Emergency & acute medicine 1 Flashcards
(228 cards)
1
Q
Three reasons why people deteriorate?
A
Airway obstruction
breathing problems
circulation problems
2
Q
Causes of airway obstruction? 6
A
- CNS depression
- foreign body (blood vomit, secretions, food)
- blocked tracheostomy
- trauma
- swelling (infections, oedema)
- laryngospasm, bronchospasm
3
Q
Ways in which airway obstruction kills you? 5
A
- cerebral oedema
- hypoxic brain injury
- pulmonary oedema
- secondary apnoeas
- exhaustion
4
Q
Three groups of causes of breathing problems (in critically unwell pt)?
A
1) CNS depression causing decreased / abolished respiratory drive
2) Poor / diminished respiratory effort (from muscle weakness or pain or restrictive abnormalities)
3) Disorders of lung function (eg pneumonia, pneumothorax, haemothorax, asthma, COPD, PE, ARDS, oedema)
5
Q
Ways in which breathing problems kill you? 5
A
- hypercapnia and apnoeas
- pulmonary oedema
- exhaustion
- hypoxic brain injury
- secondary cardiac ischaemia
6
Q
Causes of circulation problems (in critically unwell pt):
- two main types? (with 8 egs each - though don’t obsess!!)
A
Primary cardiac
- MI
- ischaemia
- arrhythmia
- cardiac failure
- tamponade
- rupture
- myocarditis
- HOCM
secondary heart problems
- asphyxia
- tension pneumothorax
- blood loss
- hypoxia
- hypothermia
- septic shock
- hyperthermia
- rhabdomyolysis
7
Q
How do circulatory problems kill? 1
A
cardiac arrest
8
Q
What is the most useful NEWS observation to identify a critically unwell / deteriorating pt?
A
resp rate!
anything above 20 should worry you!
9
Q
Assessment (& management) of critically unwell patient: AIRWAY (3 things)
A
1) look for signs of airway obstruction
2) treat the obstruction as an emergency
3) give 15L oxygen in non-rebreath mask to EVERYONE with obstruction (regardless of other stuff)
10
Q
Assessment (& management) of critically unwell patient: BREATHING (8 things)
A
1) look, listen & feel forRESP DISTRESS (learn signs**)
2) Count the RR (15secs)
3) assess QUALITY of breathing
4) note any DEFORMITY
5) Record O2 SATS (& if/what oxygen they’re on!!!)
6) Listen near the face then Palpate, Percuss & Auscultate chest
7) TRACHEA position?
8) Initiate TREATMENT (eg nebulisers, needle decompression etc)
11
Q
Assessment (and management) of critically unwell patient: CIRCULATION (10 things)
A
1) Look and feel HANDS
2) peripheral and central (sternum) CAP REFILL
3) assess VENOUS filling
4) count PULSE (and look on cardiac monitoring - nb don’t need 12 lead ecg)
5) Palpate central and peripheral PULSE
6) measure BP
7) AUSCULTATE heart
8) Look for SIGNS of poor cardiac output (brain, kidneys etc)
9) Look for HAEMORRHAGE (orifices and bruising)
10) TREAT cause of cardiovascular collapse
12
Q
Assessment (& management) of critically unwell patient: DISABILITY (7 things)
A
1) Review & treat ABC’s, check no hypoxia & hypotension
2) Check drug chart for REVERSIBLE drug-induced low GCS
3) examine PUPILS
4) Assess GCS or AVPU
5) Check lateralising signs**
6) Check capillary GLUCOSE
7) Ensure AIRWAY protection
13
Q
Assessment (& management) of critically unwell patient: EXPOSURE (2 things)
A
1) EXAMINATION
2) TEMPERATURE
14
Q
7 things to do once patient is stabilised post A-E assessment?
A
1) take a HISTORY
2) review NOTES
3) review RESULTS
4) which LEVEL of care is required?
5) REASSESS response
6) DOCUMENT everything
7) decide upon definitive TREATMENT
15
Q
Three definitions of hypotension:
A
1) Systolic BP <90mmhg
2) decrease in systolic >40mmhg or 30% from patient’s BASELINE
3) mean arterial pressure** (MAP) <60mmhg
nb beware of ‘normal’ BP in pt with chronic hypertension
16
Q
TYPES of causes of hypotension? 4
also in order that you look for them
A
1) HEART RATE
- Can be a response to BP or cause of low BP (work it out)
2) VOLUME STATUS
- Are they dry? (vomiting, diarrhoea, GI bleed etc)
- if low, give fluids
3) CARDIAC PERFORMANCE
- Is this cardiogenic shock? secondary cardiac cause?
4) SYSTEMIC VASCULAR RESISTANCE
- sepsis or anaphylaxis? (neurogenic shock is rare)
17
Q
What is the modified A-E approach in major trauma patients?
What is this also known as?
A
A: Airway maintenance WITH cervical spine protection
B: Breathing AND ventilation
C: Circulation WITH haemorrhage control
D: Disability AND neurologic status
E: Exposure AND environmental control
The primary survey
18
Q
What are some possible signs of obstruction or airway injury? 7
A
- absent breath sounds
- snoring / stridor / gurgling
- hoarse voice
- obtundation (drowsiness)
- cyanosis
- paradoxical movements / retractions / accessory muscles
- tracheal deviation / laryngeal crepitus
19
Q
What is the cause of most trauma deaths?
A
major haemorrhage (ie blood loss)
20
Q
Which injuries (/things that happen to trauma pts) could compromise the airway? 7
A
- facial fractures
- facial burns
- inhalation of hot smoke
- neck wounds
- epistaxis
- vomiting
- head injury w low GCS
21
Q
What are the two movements you can do to improve airway?
which one DO you do if worried about c-spine?
A
- chin lift
- jaw thrust
DO jaw thrust if worried about c-spine
(don’t do chin lift)
22
Q
What are the two types of airway adjuncts?
Which do you tend to do in trauma? why?
A
- oropharyngeal
- nasopharyngeal
do oropharyngeal if worried about head injury, especially basal skull fracture - also oro is used more commonly in trauma generally anyway
23
Q
How do you measure for a oropharyngeal airway?
A
“squish to squish”
ie earlobe to corner of mouth
24
Q
what are the two types of definitive airways?
A
Endotracheal intubation
Surgical airways
25
How do you fully immobilise a c-spine?
what is this called?
3 aspects
- hard collar
- blocks
- tape
three point fixation
(nb also manual stabilisation - ie someone holding head - is also effective & considered 'full immobilisation')
26
How do you size a cervical collar?
using fingers measuring from the top of
the patient's trapezius to the point of the chin
This measurement is
then used against the sizing posts on the cervical collar which is then
adjusted to the correct size (measure from the hard plastic at the
bottom to the hole)
should be secured tightly but should still be able to open mouth
27
What are the signs of ventilatory collapse? 3
- inadequate or asymmetrical chest rise & fall
- laboured breathing
- decreased or absent air entry
(nb low o2 sats is NOT a measure of adequacy of ventilation)
28
What are the 6 thoracic injuries which can compromise ventilation & be fatal?
(incl mneumonic)
ATOM FC
- Airway obstruction
- Tension pneumothorax
- Open chest wound
- Massive haemothorax
- Flail chest
- Cardiac tamponade
29
What are 8 potentially less life-threatening thorax injuries? (but still need emergency care)
- simple pneumothorax
- haemothorax
- pulmonary contusion
- blunt cardiac injury
- oesophageal rupture
- diaphragmatic injury
- traumatic aortic disruption
- tracheobronchial tree injury
30
signs of thoracic injury?
