, conduction blocks & cardiac arrest.
Suppressed SA node.
Reduced conduction at AVN / His-purkinje
5
Q
Causes of hyperkalaemia? (6-themes)
A
- increased intake (oral/IV)
- increased production [tissue injury -> rhabdo, tumour lysis, burns, ischaemia, comparment syndrome]
- decreased excretion [renal failure, hypoaldosteronism, obstructive uropathy]
- transcellular shift [metabolic/resp acidosis, hyperglycaemia]
- Pseudohyperkalaemia [lab error, haemolysed sample, thrombocytosis]
- Drugs [aldost inhib; inhibition]
6
Q
Drug causes of hyperkalaemia?
A
- ACEi / ARB
- Heparin, spironoloactone, BBs
- Digoxin
- Suxamethonium, phenylephrine
7
Q
Management of hyperkalaemia?
A
- Cardiac stabilisation - calcium chloride/gluconate
- ECF -> ICF shift - insulin/dex, salbutamol, bicarb
- Removal of K+ - fruse (from urine), resonium (from gut), dialysis (from blood)
8
Q
Dose of calcium chloride/gluconate?
A
10mls of 10%
9
Q
Dose of insulin-dex for HyperK+?
A
10 units insulin 50g dextrose, IV over 20-30mins
10
Q
Hypokalaemiea?
A
Mild 3.0-3.5
Mod 2.5-3.0
Severe <2.5
11
Q
Causes of hypokalaemiea?
A
- decreased intake
- Mg depletion -> renal potassium loss
- Mineralocorticoid excess [cushing’s, addison’s, HTN, renin, barters]
- Increased loss [drugs, burns, GI, renal, endocrine, dialysis]
- Transcellular shift [insulin-dex, beta-agonists, alkalosis]
12
Q
Mx of hypokalaemia?
A
- non-acute = 10-20mmol/hr
- acute (life threatening arrhythmia) = 20mmol in 10mins
13
Q
Status epilepticus?
A
- continuous seizure > 5 minutes
- recurrent seizures without neurological recovery
14
Q
Causes of status epilepticus?
A
epilepsy
infective
hypoxic
vascular
metabolic
physical (hyperthermia)
drug induced / withdrawal
15
Q
Ix in status epilepticus?
A
- bedside [BM, VBG/lactate]
- laboratory [UEs, toxins, TFTs, LP]
- imaging [CT / MRI brain]
16
Q
Mx of status epileptics?
A
1st. Bolus benzodiazepines (IV, IM, buccal, PR)
2nd. Typically requires I+V
- phenytoin, valproic acid, levetiracetam
3rd. Refractory status
- propofol, midazolam, barbituates
4th. thiopentone, volatile, ketamine, lignocaine
Monitor EEG
Generally require HDU/ICU + neurology consult
17
Q
Principles of mx of status?
A
Resuscitation, maintain CPP
Terminate seizure
Decrease cerebral metabolic rate
Diagnose + treat cause
Treat copmlications
18
Q
Complications of status epilepticus?
A
- aspiration
- neurogenic pulm oedema
- rhabdomyolysis
- hyperthermia
- trauma (HI, post shoulder dislocation)
19
Q
DKA?
A
Life threatening complication of DM - insulin deficiency
20
Q
Diagnostic criteria for DKA?
A
- pH < 7.3
- Ketosis (ketonaemia/ketonuria)
- HCO3 < 15
- Hyperglycaemia - may be mild/euglycaemic
21
Q
Pathogenesis of DKA?
A
- increased glucagon, cortisol, catecholamines, GH
- decreased insulin
—> hyperglycamiea -> hyperosmolality -> electrolye lost -> ketone production from metabolism of triglycerides -> acidosis
22
Q
Goals of mx DKA?
A
- establish precipitant + treat
- assess degree of metabolic derangement
- fluid resuscitation
- insulin provision
- electrolyt replacement
23
Q
Mx of DKA?
A
-insulin infusion 0.1u/kg/hr
- balanced salt solution fluid resuscitation
- when glucose<15 -> dextrose 5% 100mls/hr
- monitor ketones
- monitor pH
– LOCAL GUIDELINES
Find cause + treat - e.g. infection [cultures, CXR, CT-A/P, bloods etc]
Continue background insulin
Early escalation to medical team/DM, ITU
24
Q
Classification of tachycardia?
A
- regular vs irregular
- narrow vs wide complex
25
Types of regular narrow complex tachycardia?
- sinus tachy
- atrial tachy
- atrial flutter
- SVT
- AVNRT
- Narrow complex VT
26
Types of irregular narrow complex tachycardia?
