Emergency & acute medicine 2 Flashcards
(214 cards)
1
Q
Bowel obstruction:
- findings on history / symptoms? 6
7
- What to always ask about?
A
- nausea
- anorexia
- vomiting (faecal vomiting if obstruction is long-term)
- constipation
- no passing of stools OR wind!
- colic
- abdominal distension
Always ask about recent bowel surgery as this can cause functional ileus and also produce adhesions that -> structural obstructions
2
Q
Bowel obstruction:
- how to differentiate between small and large bowel obstruction? 2
A
Small bowel: vomiting will be more key symptoms, less pain and less distension
Large bowel: pain is more constant and there will be distension
3
Q
Bowel obstruction:
- common causes? 10
- which tend to cause small bowel obstruction and which large bowel?
- rarer causes? 3
A
Either
- functional ileus (norm post abdo surgery - lasts 2-4 days norm)
Norm small bowel
- adhesions (norm post surgery) (by far the most common cause)
- hernias
- crohn’s
- appendicitis
- volvulus (esp in kids)
Norm large bowel
- cancer (by far the most common cause)
- colonic volvulus
- benign stricture (diverticulitis, IBD, radiation-induced etc)
- faecal impaction
Rarer causes
- malignancy (for small bowel obstruction)
- TB
- foreign body
4
Q
Which types of cancer cause large bowel obstruction? 2
A
- colorectal cancer
- ovarian (or other gynae) cancer
Almost always colorectal though!
5
Q
What are the 5 groups of things that cause abdominal distension?
A
5 Fs
- fluid
- faeces
- flatus
- fat
- foetus
6
Q
Bowel obstruction:
- findings on exam? 3
- what two parts of the abode exam must you always do? 2
A
- distension
- rigidity
- absent or tinkling bowel sounds
PR!!! - can feel rectal tumours and impacted faeces
- also look for hernias in relevant areas!
Nb make sure to differentiate between ascites and obstruction by doing shifting dullness
7
Q
Bowel obstruction: investigations to consider:
- bloods? 3
- imaging? 2
A
As mentioned before: don’t forget to do PR (this should be done during exam)
- FBC
- U&E
- Amylase
- Abdo x-ray (know how to differentiate between large and small bowel obstruction on this)
- Consider CT (if don’t know cause)
8
Q
Bowel obstruction: initial management to consider:
- bedside? 3
- pharmaceutical? 1
- what does management depend on?
A
‘Drip and suck’
- NG tube
- IV fluids
- potentially catheterise
- analgesics (beware of opioids though!)
Management depends on cause!
- but is mainly conservative
- but e.g. if have strangulated hernia then go to surgery, new presentation of cancer then endoscopy and surgery etc
9
Q
Diverticulitis
- features of history? 3
- where is pain?
- what should always ask?
A
- severe pain in LEFT iliac fossa (norm)
- fever
- constipation
Have you ever had this before? (Often recurs)
Nb presents very similar to appendicitis but, normally, on other side!
- but be aware that both could be either side
10
Q
Diverticulitis: features of exam:
- systemic? 2
- local? 2
A
- febrile
- tachycardia
LIF
- tenderness
- guarding
11
Q
Diverticulitis: investigations:
- bloods? 4
- imaging? 1
A
- ESR
- CRP
- FBC
- UandE
- USS (thickened bowel walls and pericolic collections)
(Nb can do CT colonography too)
12
Q
Management for diverticulitis?
- if mild? 2
- if severe? 3
(Incl abx names)
A
Mild - outpatient treatment
- oral cefuroxime and metronidazole (‘cef and met’)
- oral analgesics
Severe - inpatient treatment
- IV abs
- analgesia
- IV fluids
13
Q
Ectopic pregnancy:
- features of history? 3
- who should you suspect in?
A
- collapse
- recurrent lower abdomen pain (may also extend to the shoulder if there’s been bleeding into the abdomen)
- vaginal bleeding
Consider in any women of child-bearing age with acute abdo pain - always do a pregnancy test!