- inspect? 5
- palpate? 1
- percuss? 1
- auscultate? 1
- on xray / ct? 1
inspect
- abnormal RR
- abnormal O2 sats
- abnormal chest movement
- chest wall bruising or wounds
- surgical emphysema
palpate
- tracheal deviation
percuss
- abnormal percussion note
auscultate
- abnormal air entry
xray / ct
- rib, clavicular, scapular or sternal fractures
31
immediate management options for inadequate ventilation in the context of trauma? 5
- 15L O2 non-rebreath mask (if not already done)
- consider the need for intubation
- needle decompression (if tension)
- chest drain (thoracocentesis) (ALWAYS PUT CANNULAS IN FIRST & HAVE FLUIDS)
- resuscitative thoracotomy
nb also can do pericardiocentecis if tamponade, but normally just do thoracotomy)
32
What is the definition of shock?
"Clinical syndrome caused by inadequate tissue perfusion and oxygenation leading to abnormal metabolic function"
33
Main cause of shock in major trauma patients? 1
other causes? 3
unlikely causes in trauma? 2
HAEMORRHAGIC (hypovolaemic)
other
- obstructive (eg pressure on great vessels)
- cardiogenic
- neurogenic
unlikely in trauma
- septic
- anaphylactic
(though can still happen)
34
What is the mneumonic when assessing circulatory signs? 4
| ie assessing if someone is in/going into hypovolaemic shock
HEP B
- Hands
- End organ perfusion
- Pulse
- Blood pressure
(nb low BP is a late sign!)
when you assess for signs of shock, take account of ABSOLUTES AND TRENDS in signs
(be aware of the 'normal' bp in someone who is normally hypertensive)
35
What circulatory signs do you assess on the hands of a trauma pt? 3
H of HEP B
- temperature
- sweating
- CAPILLARY REFILL TIME
36
How do you assess 'end organ perfusion' in trauma pts? 2
E of HEP B
- conscious level (use GCS)
- urine output (may be less easy to measure)
37
What 3 things are you assessing when you feel pulse?
- rate
- rhythm
- character / quality
38
What's the rhyme to remember where to look for blood loss / haemorrhages in trauma pts? 5
"on the floor & four more"
- external wounds
- chest cavity
- abdo cavity (incl retroperitoneal)
- pelvic cavity
- long bone fractures (esp femur)
39
What should you do immediately if you think there may be any pelvic injuries or bleeding?
put a pelvic binder on
don't put pelvis under any kind of pressure as could cause more bleeding
40
What 2 questions should you ask yourself when assessing the circulation of a trauma pt?
- are there signs of shock?
| - are there injuries which could or will cause shock?
41
immediate management options for inadequate circulation in the context of trauma? 6
(which 3 should do if actively haemorrhaging)
- optimise oxygenation (if not done already)
- 2x large bore cannulas in antecubital fossa (take some bloods from)
- fluid resuscitation
- splints / tourniquet / direct pressure for active haemorrhage
- IV tranexamic acid if haemorrhaging
- consider activation of the massive transfusion protocol
NEED DEFINITIVE HAEMOSTASIS (ie stabilise & get to surgery)
42
What are the colours and sizes of the 6 main cannulas used?
which are considered 'large bore'
- orange 14 (biggest)
- grey 16
- green 18
- pink 20 (normal wards)
- blue 22 (elderly or tricky veins)
- yellow 24 (norm just paeds)
(orange, gray, green are large bore)
nb green mainly used for CT scans
43
Which two fluids do you mainly used for resus in trauma?
- packed red cells
- WARMED crystalloid (ie saline)
don't give hartmanns in major trauma
44
do you get crossmatch or group & save in trauma pts? why?
crossmatch - as need blood now
also give O neg until have results back
(nb never order both - if chance need blood but unlikely - eg routine op then do group & save)
45
Glasgow coma scale:
- three components?
- each out of how many?
- max score?
- min score?
- how do you record?
```
eye opening (E)
- out of 4
verbal response (V)
- out of 5
best motor response (M)
- out of 6
```
```
max = 15
min = 3
```
by section, eg E4,V5,M6
(can also say total too)
46
Glasgow coma scale:
- classification of minor, moderate & severe brain injury
- at what point do you call an anaesthetist?
- definition of a coma?
- minor = 13-15
- moderate = 9-12
- severe = 3-8
call anaesthetist if 8 or lower
lower than 8 is a coma
KEEP REASSESSING as can change quickly
47
Glasgow coma scale:
| - eye opening (what each number means)
eye opening (E)
```
4 = open spontaneously
3 = open to verbal
2 = open to pain
1 = no eye opening
```
48
what 2 ways can you inflict pain to assess response?
- supraorbital pressure
| - trapezius squeeze
49
Glasgow coma scale:
| - verbal response (what each number means)
```
5 = orientated
4 = confused
3 = inappropriate words
2 = incomprehensible words
1 = no verbal response
```
50
What three things should a person be oriented to?
- time
- place
- person
nb person is know who they are (ask their name) - is the last thing that goes
51
Glasgow coma scale:
| - motor response (what each number means)
```
6 = obeys commands
5 = localises to pain
4 = normal flexion to withdraw from pain
3 = abnormal flexion
2 = abnormal extension
1 = no motor response
```
52
What to assess for in 'disability'?
1) signs of a head injury?
- bruises (head or neck)
- lacerations (head or neck)
2) pupil size & reaction to light
3) capillary glucose
4) GCS score
53
immediate management options for head injury in the context of trauma? 5
- optimise oxygenation
- maintain cerebral perfusion (BP >90mmHg)
- avoid hypoglycaemia
- avoid pyrexia
- definitive imaging & treatment
54
What are the two main signs / groups of signs of spinal injury? 2
What two things mean that you can't trust these sisngs? 2
- neurological deficit
- pain or tenderness along the spine (when palpated)
- patient is intoxicated
- patient has a distracting injury
nb in reality in trauma most people are likely to have a distracting injury so often er on side of caution and immobilise c-spine etc
55
Log rolls
- how many people do you need?
- what does each do?
- who's in charge?
```
five people
- one to stabilise the neck
- 3 to roll the
patient (height order)
- one person to examine the back/spine and perform a
```
DRE
person at neck is in charge
56
What are the signs of a spinal injury? 7
- breathing difficulties
- evidence of neurogenic shock
- spinal tenderness, bruising or swelling on log roll
- responds to pain only above the clavicle
- patient complains of loss of sensation or function
- priapism
- flexed posture of upper limbs or flaccid areflexia
57
Immediate management of spinal or suspected spinal injury? 8
| nb may not do all but would do majority
- optimise oxygenation
- ensure adequate VENTILATION
- maintain spinal cord perfusion (avoid hypotension)
- maintain immobilisation
- document thorough spinal cord examination
- urinary catheter
- NG tube
- definitive imaging & specialist advice
58
Why do you want to avoid hypothermia in trauma?
because it stops you clotting (coagulopathy) - making any bleeding worse!!
59
possible signs of MSK trauma (ie pelvis or limbs) 6
- limb deformity (or amputation)
- soft tissue injury / bruising
- patient localising pain to a limb / body part
- any splinting applied pre-hospital
- pelvic instability (palpate very gently!!)