- AF
- Atrial flutter w/ variable blcok
- Multifocal atrial tachy
- Digoxin toxicity
- Tachycardia w/ premarture
27
Types of regular wide complex tachycardia?
- Monomorphic VT
- Ventricular flutter
- Hyperkalaemia
- Ischaemia
- Regular tachycardia w/ BBB
- Sodium channel blocker toxicity (e.g. TCA, cocaine)
28
Types of irregular wide complex tachycardia?
- TdP
- Irregular VT
- VF
- Irreg tachy w/ BBB
- AF w/ pre-excitation syndrome
29
Causes of tachycardia?
- Cardiac dysrhytmia
- Non-cardiac
-- Electrolyte imbalance (hypoK/Mg)
-- Fever/sepsis
-- HyperThy
-- Ischaemia
-- Pain
-- Poisoning
-- PE
-- Resp diseases (CAP, PTx)
-- Shock
-- Trauma
-- Withdrawal
30
Management of narrow complex tachycardia?
1. vagal manoeuvre
2. adenosine 6mg-12mg-18mg IV
3. cardioversion
31
Life-threatening features in tachycardia? (clinically unstable)
- Shock
- Syncope
- MI
- Severe heart failure
32
If life-threatening features in tachycardia what is management?
- Synchronised DC shock up to x3 attempts
-- Under sedation
- If unsuccessful - amiodarone 300mg IV over 10-20mins
- Rpt DCCV
33
Mx of VT?
1. amiodarone 300mg IV over 10-60mins
2. DC cardioversion
34
What is Torsades de pointes?
- polymorphic VT due to prolonged QTc interval
35
Mx of unstable TdP?
Synchronised DC cardioversion
36
Mx of stable TdP?
IV Mg
Stop causative drugs
Treat other QT prolonging factors - e.g. hypokalaemia
37
Approach to arrhythmias?
- fast or slow
- ventricular / SVT
- compromised?
- does it need management
- underlying cause? trigger?
- will it recur?
38
Narrow regular bradycardias?
- sinus
- junctional
- complete AV block
- Atrial flutter with block
39
Narrow irregular bradycardias?
- sinus arrhythmia
- AF with SVR
- Second degree AV block
40
Wide complex regular bradycardias?
- idioventricular rhythm
- complete AV bock
41
Wide complex irreg bradycardias?
- irreg brady w/ BBB
42
Mx of bradycardia with adverse features?
- Atropine 500mcg IV
-- repeat up to max of 3mg
- Alternate drugs (isoprenaline, adrenaline)
- Transcutaenous pacing
- Transvenous pacing - expert help
43
Life threatening signs of bradycardia?
- shock
- syncope
- MI
- HF
44
Reversible causes of arrest?
Hypoxia, hypovolaemia (think bleeding in post-op/trauma), hyperkalaemia, hypothermia
Tamponade, tension, thrombus (PE/MI), toxin
45
Shockable vs non-shockable rhythms?
Shockable = VF, pulseless VT
Non-shockable = asystole, PEA
46
Principles of arrest care?
- Get help! 2222
- High quality chest compression w/ minimal interruptions
- Early defib
- Basic airway --> ?intubation + ventilation
- Adrenaline
- POCUS for diagnosis
47
How to deliver a shock?
- Chest compressions ongoing
- Pause for 5s for rhythm recognition
- If shockable, continue compressions, charge, then all hands off + O2 mask removed from patient to deliver shock
- Immediately resume CPR - only stop if clinical + physiological signs of ROSC
48
Shockable algorithm?
- VF / pVT
- 2min cycles of chest compressions
- Up to 3 shocks
- Then adrenaline 1mg IV/IO every 3-5mins
- Amiodarone 300mg IV/IO after shocks
49
Signs of peri-arrest in arrhythmia?
- Shock (SBP<90) + increased sympathetic activity
- Syncope
- HF (pulm oedema (L), raised JVP (R))
- MI
50
Indications for cardiac pacing?
Unstable, symptomatic bradycardia refractory to drug therapy
51
Causes of pancreatitis?
Gallstones
Ethanol
Trauma
Steroids
Mumps
Autoimmune
Scorpions
Hypercalcamiea
ERCP
Drugs [NSAID, thiazides, azathioprine]
52
Glasgow-Imrie score?
PaO2 < 8
Age > 55
Neutrophils > 15
Calcium < 2
Renal function [Ur>16]
Enzymes [LDH>600 / AST > 2000]
Albumin < 32
Sugar [BM > 10]
53
Presentation of pancreatitis?
Severe abdominal pain, radiating to back.
N&V
Anorexia
Often presence of risk factors [gallstones, EtOH, recent ERCP, hypertriglyceridemia]
54
Signs of pancreatitis?