14
Q
Ectopic pregnancy, investigations:
- bedside? 1
- bloods? 4
- imaging? 1
A
- pregnancy test
- CROSS MATCH (loose a lot of blood)
- FBC
- UandE
- CRP
- trans-vaginal USS
15
Q
Ectopic pregnancy management options:
- pharmaceutical? 2
- surgical? 1
A
- analgesia
- methotrexate (to terminate pregnancy - see guidelines)
- salpingectomy (as norm in Fallopian tube)
Nb may need to give blood products and/or fluids as may loose a lot of blood
16
Q
Miscarriage:
- features of history? 3
- what should you always ask about in PMHx?
- who to consider in?
A
- ACUTE VAGINAL BLEEDING
- abdo pain / cramping (not always present)
- faintness or collapse (dt blood loss)
Ask about previous pregnancies and miscarriages etc
Consider in all women of childbearing age who present with vaginal bleeding - a lot of people don’t know that they’re pregnant!
17
Q
Miscarriage: management
- pharmaceutical? 1
- other? 1
A
- analgesia
- offer support and counselling
Also fluids if dizzy etc from blood loss
18
Q
Ovarian cysts: features of history:
- type and location of pain?
- urinary and GI symptoms? 4
- gynae symptoms? 2
- what should you always ask about in post-menopausal women?
A
- lower abdomen pain, can be dull ache or sharp pain
- frequent need to urinate
- difficulty going to the toilet (constipation)
- bloating or swelling in abdomen
- feeling very full after eating very little
- difficulty getting pregnant
- very heavy or irregular periods
- any weight loss? (Could be ovarian ca)
Nb lots of women have ovarian cysts and they cause no problem at all, only really give symptoms if very large or rupture
19
Q
What other medical conditions should you always ask about if suspected ovarian cysts? 2
A
- PCOS
- endometriosis
20
Q
Two types of ovarian cysts?
A
FUNCTIONAL
- very common, form as part of menstrual cycle
- usually harmless, short-lived and asymptomatic
PATHOLOGICAL
- mech less common
- abnormal growth, majority are benign but some can be cancerous
21
Q
Investigations to consider for ovarian cysts:
- bloods? 1
- imaging? 1
A
- cancer markers (nb could be high dt other things)
- USS
22
Q
Initial management of ovarian cysts:
- bedside? 1
- pharmacological? 1
- for the majority of women?
- for post-menopausal women?
- to consider referral to?
A
- IV fluids (consider bloods if you suspect blood loss
- analgesia
Most cases will go away by themselves
- consider referring to surgeons if massive or ruptured
Higher risk of cancer if woman is post-menopausal
- maybe suggest monitoring over a year
23
Q
Pancreatitis: findings on history:
- type and location of pain?
- associated symptoms? 2
A
severe epigastric pain, may radiate through to the back (irritation of retroperitoneum)
- nausea
- vomiting
24
Q
Pancreatitis: findings on exam:
- in all? 1
- if severe? 4
A
Epigastric tenderness
- tachycardia
- hypotension
- oliguria
(Nb these mainly due to dehydration) - grey turners (flank) or cullen’s (umbilical) bruising
25
Causes of pancreatitis? 11
(Acronym)
Which are the two commonest causes?
I GET SMASHED
- idiopathic
- gall stones (38%)
- ethanol (35%)
- trauma
- steroids
- mumps
- autoimmune
- scorpion venom
- hyperlipidaemia, hypercalcaemia, hypothermia
- ERCP and emboli
- drugs (some diuretics, oestrogen, some abs)
26
Pancreatitis: investigations to consider:
- bloods? 7
- imaging? 4
- FBC
- UandE
- LFTs
- amylase
- lipase (more specific and sensitive)
- ABG / VBG
- CRP
- AXR (lack of psoas shadow - dt high retroperitoneal fluid)
- upright CXR (to exclude bowel perforation)
- USS
- CT
What investigations you get will depend on if this a first presentation or cause is unknown etc
27
Initial management of pancreatitis:
- bedside to consider? 3
- medications to consider? 2
- possible surgery? 1
definitely admit these patients
- NBM, likely need an ng tube
- IV fluids (often dehydrated from vomiting)
- keep an eye on obs
- IV analgesia (strong - morphine!) - definitely this!!