- neurovascular compromise distal to injury
60
immediate management options for MSK injury in the context of trauma? 6
do not get fixated on MSK injuries until ABCD sorted (unless pelvic haemorrhage - pick up inC)
- maintain oxygenation
- maintain tissue perfusion (avoid hypotension)
- apply splints
- analgesia
- IV antibiotics (if open wound)
- monitor for complications
61
Why do we apply splints to limb injuries? 3
- reduces blood loss
- lessens pain
- improves alignment
62
What are the three major immediate complications you monitor for in MSK injuries?
- compartment syndrome
- skin necrosis
- nerve compression (or any neurovascular compromise)
63
What happens to majority of major trauma patients when they come into resus?
- primary survey (w immediate management)
- trauma CT series once stabilised (ideally within 30 mins)
- secondary survey / definitive management / surgery
64
What is an 'LMA' (in trauma context)?
laryngeal mask airway
65
When is RR useless as clinical sign?
When you are ventilating them - as you are giving them a respiratory rate
66
Why are burns patient at high risk of compromised airway?
inhaled smoke -> oedema in pharynx / larynx
67
What three things are you looking at when you look at pupils?
- equal?
- size (in mm)
- reactive?
68
What are all of the possible airway management techniques:
- manoeuvres? 2
- temporary airways? 3
- definitive airways? 2
- chin lift
- jaw thrust
- oropharyngeal airway (aka guedel)
- nasopharyngeal airway
- laryngeal mask airway
definitive:
- endotracheal intubation
- surgical airways
nb use suction as well
(also boogie if intubating)
also always plan for vomiting
69
How do you measure a nasopharyngeal airway?
match diameter to diameter of pinky finger
70
What are examples of traumatic primary brain injuries?
- skull fracture
- concussion
- contusion
- intracranial haematoma
- diffuse axonal injury
- penetrating injury
71
what's the difference between concussion and contusion?
concussion
- microscopic damage (so can't see on CT)
- widespread damage
contusion
- is a bruise on the brain
- is macroscopic, can see localised 'bruises' on ct
- damage is more focal
72
what is cerebral perfusion pressure?
what are the two things that affect it?
what's the equation?
a measure of how perfused, and thus how oxygenated, the brain is
1) intra cranial pressure (ICP)
2) blood pressure, measured using mean arterial pressure (MAP)
CPP = MAP - ICP
basically you always want the blood pressure to be higher than the ICP so that there's enough pressure to pump blood into the brain
73
how do you calculate mean arterial pressure?
((2x diastolic) + systolic) / 3
74
What will happen to the cerebral perfusion pressure if the blood pressure drops?
it will decrease
so when loosing blood, be aware that this will cause secondary brain injury even if original trauma is nowhere near brain
treat this with fluids (warmed saline & blood) and stop the bleeding etc
75
what will happen to the cerebral perfusion pressure if there is raised ICP?
it will decrease
therefore brain will become hypoxic quickly, must ensure BP is kept high so that don't decrease CPP further then may have to do emergency craniotomy etc to relieve pressure
76
What is the monro-kellie doctrine and what is it relevant for?
brain is fixed volume so when there is an intra-cranial mass increasing in size the body compensates by getting rid of other fluid in the brain (ie CSF and venous blood)
once it can no longer compensate then start getting brain herniation etc
77
How do you prevent secondary brain injury secondary to major head trauma?
- bedside? 5
- definitive? 2
- ensure good airway
- give high flow oxygen
- maintain BP (control bleeds, give fluids)
- repeat observations
- prevent hypoglycaemia
(ie do good A-E)
- early CT
- liaise with neurosurgery
78
What are the indications for a definitive airway? 3
- failure of airway maintenance / protection
- failure of oxygenation / ventilation
- anticipated clinical course (ie going straight to surgery)
79
what are the four types of hypoxia?
1) Hypoxic hypoxia - ↓ O2 supply
2) Anaemic hypoxia - ↓ haemoglobin function
3) Stagnant hypoxia – inadequate circulation
4) Histotoxic hypoxia – impaired cellular O2 metabolism
80
How do you assess breathing (B) in a trauma A-E?
- inspect 4
- palpate 3
- percuss 1
- auscultate 1
- main treatment? 1
inspect
- signs of respiratory distress
- thorax injury / asymmetry / deformity / raised JVP
- COUNT RR
- O2 sats (on 15L)
palpate
- tenderness
- surgical emphysema
- trachea position
percuss
- both sides of chest
auscultate
- both sides of chest
15L high flow O2 in non-rebreath mask
81
Signs of a tension pneumothorax?
- severe respiratory distress
- unilaterally hyper-expanded chest with reduced movement
- hyper-resonant & decreased air entry on affected sign
- tracheal deviation (this is a late sign!!
82
How do you treat a tension pneumothorax? (incl landmarks)
1) needle decompression (stick a cannula in)
- 2nd intercostal space mid-clavicular line
2) chest drain (trauma-sized)
- 5th intercostal space, mid-axillary line (safe triangle from bottom of the hair line in blokes)
nb 5th intercostal space is known as nipple line but only true in fit young men
83
What is an open pneumothorax?
How do you treat?
open wound in chest wall (only has to be >60% size of trachea to cause a problem)
- when chest expands air goes in defect rather than trachea -> no gas exchange in pleural space
treat with an occlusive dressing which lets air out but not in!
nb multiple small wounds can cause this, doesn't just have to be one large wound - need to cover all!
84
When is it hard to spot a haemothorax?
how do you overcome this?
when patient is supine
ie all major trauma
FAST ultrasound scan
AND percuss laterally as far as you can go
85
What is the gelly LMA called?
I gel
86
What is the first line airway management for an in-hospital cardiac arrest?
I gel (the jelly Laryngeal mask)
87
Massive haemothorax
- definition (by volume)?
- norm caused by?
- How do you manage? (& what to be careful of)
>1500ml blood in the thorax
significant injury to major vessels in chest
put two large bore cannulas in, cross match & other bloods then give warm saline & blood FIRST
THEN insert a chest drain
(this is because draining all that blood will probably make them less haemodynamically stable so you need to have venous access before you do it)
also nb they will probs already be haemodynamically unstable as a lot of blood is in chest instead of not circulating (so approach in a full A-E)
88
Flail chest
- what is it?
- what does it look like?
- what norm caused by?
- what deeper injury is normally present?
Mobile segment of chest wall- two or more ribs broken in two or more places
an area of the chest goes in during inspiration & out during expiration (ie opposite to the rest of the normal chest)
indicator of high force injury
lung often crushed underneath = pulmonary contusions
89
Flail chest findings:
- inspection? 3
- palpation? 1
- auscultation? 1
- other obs finding? 1
- CXR? 2
- respiratory distress
- visible injury
- classic flail chest movement (may not see!)
- tenderness to palpate
- reduced air entry
- hypoxaemia
CXR
- rib fractures
- lung contusions (this may occur hours later!!)
90
Flail chest management:
- to do immediately? 2
- to assess for / anticipate? 2
- early intubation and / or intubation
- ANALGESIA (as need them to be able to breath well!!)
assess for haemothorax and shock (likely to coexist)
anticipate worsening hypoxia
91
```
Cardiac tamponade
- what is it? & what happens as a result?
- what norm caused by?
- how does it present? 3
how is it normally picked up?