Tender epigastrium +/- guarding
Cullen's / Grey-Turner's
55
Mx of pancreatitis?
- Supportive [fluid resuscitation, analgesia, anti-emetic. Nutrition]
- Risk stratification [Glasgow-Imrie score OA + 48hrs]
--> Escalation to ITU if severe
- Surgical - ERCP/lap chole
56
Complications of pancreatitis?
Local [pseudocyst, pancreatic necrosis]
Systemic [SIRS, ARDS, AKI, multi-organ failure, death]
57
DDx RUQ pain?
- GI [PUD, cholecystitis, appendicitis, hepatitis]
- Urinary [pyelonephritis]
- Resp [pneumonia]
58
DDx epigastric pain?
- GI [PUD, cholecystitis, oesophagitis/perf]
- Cardiac [MI]
59
DDx LUQ pain?
- GI [PUD, perforation, splenic rupture]
- Urinary [Pyelonephritis]
- Resp [pneumonia]
60
DDx RLQ pain?
- GI [appendicitis, crohn's, perforation]
- Gynae [ovarian torsion/abscess; ectopic]
- Urinary [calculus, pyelo]
61
DDx LLQ pain?
- GI [diverticulitis, hernia, perforation, UC]
- Gynae [ovarian, ectopic
- Urinary [calculus, pyelo]
62
What is compartment syndrome?
- Limb threatening condition caused by raised pressure within a fascial compartment
- Causes compression of blood vessels, muscles and nerves within the compartment
--> irreversible muscle & nerve damage
63
Presentation of compartment syndrome?
Caused by?
- pain out of proportion
- 6Ps
- Caused by:
-- Trauma [fracture, crush injury, burns]
-- External compression [casts, dressings]
-- Bleeding disorder
-- Reperfusion injury [tourniquests; thrombectomy]
-- Extravasation
-- Arterial injury
64
Signs of compartment syndrome?
- pain with passive stretch
- paraesthesia
- tense compartment (woody)
- paralysis
- pulseless
65
Common locations of CS?
- forearm (esp volar)
- lower leg (esp anterior) - tibial shaft
- thigh
- upper arm
- hand
- foot
- back
- abdomen
- buttocks
66
Ix in compartment syndrome?
- XR (?fracture)
- Bloods (FBC, UE, CK, G&S)
- Compartment pressure measurement
67
Mx of compartment syndrome?
- IV access [fluid, analgesia, anti-emetic]
- Relieve pressure
- Reduce + splint any fractures
- Urgent referral to ortho/plastics
--> fasciotomy
68
Complications of compartment syndrome?
- Local [gangrene, loss of limb, muscle contracture]
- Systemic [rhabdomyolysis, renal failure]
69
Abdominal compartment syndrome?
- intra-abdominal hypertension with new organ failure
--> compression, thrombosis. Renal failure. Decreased tidal volumes. Decreased CO
70
Management of abdominal compartment syndrome?
- Monitor IAP
- Improve compliance - sedation, analgesia, neuromuscular block
- NG tube, rectal decompression, enemas
- Correct positive fluid balance
- Organ support
+/- surgery - decompression with delayed closure
71
What is anaphylaxis?
Severe, life-threatening, systemic hypersensitivity reaction
72
Characteristics of anaphylaxis?
Rapidly developing airway, breathing and circulation problems associated with skin + mucosal changes
- Pharyngeal/laryngeal oedema
- Bronchospasm / tachypnoea
- Hypotension / tachycardia
73
Causes of anaphylaxis?
- Allergens (insect stings, nuts, eggs, dairy, fruit)
- Medications (abx, NSAIDs, contrast)
- Unidentified
74
DDx of anaphylaxis? (conditions which mimic anaphylaxis)
- Urticaria
- Angioedema
- Dystonic reactions
- Carcionoid
- Red-man syndrome (Vanc)
- Acute resp distress
- Shock
75
Pathophysiology of anaphylaxis?
- IgE mediated hypersensitivity
- Profound histamine and serotonin release from basophils / mast cell degranulation
76
Symptoms of anaphylaxis?
- angioedema
- stridor
- resp distress
- bronchospasm
- hypotension / collapse
- abdo cramps
- diarrhoea
- flushing
- urticaria
- coagulopathy
77
Ix in anaphylaxis?
- Clinical diagnosis, but investigations can help in longterm managment
-- tryptase, RAST, CAP, skin testing
78
Mx of anaphyalxis?
- Stop trigger. Get help.
- Supine. 100% O2
- Adrenaline 0.5mg IM (rpt every 5 mins)
- IV access + fluid boluses
- Hydrocortisone IV
- If persistent hypotension after x2 adrenaline -> infusino
79
Mx of anaphylactic cardiac arrest?
- Extended CPR
- Raise legs
- 2L IV fluids stat
- Increasing adrenaline
- H1/H2 antagonist
80
Mx of persistent bronchospasm / angioedema in anaphylaxis?
- Bronchospasm [as per asthma emergency]
- Angioedmea [nebulised adrenaline; ETT; cricothyrdoiotomy/tracheostomy]
81
What are biphasic reactions?
- Recurrence of anaphylaxis symptoms soon after the initial episode
- may occur >24 hrs after initial episode, usually less severe
82
Risk factors for biphasic anaphylaxis reactions?
- delayed adrenaline
- slow response to adrenaline
- repeated doses of adrenaline
83
Does of adrenaline in anaphylaxis in kids?
- IM adrenaline 1:1000 (1mg/mL) 0.01mg/kg
- Repeat every 3-5mins
84
What is sepsis?
- Life threatening organ dysfunction due to dysregulated host response to infection
-- qSOFA (sequential organ failure assessment) 'HAT'
--- Hypotension
--- Altered mental status
--- Tachypnoea
85
Septic shock?
- Sepsis +
-- Persistent hypotension - requiring vasopressors
-- Lactate >=2
86
Criteria for SIRS?
- Systemic inflam response syndrome
- >=2 of the following
T >38 or <36
HR>90
RR>20 / PaCO2 < 32mmHg
WCC>12
Sepsis = SIRS + confirmed infection
87
Mx of sepsis?
- Resuscitation
- Sepsis 6 (Lactate, BCs, UO; abx, IVI, O2)
- Source control
- IVI. +/- vasopressors
88
Causes of APH? Features?
- Abruption - bleeding, painless
- Praevia - small bleeds, painless
- Uterine rupture - painful, fetal distress, no UO
89
Causes of PPH?
- Uterine atony - assos w/ multiples, prolonged labour, polyhydramnios
- Retained PoC / placenta
- Genital tract trauma
- Uterine inversion
- Ac-/In-/Per- Creta
90
Causes of haemorrhage in pregnancy? (Ts)
- Tone
- Trauma
- Tissue
- Thrombin
91
Management of haemorrhage in pregnancy?
- MDT [obstetrics, haematology, radiology, GenSurg, blood bank; neonatologist; ODPs/orderlies]
- Left lateral tilt
- CTG
- O2
- IV fluids +/- O- blood (6 Units)
- Warming
- Correct coagulopathy (TXA, RBCs, FFP, Cryo, Platelets)
- Uterotonics [bimanual copmression; syntocinon; ergometrine; carboprost]
- Surgery [embolistaion; clamp iliacs; caesarian hysterectomy]
92
Mx of Obstetric arrest?
- Left lateral position / manual displacement of uterus (relieves aortocaval compression)
- O2, IV access, fluids etc
- Algorithm is the same as non-pregnant women (DCCV & drug doses the same)
- If no response at 4 minutes -> peri-mortem CS
93
DDx of maternal collapse?
- Anaphylaxis
- PE
- Amniotic fluid embolus [collapse during labour]
- APH (abruption, praevia, rupture, ectopic)
- Eclampsia
- Intracranial haemorrhage
94
ROTEM?
Rotational thromboelastography
- gives information about bloods ability to clot
(rather than individual components values)
95
What types of analgesia are there?
Huge variety. Different classes, different routes. depending on patient situation - acute / chronic; duration required
- Simple (paracetamol. COX-inhibitors: aspirin, diclofenac, ibuprofen, parecoxib)
- Weak opiate (codeine, dihydro-, tramadol)
- Strong opiate (morphine, fentanyl)
- Neuropathic (amitriptyline,
- Sedative (ketamine)
- Inhaled (NO2, penthrox)
- Regional (local anaesthetics; regional)
- Spinal (opiates/ anaesthetics)
-- Given by doctors/nurses (PO, IV, SC)
-- Patient administered (PCA, PCEA)
96
What is adrenal crisis?
- Acute deterioration with hypotension, resolving with IV steroid
- Chronic adrenal insufficiency + trigger
OR
- Acute adrenal sufficiency
97
Causes of chronic adrenal insufficiency?
- Chronic steroid therapy
- Chronic adrenal grand dysfunction (Addison's, malignancy, infection)
- Chronic anterior pituitary dysfunction (granulomatous disease [TB/sarcoid], neoplasm, iatrogenic)
98
Acute stressors precipitating adrenal crisis?