```
injury to myocardium -> blood leaks out into pericardial sac -> heart unable to fill properly which often -> shock
norm sharp, penetrating injury to myocardium, but can be blunt
92
Cardiac tamponade
- how does it present? 3
- how is it normally picked up?
- investigation? 1
- management?
- shock (low BP & high HR)
- distended neck veins
- muffled heart sounds (hard to detect in loud resus room)
norm picked up dt clinical suspicion (ie always suspect if major trauma to thorax!!)
can do bedside ultrasound (is this part of FAST?)
resuscitative thoracotomy (normally - can also try and drain but drain often kinks)
93
if a mjor trauma patient starts having a cardiac arrest in eg resus?
resuscitative thoracotomy (instead of CPR)
94
along with blood products & fluids, what drug can you give to control haemorrhaging?
transaxemic acid
95
Out of the obs, which is the first and last to go in haemorrhaging shock?
other important early sign of shock?
- RR increase first
- then HR increases
- BP drops last
patient is anxious and / or confused
96
which type of haemorrhage is really hard to spot?
retroperitoneal
97
What two main types of shock do you think about in major trauma patients?
haemorrhagic
non-haemorrhagic
- obstructive, cardiogenic, neurogenic
(septic and anaphylactic are rare in trauma but do happen)
98
Signs of a haemothorax
- inspection? 1
- obs? 1
- percussion? 1
- auscultation? 1
visible wounds / bruising
raised RR
dull to percussion (though when supine likely to miss!!)
reduced air entry
99
Abdominal haemorrhage:
- what can cause?
- what to look for? how?
- what is a very late sign?
- what may not be present?
blunt or penetrating trauma
high index of suspicion - do FAST scan and trauma CT
abdo distension is very late sign
tenderness may not be present
100
pelvic haemorrhage
- what sort of injury causes it?
- which vessels are norm damaged?
- how much volume can be lost?
large force needed to fracture pelvis (is very strong)
large vessels
large volume can be lost very fast
101
Signs of pelvic fracture? 5
- bruising around pelvis
- perineal bruising
- blood at penile meatus
- blood in vagina
- blood in rectum (very ominous)
102
pelvic fracture management? 4
- pelvic binder
- tie feet together
- fluid bolus & assess response
- blood products (major haemorrhage protocol)
- interventional radiology
never stress test the pelvis!!
103
femor fractures:
- how much blood can loose?
- immediate managament?
1500ml from each leg
splint early
- reduces movement
- protects clot
104
investigations in major trauma:
- bloods? 7
- bedside imaging? 3
- definitive imaging? 1
- group & save
- VBG
- FBC
- U&E
- LFTs
- coag
- amylase
- CXR
- pelvic XR
- FAST US scan
(also diagnostic peritoneal lavage - rarely used in uk)
trauma CT (head, thorax, abdo, pelvis)
105
What are the 6 steps of oxygen delivery to the tissues?
1) VENTILATION (convection of O2 from environment to body)
2) OXYGEN UPTAKE (diffusion of oxygen into the blood)
3) reversible chemical BONDING with Hb
4) CARDIAC OUTPUT (convective transport of O2 to the tissues
5) DIFFUSION into the cells / organelles
6) The redox state of oxygen
hypoxia can occur due to problems at any of these stages
106
What is the 'trauma triad of death'
COAGULOPATHY
causes lactic acidosis
-> METABOLIC ACIDOSIS
causes decreased myocardial performance
-> HYPOTHERMIA
this halts coagulation cascade
-> COAGULOPATHY
etc etc
107
What is clinically significant hypothermia?
what is the main problem it causes?
How can it be prevented / managed in resus? 2
body temp <36deg for 4 hours or more
clotting factors stop working so you're unable to clot to control haemorrhages
- give WARMED fluids
- limit exposure (keep covered up as much as possible - surgery will also cause further hypothermia)
108
What are the the three things that lead to coagulopathy in trauma patients?
how to manage?
- hypothermia
- activation of the fibrinolytic system
- haemodilution from fluid resuscitation
give clotting product and tranxaemic aciud etc alongside packed red cells and saline
109
Why do trauma patients get lactic acidosis?
what can exacerbate this?
How does acidaemia worsen shock? 3
they get shock (tissue hypoperfusion with reduced oxygen delivery) -> anaerobic respiration -> lactate production & lactic acidosis
anything which further reduces the tissue perfusion, eg aorta cross-clamping, use of vasopressors etc
Acidaemia causes:
- reduced cardiac output (depresses
myocardial contractility) so exacerbates shock
- inhibits coagulation enzyme function and
- causes right shift of the oxygen dissociation curve.
110
Signs of increased intracranial pressure
- neurological? 5
- eyes? 3
- vital signs? 3
- changes in level of consciousness
- changes in speech
- headache
- seizures
- vomiting
eyes:
- papilloedema
- pupillary changes
- impaired eye movement
```
cushing's triad:
- high systolic BP
- low HR
- irregular resp pattern
(nb this is a pre-terminal sign)
```
111
Signs of increased intracranial pressure in infants? 4
- bulging fontanelle
- cranial suture seperation
- increased head circumference
- high pitched cry
112
Another word used to describe brain herniation?
coning
113
Assessing breathing in acutely unwell pt:
- what do you look for signs of? 1
- two relevant obs? (& extra to that)
- observe? 4
- palpate? 2
- percuss? 1
- auscultate? 1
1) look for signs of respiratory distress
2) obs
- RR (and quality/ depth: is it shallow?)
- O2 sats (and fi02)
3) observe
- chest deformity
- raised JVP
- abdo ditension
- ankle oedema
4) palpate
- equal chest expansion
- trachea position
5) percuss
- lung fields
6) auscultate
- lung fields
114
What are the signs of respiratory distress? 8
- very high (>30) OR v low RR
- Tripodding
- accessory muscle use
- pursed lip breathing
- distended neck veins
- colour changes (blue, red, pale)
- sweaty
- agitated
115
what is agitation a sign of?
brain failure
| - think hypoxia and then hypoglycaemia
116
Which area of the lungs should you not forget to auscultate?
the axilla (and also bases)
hear right middle zone pneumonias there?
117
What are the different oxygen delivery systems:
- ones without ventilation? 5
- one with ventilation? 4
- nasal cannula
- high flow nasal cannula (just ITU)
- simple face mask
- venturi mask (simple mask plus a venturi valve)
- non-rebreath mask
- bag-valve mask
- cpap (non-invasive ventilation)
- bipap (non-invasive ventilation)
- invasive ventilation (IV)
nb NIV = non-invasive ventilation
118
What is a simple face mask also called?
hudson mask
119
What % of oxygen are you effectively giving to the pt through a non-rebreath mask?
85%
120
Who do you use venturi masks for?
what are the 5 different valve colours - and what concentration?
people with chronic lung disease (retainers) who you need at a certain o2 sats
green = 60% (never see as should be on critical care)
red = 40%
yellow = 35%
white = 28%
blue = 24%
"green should be on sterile ICU, red is bad, yellow's a bit better, then white, then blue you're nearly in the all clear"
(nb these % are printed on the valves)
121
What's the difference between cpap and bipap?