- Infection [especially gastro]
- Trauma/surgery
- Reduced steroid dose [non-adherent, tapering]
- Stress
- Pregnancy
- Drugs
99
Causes of acute hypothalamic-pituitary-adrenal axis? (Rare)
Pituitary failure
- Pituitary apoplexy [post-partum / adenoma]
- Complication of neurosurgery
Adrenal gland failure
- Waterhouse-Friedrichsen [adrenal infarction due to DIC]
- Checkpoint-inhibitor immunotherapy
100
Signs & symptoms of adrenal crisis?
- Hypotension, vasodilatory shock
- Fever
- Nausea/vomiting
- Abdo pain + tenderness
-- Can mimic abdominal sepsis/pancreatitis
- Delirium
- Features of trigger [trauma/surgery/infection]
101
Signs in chronic adrenal insufficiency?
- Hyperpigmentation
- Vitiligo
- Chronic fatigue
- Anorexia
- Vomiting
- Weight loss
102
Mineralocorticoid deficiency leads to..?
Occurs in primary adrenal insufficiency (Addisons)
- Hyperkalaemia
- Non-anion gap metabolic acidosis
103
Glucocorticoid deficiency leads to..?
- Hyponatraemia
- Hypoglycaemia
104
Renin-angiotensin-aldosterone axis?
- Renin released due to high K+
- Catalyzes production of angiotensin
- Angiotensin stimulates adrenals to secrete aldosterone
- Aldosterone signals kidney to excrete potassium
105
Diagnosing adrenal insufficiency?
- Random cortisol
- ACTH stimulation test (synacthen)
106
Mx of adrenal crisis?
- Treat trigger
- IV Hydrocortisone 100mg stat
-- 50mg IV Hydrocortisone QDS
- Resuscitation with fluid +/- vasopressors
107
Prevention of adrenal crisis?
- Maintenance steroids (hydrocortisone, fludrocortisone)
- Sick day rules (double dose)
- Severe stress (major surgery, severe infection) - 50mg IV Hydrocortisone QDS
108
Pathophysiology of adrenal crisis?
- Cortisol and aldosterone deficiency
-- Aldosterone deficiency -> Na wasting; retentino of K+ & H+ -> Hypotension, hyperkalaemia, metabolic acidosis (non-anion-gap)
-- Cortisol deficiency -> increased inflam cytokines, vasodilation, hypoglycaemia, decreased fatty acids
109
What does adrenal gland produce?
- Zona Glomerulosa -> mineralocorticoids -> aldosterone
- Zona Fasciculata -> glucocorticoids -> cortisol
- Zona Reticularis -> sex steroids -> testosterone
- Adrenal medulla -> catecholamines -> adrenaline
110
Effects of cortisol?
-- Released in response to ACTH
- Suppress inflammation (cytokines)
- Vasoconstriction (w/ catecholamines)
- Catabolism (gluconeogenesis, production of free fatty acids & amino acids)
111
Mx of STEMI?
- Monitored resus bed
- IV access, bloods, ECG
- O2 >93%
- Analgesia (IV morphine titrated to effect) + antiemetic
- GTN, anti-platelet (aspirin 300mg + ticagrelor 180mg)
- Reperfusion strategy: PCI vs thrombolysis
- PPCI within 2 hours of medical contact
- Secondary prevention
112
When to use fibrinolysis in STEMI?
- <12 hours of symptoms
- PCI not possible in 2 hours
113
Mx of NSTEMI?
- Monitored resus bed
- IV access, bloods, ECG
- O2 > 93% (or if pt shocked)
- Analgesia titrated to effect; + antiemetic
- GTN, DAPT (aspirin 300, ticagrelor 180); anticoagulation (fonda)
114
Mx of acute asthma?
- O2 > 92%
- Beta-agonist - salbutamol neb/MDI/IV
- Anticholinergic - ipratropium neb
- Corticosteroids - HC / pred
- Aminophyline
+/- adrenaline, Mg
115
Markers of severe asthma?
- Accessory muscle use
- HR > 110
- RR 25-30
- PEFR < 50%
- SpO2 < 92%
116
Markers of imminent resp arrest in acute asthma?
- Altered mental status
- Paradoxical respiration
- Bradycardia
- Silent chest
- High pCO2 on ABG
117
Causes of pulmonary oedema?
- Cardiogenic
-- acute heart failure, MI,
- Non-cardiogenic
-- ARDS, reperfusion, neurogenic, transfusion reaction (TRALI), allergic alveolitis, HAPE, contusion
118
Problems with ventilation in acute asthma?
- Breath stacking (dynamic hyperinflation)
-- Barotrauma -> PTx
-- Increased intrathoracic pressure -> obstructive shock -> arrest
119
Emergency mx of acute cardiogenic pulmonary oedema?
- A - positioning
- B - High flow O2, consider early CPAP
- C - nitrates, furosmide
- D - morphine
- E - positionging
120
Presentation of acute pulmonary oedema?
- Breathless, sweaty, agitated
+/- precipitating event (cardiac ischaemia, MVR, arrhythmia, sepsis)
121
Define anaphylaxis?
Life threatening generalised hypersensitivity reaction
122
Characteristics of anaphylaxis?
Life threatening, rapidly developing A/B/C problems.
Usually associated with mucosal/skin change
123
Mx of anaphylaxis?
- STOP trigger
- Call for help
- O2 15L NRB
- Adrenaline 0.5mg IM, repeat at 2 mins, onto infusion if no improvement
- Fluids
- Consider steroid / antihistamine
124
Classification of hyponatraemia?
Brief explaination?
- Hypovolaemic (Na loss > water loss)
- Normovolaemic
- Hypervolaemic (increased TBW relative to Na -> oedematous)
- Pseudohyponatraemia [hyperglycaemia; hyperlipidaemia; hyperproteinaemia]
125
Causes of hypovolaemic hyponatraemia?
- Renal (urine Na > 20)
-- Addisions; CKD; RTA; diuretics; cerebral salt wasting
- Extra-renal (urine Na < 20)
-- 3rd space losses [burns; pancreatitis; SBO; cirrhosis]; sweating/D&V with continued water intake
126
Causes of euvolaemic hyponatraemia?
- SIADH (Urine Osm > Serum Osm)
- Exercise
- Iatrogenic
- Amphetamines
- Tea & toast diet
- polydipsia (water/beer)
127
Causes of hypervolaemic hyponatraemia?
- Renal failure
- Heart failure
- Cirrhosis
- Nephrotic syndrome
- Hepato-renal syndrome
128
Causes of SIADH?
Malignancy [SCLC]
ADH secretion
Drugs [SSRI, carbamaz, amitrip]
CNS disease [meningitis, SAH]
Hormone deficiency [Thyroid/ Addisions]
Other
Pulmonary
129
Mx of Hyponatraemia?
ASYMPTOMATIC
- SLOW correction
- Water restriction
- Demeclocycline
SYMPTOMATIC
- Hypertonic saline
130
Complications of hyponatraemia?
- Cerebral oedema
- ECG changes
- Pontine myelinolysis in overcorrection
131
What is necrotising fasciitis?
- Severe rapidly progressing bacterial soft tissue infection of subcut tissues + fascia
132
Causative organisms of Nec Fasc?
- Strep (grp A)
- Staph aureus
- Clost. pefringes
- Vibrio vulficians
133
Risk factors for Nec Fasc?
- DM
- EtOH
- PVD
- Renal failure
- Malignancy
- Skin trauma including surgery
134
Symptoms/signs of Nec Fasc?
- Rapid spreading cellulitis
- Sepsis + haemodynamic instability
- Pain out of proportion
- Erythema -> tense swelling -> dark blisters -> gangrene
- Crepitus
-- Rapid spread
135
Investigations in Nec Fasc?
- Do not delay surgical intervention!
- Bloods [cultures; full panel; CRP; CK]
- Imaging [XR/CT/MRI will reveal subcut gas]
136
Management of Nec Fasc?
- Supportive resuscitation
- Extensive surgical debridement
- Broad spec abx as per local guidelines
- Often require ITU post-op +/- hyperbaric O2
137
What is in a massive transfusion pack?
- Packed RBCs
- Platelets
- Fresh frozen plasma
Ratio of 2:1:1
138
5 commonest causes of critical bleeding?
- Trauma
- GI haemorrhage
- Ruptured AAA
- Obstetric haemorrhage
- Surgical
139
What is trauma's lethal triad?
In the context of bleeding
- Hypothermia
- Coagulopathy
- Acidosis
140
How does Tranexamic Acid work?
- Antifibrinolytic; competitively inhibits plasminogen -> plasmin
141
What are recommendations for TXA in trauma?
CRASH2 trial showed improved survival in trauma patients given TXA
1g loading dose, 1g infusion
142
What is damage control surgery in trauma?
Damage control surgery = abandonment of definitive surgery, rapid haemostasis, packing and closure -> transfer to ICU for warming, correction of coagulopathy and inotropes -> definitive treatment undertaken later
* Used when ongoing bleeding after 10 U RBC; pH<7.2 / T<35
143
MDT involved in Obstetric haemorrhage?
- Anaesthetics + ODP
- Obstetrics
- Haematology / blood bank
- Radiology
- GenSurg/Urology
- Neonatologists
- Orderlies
144
Causes of major haemorrhage in trauma?
- Blunt vs penetrating trauma
- Chest
- Abdomen
- Pelvis
- Long bones
- Retroperitoneum
145
Define critical bleeding?
Major haemorrhage that is life threatening and likely to require massive transfusion.