When would you use each?
both give positive pressure
cpap gives continuous level of pressure
- type 1 (hypoxic) resp failure
- heart failure (pushes fluid out of lungs)
bipap gives one pressure for when breath in and different for when breath out
- type 2 resp failure
122
as well as with primary lung problems, what else can you use cpap for?
pulmonary oedema which is resistant to diuretics etc - it pushes the fluid back into the blood and off the lungs
123
What investigations can you do if someone has a breathing problem:
- bedside? 2
- bloods? 4
- imaging? 2
bedside
- ECG (even if just to get a baseline)
- PEFR (if asthma)
bloods
- ABG
- blood culture (if think infective)
- routine: FBC, U&E, LFTs
- clotting (if predicting need procedure!)
imaging
- CXR
- CTPA / VQ scan
(nb only do a d-dimer if done a wells score first)
124
What immediate treatments (ie during A-E) can you give someone with a breathing problem? 6
- SIT THEM UP as much as possible (so important but so often missed!)
- oxygen (15L non-rebreath if critically unwell)
- nebulisers (salbutamol - o shit me for asthma)
- GTN (if pulm oedema)
- needle decompression if tension pneumothorax
- chest drain if large effusion/haemothorax
(abx & steroids may be later down line but not immediately
125
what flow rate(s) can/should you use for:
- simple nasal cannula?
- simple face mask?
- venturi?
- non-rebreath?
- bag valve mask?
- non-invasive ventilation?
- invasive ventilation?
simple nasal cannula
= 1-6L (though in reality give 1-4L)
simple face mask
= 5-10L
venturi
= look on particular valve, it will say!
non-rebreath
= 15L
bag valve mask
= 15L
non-invasive ventilation
= Any rate
invasive ventilation
= any rate
nb these are all litres per minute
126
What are the two main indications for oxygen?
- hypoxia (ie lower than normal range)
- acutely unwell
nb the feeling of breathlessness on its own is not an indication for oxygen - neither is heart attack with low sats etc
127
What are the two different oxygen target ranges and who are they used for?
88-92%
- people at risk of type 2 resp failure / retainers
= chronic lung disease (COPD, fibrosis, bronchiectasis, CF)
- NOT asthma!
(nb if acutely unwell though, give 15L non-rebreath)
94-98%
- everyone else
94-98%
128
When should you not use target oxygen ranges?
in palliative care - treat the symptoms not the sats
129
if oxygen sats are unrecordable, what two things could this mean?
- circulation failure (normal reason)
| - sats in 60s/70s
130
What should you be aware of when prescribing or titrating oxygen up for a pt?
look at their trends of oxygen requirements
Beware of ‘oxygen creep’ = people gradually needing more and more oxygen
Find out underlying reason why his o2 requirement is going up (eg undetected pneumonia / PE etc)
131
What should you give to patients who are struggling to breath as well as having low sats (ie in addition to oxygen)?
ventilation!!
eg bag valve, NIV, IV
need both oxygenation and ventilation to survive
132
Taking a breathlessness history, what associated symptoms should you ask about:
- specific? 8
- systemic/general? 6
- cough
- wheeze
- haemoptysis
- chest pain
- palpitations
- orthopnoea
- paroxysmal nocturnal dyspnoea
- ankle swelling
AW FS FIN
- appetite
- weight loss
- fatigue
- sleep
- fever
- (itch)
- night sweats
133
What PMHx should you always ask when taking a breathlessness hx? 2
- any chronic lung problems (list them)
| - any episodes like this before? how many? when? need intubation/ICU?
134
Who should get a blood gas?
- CRITICALly ill
- unexpected or inappropriate hypoxaemia (SpO2 <94%) or any pt requiring oxygen to achieve this target range.
- deteriorating O2 sats or increasing breathlessness with previously stable hypoxaemia
- deteriorating patient who now requires a significant (FiO2) to maintain a constant oxygen saturation.
- risk factors for hypercapnic respiratory failure who develops acute breathlessness, deteriorating oxygen saturation or drowsiness or other symptoms of CO2 retention.
- Breathlessness and are thought to be at risk of metabolic conditions
- Acute breathlessness or critically illness and poor peripheral circulation in whom a reliable oximetry signal cannot be obtained.
- any other evidence that would indicate that blood gas results would be useful in the patient’s management
(e. g., an unexpected change in ‘‘track and trigger’’ systems such as a sudden rise of several units in the NEWS or an unexpected fall in oxygen saturation of 3% or more, even if within the target range).
135
When do you need to do an ABG? 2
and when will a VBG do?
ABG if a primary respiratory problem OR need to know accurate O2 for other reason (eg sats probe not working or CO poisoning)
VBG is fine for most things
136
What are the four main things you look at on a blood gas?
What are the 10 other things that are also on there?
1) pH
2) PaO2
3) PaCO2
4) Bicarb (aHCO3)
- base excess
- sodium (Na)
- potassium (K)
- Chloride (Cl)
- Calcium (Ca2+)
- glucose
- lactate
- Hb
- COHb (carboxyhaemoglobin)
- MetHb
137
What can you interpret about CO2 from a VBG?
if CO2 is normal on a VBG then it's not going to be high on an ABG (as venous blood has more CO2 than arterial blood)
138
What should you always use when doing an ABG?
local anaesthetic (use an insulin needle)
| also do an Allen's test to test ulnar collateral
139
What value should the PaO2 be?
it should be over 10 less than the % oxygen breathed in
eg if breathing on room air (21% O2) then PaO2 should be at least 11 kPA (ideally 13/14)
if way over this then may be over-oxygenated (which can also cause harm) so titrate down
140
What is the normal pH range?
7.35-7.45
141
What is the normal range of PaCO2?
4-6 kPA
142
What is the normal range of HCO3?
22-30mmols
143
What is the normal base excess?
-2 to +2
144
What is the 6 step approach to interpreting blood gases?
1) clinical picture (how is pt clinically? what are you predicting?)
2) PaO2 (is pt hypoxic?)
3) pH (acidotic or alkalotic?)
4) PaCO2 (low or high?)
5) Bicarbonate (low or high?)
6) other things if needed - incl lactate, hb, glucose and salts
145
What should you always know before interpreting a blood gas?
How much oxygen the pt is on? (FiO2)
146
What are the three most common causes of metabolic acidosis?
- lactic acidosis
- ketonic acidosis (eg DKA, starvation)
- uraemic acidosis (kidney problems)
nb less commonly salicylic poisoning (aspirin, alcohol etc)
147
How does the body compensate for metabolic acidosis? 2
1) uses up bicarb (so have low bicarb)
| 2) hyperventilates to blow off CO2 (so get low CO2)
148
You rarely see metabolic alkalosis, what's the one thing which you do see it in?
kids who are vomiting a lot
149
In terms of anion gaps, which type of metabolic acidosis are you most likely to see?
things that cause RAISED anion gap acidosis is by far the most common
150
What does hypoxaemia and hypotension lead to?
and why?
lactic acidosis
as if muscles aren't getting enough oxygen then they start to do anaerobic respiration -> lactate production
151
What's the most common cause of respiratory alkalosis?
hyperventilation
152
What does a high bicarb normally indicate?
and why?
someone with long-standing hypercapnia - ie CO2 retention = so body gradually compensates by running a higher bicarb (takes weeks to do this) to cope with the long-standing resp acidosis from high CO2
153
What do you need to be aware of when measuring BP, especially in trauma pts?
if pt normally has high blood pressure then a 'normal' reading may actually be showing hypotension
154
How do you tell if a person with sepsis is in shock?
if they have sepsis and are hypotensive but do NOT respond to a fluid bolus, then they are in shock
155
What are the four types / mechanisms of shock? (with examples)
HYPOVOLEMIC
- eg blood loss, burns, pancreatitis
CARDIOGENIC
- eg MI, arrythmias
OBSTRUCTIVE
- eg tension pneumothorax, cardiac tamponade
DISTRIBUTIVE
- eg sepsis, anaphylaxis, neurogenic shock
156
What is neurogenic shock?