OR smaller volume of bleeding into critical area/organ - intra-cranial, spinal or occular
146
Goals of management of major trauma?
- Find the bleeding + stop the bleeding
- Rapidly restore blood volume
- Maintain blood composition (and so function)
- Avoid hypothermia
147
What is Rhesus disease?
- Rh(-) mother exposed to Rh(+) blood will produce Anti-D antibody which can cross placenta and cause abortion of a Rh(+) foetus
- can occur with: incompatible blood or foetal-maternal haemorrhage
148
What are transfusion reactions?
Adverse event associated with transfusion of blood products. Can be classified as: acute (<24hrs) or delayed (>24hrs); and as immunological or non-immunological
149
Acute, immunological transfusion reactions?
- ABO incompatibility
- Haemolytic
- Febrile
- Urticaria
- Anaphylaxis
- TRALI
150
Pathophysiology of Transfusion Related Acute Lung Injury?
TRALI -> activated pulmonary neutrophils leads to non-cardiogenic pulmonary oedema; fever & shock
151
Symptoms of ABO incompatibility?
- chest pain, jaundice, shock, DIC
- rapid intravascular haemolysis
152
Acute, non-immunological transfusion reactions?
- TACO
- Sepsis
153
Pathophysiology of TACO?
- Increased intravascular volume -> pulmonary oedema
154
Define massive transfusion?
- >half of circulating volume in 4 hours
- Whole circulating volume in 24 hours
(Circulating vol is approx 70mls/kg)
155
Complications of massive transfusions?
- Air embolism
- Hypothermia
- Hypocalcaemia
- Citrate toxicity
- Lactic acidosis
156
How is blood stored?
- Fridge approx 4'C
- Solution: saline, adenine, glucose, mannitol
- Citrate
-- Binds Ca++ preventing clotting
157
Treatment for tension pneumothorax?
Life threatening emergency.
- O2 (15L NRB)
- Urgent needle decompression -> cannula, 2nd intercostal space in mid-clavicular line
- Progress to chest drain
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What is a pneumothorax?
Air in the pleural cavity
159
Types & causes of pneumothorax?
- Spontaneous
-- Primary (thin, smoker)
-- Secondary to Resp disease (COPD, bullae)
- Traumatic
-- Blunt
-- Penetrating
- Iatrogenic
-- Ventilation - barotrauma
-- CPR
-- CVC
160
Treatments for recurrent pneumothoraces?
- Pleurodesis
- Surgery (thoracostomy, pleurectomy)
161
Contraindication to pleurodesis? Why?
- Cystic Fibrosis
- May require lung transplant in future, pleurodesis makes this complicated/impossible
162
What is asthma?
Chronic, reversible airway inflammation / obstruction due to bronchoconstriction.
Sensitivity to variety of stimuli.
Extrinsic - allergic
Intrinsic - non-allergic
163
Pathophysiology behind acute asthma attack?
- Early = bronchospasm
- Later = airway oedema and mucus
164
Indications for intubation in acute asthma?
- Hypoxia (PaO2 < 8)
- Hypercapnia (PaCO2 > 6)
- Drowsiness/tiring
165
When to refer acute asthma to ITU?
- Early!
- Acute severe / life-threatening, failing to respond to therapy
-- i.e [reduced PEFR; persistent/worsening hypoxia; hypercapnia; acidosis; exhaustion; drowsiness]
- Have a high index of suspicion if prev ITU admissions
166
Management of acute asthma?
- A-E
- Risk stratify mild / mod / severe / life-threatening
- Neb salbutamol
- PO/IV steroid
- Neb ipratropium
- IV salbutamol
- IV Mg
- Regular ABG monitoring + early escalation to critical care
167
Management of chronic asthma?
1) B agonist
2) + ICS
3) + LABA
4) + LTRA
5) Daily steroid
168
What is shock?
- Life threatening state of cellular + tissue hypoxia most commonly occurring due to circulatory failure
- If untreated -> organ dysfunction + death
169
Types of shock?
*CHODE*
- Cardiogenic
- Hypovolaemic
- Obstructive
- Distributive (due to vasodilation eg sepsis)
- Endocrine
170
Causes of acute renal failure?
- Pre-renal: hypovolaemia; sepsis; low CO
- Renal: ATN; hypoxia/hypoperfusion; toxin/drugs; abdominal compartment syndrome; hepatorenal syndrome
- Post-renal: obstructive uropathy
171
Signs of shock?
- Drowsiness
- Reduced cap refil
- Oliguria
- Hyperlactaemia
172
Causes of cardiogenic shock?
- Impaired contractility (MI, cardiomyopathy)
- Dysrhythmia
- Valvular dysfunction
- Left ventricular outflow obstruction
173
Causes of obstructive shock?