Neurogenic shock is a distributive type of shock resulting in low blood pressure, occasionally with a slowed heart rate, that is attributed to the disruption of the autonomic pathways within the spinal cord. It can occur after damage to the central nervous system, such as spinal cord injury and traumatic brain injury
157
What is the management of someone in anaphylactic shock?
incl 3 drugs that are given?
A-E assessment and management
- incl a fluid challenge
- IM adrenaline
- IM/IV chlorphenamine
- IM/IV hydrocortisone
158
What type of fluid often gives anaphylactic reactions?
colloid fluids
159
What is the dose of adrenaline given to an adult with anaphylaxis and which route?
500micrograms IM
- repeat after 5 mins if no better
(nb smaller if a child)
(nb IV can be given if experienced)
160
What's the initial management of sepsis and the timeframe this should happen within?
BUFALO
- blood cultures
- urine output (measure hourly)
- fluid resuscitation
- antibiotics (after cultures if poss)
- lactate measurement
- Oxygen
should happen within 1 hours
(also give vasopressors later down the line)
161
What is cardiogenic shock?
tissue hypoperfusion that is primarily attributable to damage to the heart
162
What are the two main types of cardiogenic shock?
MI
arrythmias
163
What is syncope?
What are the three most important things in this definition?
a transient loss of consciousness caused by transient global cerebral hypoperfusion characterised by rapid onset, short duration, and spontaneous complete recovery
- brief LOC
- spontaneous recovery
- complete recovery
164
What is the 'rule of 15%' for syncope?
which conditions does this apply to? 6
acronym to remember?
15% of these listed conditions present as a syncopal episode alone!
A PEARS
- ACS
- PE
- Ectopic pregnancy
- Aortic dissection
- Ruptured AAA
- Subarachnoid haemorhhage
Eg 15% of PEs present with just a transient LOC
165
What are the three groups of causes of syncope?
which do you really worry about?
NEURALLY MEDIATED SYNCOPE (aka reflex)
ORTHOSTATIC HYPOTENSION SYNCOPE
CARDIAC SYNCOPE
really worry about cardiac syncope
166
NEURALLY MEDIATED SYNCOPE (aka reflex)
| - 4 types & examples of each
- vasovagal (mediated by orthostatic or emotional stress)
- situational (cough, sneeze, GI, micturation, post-exercise)
- carotid sinus sensitivity
- atypical forms (without apparent triggers or typical presentations)
167
ORTHOSTATIC HYPOTENSION SYNCOPE
- primary autonomic failure (pure autonomic failure, parkinsons, lewy body dementia etc)
- secondary autonomic failure (diabetes, uraemia, spinal cord injuries)
- drug-induced (alcohol, vasodilators, diuretics, anti-depressants)
- volume depletion (haemorrhage, diarrhoea)
168
CARDIAC SYNCOPE
| - 2 groups of causes (1st divided into 3 with examples, 2nd divided into 2 with examples
ARRYTHMIAS
- bradycardia (sinus node dysfunction, AV conduction disease etc)
- tachycardia (eg SVT)
- drug-induced (any drugs that can -> arrythmia)
STRUCTURAL HEART DISEASE
- cardiac (valvular, MI, congenital, tamponade etc)
- other (PE, pulm HTN, aortic dissection)
169
What are the four main groups of causes of 'collapse'? (nb this is not just syncopes)
Head
Heart
Vessels
Drugs
170
What are 5 common differential diagnoses for 'head' cause of 'collapse'? (add clinical clues/things to check too)
- hypoxia (check sats)
- hypoglycaemia (pmh diabetes, check glucose)
- epilepsy/seizure (post-ictal period, pmh epilepsy)
- affective
- dysfunction of brainstem (eg vertebrobasillar stroke, TIA, migraine) (look for cerebellar signs)
nb stroke does not cause LOC)
171
What are 5 common differential diagnoses for 'heart' cause of 'collapse'? (add clinical clues/things to check too)
- heart, eg IHD (chest pain etc)
- emboli (pleuritic chest pain, risk factors etc)
- aortic obstruction, eg stenosis, HOCM (syncope on exertion)
- rhythm disorders, eg CHB (complete heart block)
- tachyarrythmias, eg VT, SVT, long QT (hx palpitations, electrolyte disturbances
172
What are 7 common differential diagnoses for 'vessels' cause of 'collapse'? (add clinical clues/things to check too)
- vasovagal (ask re prodrome)
- ENT (eg BPPV, labyrinthitis, meniere's)
- situational (eg micturation syncope, cough syncope)
- sensitive carotid sinus (what doing when happened, neck contact)
- ectopic pregnancy (pregnancy test)
- low vascular tone
- subclavian steal syndrome (atherosclerosis risk factors)
173
What are 4 common types of drugs for 'drugs' cause of 'collapse'?
- antihypertensives
- betablockers
- recreational drugs
- insulin or other hypoglycaemic drugs
174
What exams/tests etc should form part of a full neurological assessment? 11
- cranial neuro exam
- LL and UL neuro exam
- cerebellar exam
- gait
- GCS
- AMTS
- pupils
- fundoscopy
- NIHSS (for severity of stroke)
- lateralising signs
- capillary glucose
175
Causes of hypoglycaemia in known diabetics? 6
- hypoglycaemic agents (insulin, sulphonylureas)
- decreased glucose delivery (missed meals or overnight fasting)
- reduced endogenous glucose production (alcohol ingestion)
- increased glucose utilisation (exercise)
- increased insulin sensitivity (weight loss, increase in exercise)
- reduced insulin clearance (kidney failure)
176
Causes of hypoglycaemia in people with no hx of diabetes? 9
acronym?
ExPPLAINS H
- EXogenous drugs (eg insulin, alcohol intoxication, quinine, beta blocker OD, valproate OD, salicylate OD)
- pituatory insufficiency
- post-prandial (post-meal) hypoglycaemia
- liver disease
- addison's disease
- islet cell tumour (eg insulinoma)
- immune hypoglycaemia (eg in Hodgkins lymphoma)
- infection (severe sepsis, malaria)
- non-pancreatic neoplasms (small cell carcinomas, sarcomas etc)
- non-insulinoma pancreatogenous hypoglycaemia (NIPH) syndrome
- starvation and malnutrition
- hypothyroidism (myxoedema coma)
nb hypos are much more common in diabetics than non-diabetics - these are rare
177
Tongue biting during 'collapse' - what does it mean?
Side of tongue = seizure
tip of tongue could be seizure or syncope
178
What are the 'voyeurs' zones of a CXR? 3
| ie the points which people miss things in
- apices
- behind heart
- bases of lungs
179
Shoulder dislocations: what is by far the most common direction of dislocation?
what innervation should you always check with shoulder dislocation?
anterior dislocation
(need a lot of force for posterior dislocations - normally seizures too)
regimental band anaesthesia
180
What sort of acid-base disorder does hypoxia cause? and why?
metabolic acidosis
as muscles use anaerobic respiration instead of aerobic and so build up lactate -> lactic acidosis
(also some resp acidosis is hypercapnic as well)
181
What are the two things which determine systemic blood pressure?
systemic BP = cardiac output x systemic vascular resistance
182
What are the 6 vital signs measured on a typical news chart?
- RR
- O2 sats (and FiO2)
- systolic BP
- pulse
- temperature
- level of conciousness (ACVPU)
183
What does each total NEWS score trigger?
| in terms of freq of obs needed and who needs to review
0
- min 12 hourly obs
1-4
- min 4-6 hourly obs
- nurse review
5+ (or 3 in one parameter)
- min 1 hourly obs
- FY/SHO review
7+
- continuous obs monitoring
- speciality registrar or above review
- consider referral to HDU/ITU
184
What is the risk stratification score for community-acquired pneumonia?
What are the cut offs for each parameter? (incl a way to remember these)
CURB-65
Confusion
- new confusion (technically AMTS < 8 or 2 below normal)
Urea
- Urea >7
Resp rate
- RR >30
Blood pressure
- systolic BP <90 or diastolic BP <60
65
- if 65 and over
"remember 30,60,90"
185
What level of care and what antiobiotic(s) - incl route -should people be on for which CURB-65 score for CAP?
(also what to change to if someone pen allergic?)
low curb (0-1)
- home, if poss
- ORAL amoxicillin (clarithromycin if pen allergic)
mid curb (2)
- norm inpatient
- ORAL amoxicillin AND clarithromycin
high curb (3)
- inpatient
- IV amoxicillin or co-amoxiclav AND clarithromycin
very high curb (4-5)
- consider HDU/ITU
- IV co-amoxiclav AND clarithromycin (plus test for atypicals)
186
What are the negative side effects / potential complications of giving oxygen? 4
- can reduce resp drive in CO2 retaining pts -> further hypercapnia
- vasoconstriction (the opposite: low O2 -> vasodilation, to get as much blood to areas as possible)
- can worsen affects of MI/strokes (dt vasoconstriction worsening lack of perfusion)
- can get HAP or VAP from use of oxygen devices
187
What are the two types of diagnostic clinical tests? (ie in what you're looking for)
and what does each mean practically
rule in
- a positive test result keeps diagnosis X on the differentials list
- eg a positive d-dimer = PE is a possibility
rule out
- a negative test results removes diagnosis X from the differentials list
- eg two negative troponins = not an NSTEMI
(nb also do clinical tests to also test suitability for treatment - eg clotting bloods before procedure - and tests to monitor progression of disease or treatment etc)
188
How do you calculate the sensitivity and specificity of a test?
sensitivity = TP / (TP + FN)
specificity = TN / (TN + FP)
189
Apart from VTE, what are the other main causes of embolus? 4
and who do they occur in?
air
- eg central venous catheter in ITU
fat
- eg post trauma or long bone fracture
amniotic fluid
- pregnancy, peri-childbirth
talc
- norm IVDUs
190
Pulmonary embolus:
| - risk factors? 8
- recent surgery
- long bone fracture
- poor mobility
- pregnancy
- COCP
- active cancer
- previous DVT or PE
- FHx DVT or PE
191
Pulmonary embolus:
- symptoms? 8
(which are most important of these)
(two only happen if massive)
- SOB (most important)
- cough
- haemoptysis (<5%, rare!)
- chest pain (often pleuritic)
- dizziness
- associated leg swelling
- collapse (if massive)
- cardiac arrest (if massive)
192
Pulmonary embolus:
- most common sign on examination in non-massive PE?
- other main sign in non-massive PE?
- what other signs should you always look for?
- which signs / findings in investigations occur in massive and submassive PEs? (3 for sub-massive, 2 for massive)
(which are most important of these)
tachycardia most common (though often no clinical signs)
- tachypnoea also
always look for calf and thigh swelling - ie signs of a DVT
- also check JVP!
SUBMASSIVE PE
- hypoxia (incl cyanosis)
- Cardiac echo or ECG suggests right heart strain
- positive cardiac biomarker (eg troponin)
MASSIVE PE
- hypotension
- cardiac arrest
nb may also find a pleural rub but this is rare
193
Initial investigations for PE (incl findings):
- bedside? 2
- bloods? 5
- imaging? 2
- WELLS score
- ECG
- d-dimer (if appropriate)
- troponin (to exclude ACS)
- FBC
- U&Es
- clotting (INR if on warfarin)
- CXR (need to do before CTPA or VQ scan)
- CTPA or VQ scan
nb there are different wells scores for DVT and PE (if suspect both, use PE one)
194
Initial treatment / management of:
- non-massive PE? 1
- sub-massive PE? 1
- massive PE? 2
- management of all? 1
NON-MASSIVE
- Compression stockings
- DOAC or LMWH bridge to warfarin for 3 months!
SUB-MASSIVE
- DOAC or LMWH bridge to warfarin for 3 months! (consider ALTEPLASE if worsens)
MASSIVE
- alteplase (ie thrombolysis)
- DOAC or LMWH bridge to warfarin for 3 months!
- (can also have inotropes if need etc)
ALL
- further investigation if unprovoked, no risk factors etc - esp for cancer
nb the actual size of the clot visualised on CTPA is poorly related to mortality, go on the clinical signs, hypotension etc not the size on CTPA
195
Differential diagnosis for PE? 8
- ACS
- pericarditis
- aortic dissection
- pneumonia
- pleurisy
- pneumothorax
- MSK chest pain
- GORD or other upper GI symptoms
196
How should d-dimer be used in diagnosing PE & DVT?
Should do WELLs score:
- if high (4+): do CTPA or VQ scan
- if low (<4): do d-dimer
If d-dimer negative (in low WELLS score):
- find alternative diagnosis
If d-dimer positive (in low WELLS score):
- do CTPA or VQ scan
ie d-dimer is only used for people who are deemed to be at low risk of VTE to rule OUT this as a DDx, people deemed high risk should always have imaging!
197
When do you use a VQ scan instead of CTPA for PEs?
use VQ scan in:
- women under 40 (as scan increases risk of breast cancer) - should do this!
- pregnant women ALWAYS
198
When is d-dimer never useful? 4
- during pregnancy
- after major surgery
- after trauma
- in sepsis
in these situations will almost always get a high d-dimer regardless of whether have PE or not
199
How do you decide where people with PE are managed?
If sub-masssive or massive, manage on HDU/ITU
if non-massive, do PESI score
If high risk pesi, admit to hospital and treat with anticoagulation there
If low risk, give anticoagulation and send home
nb use your clinical judgement as well!!!
200
What is the other score, alongside WELLS, which can be used to assess likelihood of PE? when is it used?
PERC score
(PE rule-out criteria)
It is a very quick and easy tool to use in the emergency department to help you to decide whether you should initiate treatment for a PE. It takes into account the following:
- Age >50
- Heart Rate >100
- SaO2 on RA <95%
- Unilateral leg swelling
- Haemoptysis
- Recent surgery or trauma
- Previous PE or DVT
- Hormone use
DON'T NEED TO KNOW CRITERIA - just need to know about it and that you should use it if you suspect a PE to help decide likelihood (basically like another wells score)
IF THEY SCORE ON ONE OR MORE CRITERIA then do CTPA (I think - check this!*)
201
What is the first indicator of a developing AKI?
reduced urine output
| creatinine takes about 24hrs to have a significant rise
202
What % drop in renal function is normal when starting an ACEi or ARB?
If more than this, what could be wrong?