- Intravascular: PE, other emboli (Eg air)
- Extravascular: tamponade, tension PTx, hyperinflation (severe asthma), abdominal compartment syndrome,
174
Causes of hypovolaemic shock?
- Haemorrhage.
--- Traumatic
--- Non-traumatic (GI bleed, obstetric, epistaxis, coagulopathy)
- Fluid loss
--- DKA
--- Burns
--- 3rd space (pancreatitis, burns, anaphylaxis)
--- Iatrogenic
175
Causes of distributive shock?
- Neurogenic
- Liver failure
- Adrenal insufficiency
- Anaphylaxis
- Sepsis
- Drugs
176
Endocrine causes of shock?
- Adrenal insufficiency
- Hypothyroid
-
177
Uterotonic management options?
- Bimanual compression
- Syntocinon
- Ergometrine
- Carboprost
178
Causes of venous thromboembolism?
Virchow's triad
- Circulatory stasis
- Vessel wall injury
- Hypercoagulable state
179
Risk factors for VTE?
Primary
- coagulant deficiency
- Factor V Leiden
Secondary
- immobility, surgery, malignancy, smoking, pregnancy, COCP
180
ECG findings in right ventricular strain?
- T-wave inversion in II, III, aVF, V1-V4
181
Treatment options for PE?
- LMWH
- Thrombolysis if clinically massive PE + haemodynamic compromise
- IVC filter if anti-coag contraindiciated
182
Causes of cirrhosis?
- Alcohol
- NAFLD
- Congenital: haemochromatosis, wilson's
- Autoimmune: PBC/PSC, hepatitis
183
Causes of ascites?
- Portal HTN
- CCF
- Intra-abdominal malignancy
184
Causes of abdominal distension?
- Fat
- Fluid
- Faeces
- Flatus
- Foetus
185
Complications of cirrhosis?
- Portal HTN
- Varices
- Coagulopathy
- Encephalopathy
- Hepatorenal syndrome
- HCC
186
ECG changes in Tricyclic Antidepressant overdose?
- QRS prolongation
- Right axis deviation of terminal QRS
-- often also tachycardia, RBBB
187
Presentation of TCA overdose?
- CNS: agitation, seizures, coma
- CVS: tachycardia, broad complex tacyhydysrhhythmia
- Anticholinergic:
188
Treatment of TCA overdose?
- Intubation + ventilation - hyperventilation for pH > 7.5
- IV Sodium Bicarbonate
- IV fluids
- ITU
189
Patholophysiology of TCA overdose?
- Blocks fast Na+ channels (most common in right heart)
- Anti-cholinergic
190
Antibiotic use in neutropenic sepsis?
- Broad spectrum (Gent / Pip/Taz)
- If abdominal source + metronidazole
- If MSRA+ -> + vancomycin
- If failure to improve -> + anti-fungal
- Remove indwelling lines
- Reverse barrier nurse in side room
191
Causes of hypercalcaemia?
- Hyperparathyroid
- Malignancy (lysis of bone or PTHrP)
- Drugs (thiazide)
- Hyperthyroidism
- Addison's
- Sarcoid
192
Symptoms of hypercalcaemia?
- Bone pain
- Depression
- Abdominal pain
- Renal stones
193
Symptoms/signs of hypocalcaemia?
- Tingling
- Cramps
- Chvostek (tap -> mouth twitch)
- Trousseau's (carpopedal spasm with BP cuff)
- Hyperreflexia
- Seizure
194
Calcium regulation?
- PTH
- Calcitonin
- VItamin D
195
what is myeloma?
- Haematological cancer
- Proliferation of plasma cells
- Treatable but not curable
196
Complications of sickle cell disease?
- Vaso-occlusive crisis
- Aplastic crisis
- Sequestration crisis
- Haemolytic crisis
197
Pathophysiology of vaso-occlusive crisis in sickle cell disease?
- Sickle-shaped RBCs obstruct capillaries and restrict blood flow --> ischaemia, pain, necrosis, organ damage
198
Management of vaso-occlusive crisis?
- Supportive
- Analgesia
- RBC transfusion
199
Causes of haemolysis?
- Acquired [autoimmune; prosthetic valves; malaria; drugs]
- Congenital [hereditary spherocytosis; G6PD deficiency; sickle cell; thalassaemia]
200
What is sickle cell disease?
- Congenital
- HbS haemoglobinopathy causing rigid, distorted & dysfunctional erythrocytes
201
Precipitants to sickle cell crisis?
- Infection
- Dehydration
- Hypoxia
- Drugs
202
What triggers aplastic crisis in sickle cell?
- Parvovirus
203