Get drop of up to 20% in renal function
if >20% then may be renal artery stenosis
203
What is the immediate management of hyperkalaemia? 4 (when do you give each)
nb need to know doses
1) 10mls of 10% calcium gluconate IV
- only give if ECG changes or K >7
- this protects the heart (doesn't actually affect K levels)
2) Give insulin dextrose (10 units of insulin AND 50ml of 50% dextrose)
3) Salbutamol 5mg neb
(haemofiltration or dialysis if not responding to above)
204
as well as tall tented t-waves what other ECG signs of hyperkalaemia are there? 3
- flattened P waves
- broad bizarre QRS
- any arrythmia
205
Questions to ask someone with COPD to ascertain severity? 11
- how many times been into hospital in the last year with it?
- how many exacerbations in last year? courses of steroids +/- Abx?
- ever had any NIV/CPAP/BiPAP or been intubated?
- ever been to HDU/ICU with it?
- how often go to GP with it?
- MRC dyspnoea scale (or ask: what can you do before you get breathless?)
- how many inhalers on? which ones?
- how often do you need to use reliever?
- Any home oxygen?
- any home nebulisers?
- any rescue packs at home?
206
What is an indicator on VBG/ABG of chronic CO2 retention?
high bicarb
207
Three ways to differentiate delerium from chronic confusion?
ACUTE ONSET
- get a collateral hx if possible
FLUCTUATION IN CONSCIOUSNESS
- main sign
REALLY POOR ATTENTION SPAN
- talking about one thing and then going on to something else
208
What are the commonest groups of causes of delerium? 4
- infection
- medications
- electrolyte disturbances
- pain (incl from constipation or urinary retention)
nb the worse you baseline cognitive 'reserve' - the smaller the trigger required to send you into delerium
209
What's a really good test to see if someone has a reduced attention span?
ask them to say the months in reverse
210
When should you do a urine dip and when should you send an MSU?
Urine dip in younger people, useless if over 60 - just send an MSU
urine dip is also good for kidney stones in young people
211
Common differential diagnoses for abdominal pain in the ED:
- GI? 6
- Urology? 2
- genital/gynae? 4
- other? 2
- peptic ulcer disease
- biliary tract infections
- pancreatitis
- appendicitis
- bowel obstruction
- diverticulitis
- Renal colic
- UTIs (incl pyelonephritis)
- Pelvic inflammatory disease
- Ovarian cyst
- ectopic pregnancy
- Miscarriage
- AAA
- DKA
212
Features of Hx for ruptured AAA:
- norm presenting symptoms? 2
- HPC?
- which age and gender most common?
- other common risk factors? 3
- other rare risk factors? 3
intermittent or continuous ABDO PAIN that radiates to the back, illiac fossa or groin
Pts may also COLLAPSE
- men (5x more common)
- old
- high BP
- smoking
- FHx
rare risk factors
- syphillis
- ehlers danlos
- marfan's
213
Features of exam for ruptured AAA:
- general inspection/obs?
- abdo exam?
shock
- pale
- low BP
- high HR
- poor tissue perfusion (incl confusion)
- rigid abdomen
- pulsatile, EXPANSILE mass
214
Investigations for suspected ruptured AAA:
- bedside? 1
- bloods? 2
- imaging? 1
- ECG
- crossmatch lots of units (?10)
- amylase (not sure why)
- ultrasound is diagnostic (but if sure is ruptured then don't waste time) - can also CT if really not sure
215
Who is screened for AAA and at what age?
men
age 65
216
What is the definition of an aneurysm?
How large is an AAA?
At what size are AAAs operated on?
if the artery dilates >50% then it is known as an aneurysm
AAA is aorta diameter of >3cm
Operated on when >5.5cm diameter
217
Initial management of ruptured AAA:
- who should you call?
- what should you do at the bedside?
- what meds should you consider prescribing? 2
- biggest aim?
- inform theatres and experienced anaesthetist immediately
- IV access with two wide-bore cannulas and give pt O- blood (though don't raise BP too much as may rupture a contained leak: aim for systolic <100)
- consider prophylactic Abx: CEFUROXIME and METRONIDAZOLE (as w most abdo surgeries)
GET PT TO THEATRE ASAP!
218
Appendicitis, features of history:
- commonest presenting complaint and description?
- associated symptoms?
- risk
- what should you always ask?
INITIAL GENERALISED abdominal pain usually becoming localised to the RIF just a few hours later
- nausea and vomiting
- anorexia
- acute diarrhoea
- have you had your appendix removed?
219
Appendicitis: common DDx to consider? 4
- gastroenteritis
- diverticulitis
- ectopic pregnancy
- ovarian cyst
220
Appendicitis: findings on exam?
two tests do to check?
tenderness in the right iliac fossa (MCBURNEY['S POINT) with considerable guarding due to localised peritonitis (also rebound tenderness)
PSOAS SIGN:
- extension of right hip (with flexion of the R knee) with the person lying down on their left side is painful
ROVSIG SIGN:
- palpation in LIF induces pain in RIF
be aware of anatomical variation!!! - so can still suspect if not in the typical location
221
Investigations:
- bloods? 4
- imaging? 2
- FBC (look at WCC)
- ESR
- CRP
- UandEs (dehydration)
- USS
- CT (highly specific and sensitive, but rarely done)
nb imaging is often not done if story is classical
222
Initial management of appendicitis:
- bedside? 2
- definitive? 1
- IV fluids
- antibiotics (refer to guidelines)
- laparoscopic appendectomy (refer to gen surg)
223
How do you differentiate biliary colic from cholecystitis and from cholangitis?
all have epigastric/RUQ pain +/- vomiting
cholecystitis also has fever
cholangitis has fever and jaundice (or deranged LFTs)
nb also vomiting makes the pain better in colic as it dislodged the stone from the gall bladder neck, but doesn't make better in cholecystitis
224
Cholecystitis:
- history of pain?
- associated symptoms? 2
Continuous epigastric or RUQ pain which might also include the R shoulder - this pain might have come on and been made a lot worse after the patient has just eaten - or has eaten a particularly fatty food
- vomiting
- fever
225
Cholecystitis:
- physical exam findings?
- special test to do?
- what complication should you look for?
Tender in epigastrium/RUQ with possible gall bladder mass with guarding and some rigidity
- also fever
MURPHY'S SIGN
- 2 fingers over RUQ and ask pt to breath in as you push down gently, if this causes increased pain/arrest of respiration, then is positive
- nb only positive, if the same test in the LUQ does not cause pain
look out for signs of sepsis indicative of biliary sepsis or empyema of the gall bladder
226
What investigations do you need to get for cholecystitis, what would you see on these?
- bloods? 2
- imaging? 1
- FBC (high WCC)
- LFTs (marginal elevation of ALP, bilirubin and ALT possible)
- USS (may see: thick walls, shrunken GB, stones, dilated CBD)
Nb highly elevated LFTs may be more suggestive of bile duct obstruction
227
Initial management of cholecystitis:
- bedside? 2
- pharmacological? 2
- definitive management? 1
- NBM
- IV fluids
- opioid analgesics
- IV abs (trust guidelines)
- surgical management (but not an emergency, usually wait for symptoms to settle before operating)
Nb also correct any other things - e.g. low potassium from vomiting
228
What are the symptoms of Charcot’s Triad? 3
And what are these for?
Symptoms of cholangitis:
- RUQ pain
- jaundice
- fever and riggers