- IV antiemetics (e.g. cyclizine)
Can do ERCP and gall stones removal
28
Peptic ulcer disease: findings on history:
- hx of pain?
- associated symptoms? 2
Sharp epigastric pain
- Might be associated with oesophagitis like pain - sharp central chest pain that is worse with lying and might be accompanies by heart burn, metallic taste in mouth
- Pts often point with a single finger to the point where the pain is (helps differentiate from cardiac pain)
- can have relationship with food
- Anorexia and weight loss (if it's been going on a while)
- Some nausea and vomiting (though not a lot - vomiting might relieve the pain)
29
Of duodenal ulcers and gastric ulcers:
- which is made worse by eating and which is made better?
- which is more common?
```
duodenal ulcers (commonest)
- made worse by food
```
gastric ulcers
- eased by food)
30
Causes of peptic ulcer disease:
- drug classes? 3
- bacteria? 1
- lifestyle? 2
- things that aggravate symptoms? 2
- NSAIDs
- steroids
- SSRIs
- h. pylori
- alcohol
- smoking
aggravate symptoms
- food (large meals, spicey, caffeine)
- stress
nb also more common in people with O blood group
31
Investigations for peptic ulcer disease:
- bedside? 1
- bloods? 2
- imaging? 1
- other? 1
ECG (rule out cardiac cause)
- FBC (anaemia)
- UandE
- Endoscopy
- can test for h. pylori using fancy tests (think the carbon dioxide or something one is gold standard?)
32
Who gets an endoscopy for peptic ulcer disease? 2
- over 55
| - red flags (weight loss, anaemia etc)
33
Management of peptic ulcer disease:
- if caused by drugs? 2
- if caused by h. pylori? 3
- if caused by lifestyle? 2
(incl abx names)
drugs cause
- stop offending drugs
- PPI
h. pylori cause ('triple therapy')
- PPI
- amoxicillin
- clarithromycin
lifestyle causes
- reduce / stop alcohol
- stop smoking
nb monitor with endoscopy if concerned that could be malignant
34
Pelvic inflammatory disease:
- what is it?
- risk factors? 5
- symptoms? 4
This is an inflammation of the upper part of the female reproductive tract (ovaries, fallopian tubes, uterus and surrounding pelvis) - MEN CAN'T GET IT!
risk factors:
- previous STI (biggest!)
- unprotected sex
- young age of onset of sexual activity
- multiple partners
- use of IUD
symptoms
- lower abdominal pain (typically bilateral)
- deep dyspareunia (pain during sex)
- new or different vaginal discharge
- abnormal vaginal bleeding (post-coital, inter-menstrual, menorrhagia)
(can also have nausea and vomiting)
35
pelvic inflammatory disease: features of exam:
- what four exams should be perfomed?
- areas pain elicited? 3
- other findings? 2
- abdominal
- external genetalia
- bimanual
- speculum
- cervical motion tenderness
- uterine tenderness
- adnexal tenderness
- abnormal, purulent vaginal discharge
- erosions or erythema in cervix or vagina
nb can also get temperature
36
Commonest causes of pelvic inflammatory disease?
- gonorrhoea
- chlamydia
- bacterial vaginosis
37
possible investigations for pelvic inflammatory disease (excluding speculum and bimanual exams)
- during speculum exam? 2
- imaging? 1
- culture of discharge (also can do urethral and anal swabs)
- tissue biopsy
- USS
38
Initial management of pelvic inflammatory disease:
- medication? 2
- who to refer to? 1
- analgesia
- antibiotics
- gynae review
39
renal colic:
- description of the pain?
- other symptoms? 4
intermittent pain
- anywhere from the flank / loins / hypochondrium TO the groin
- may be severe and coming and going in waves (dt ureteric peristalsis)
- anuria or dysuria
- increased frequency, urgency, suprapubic tenderness
- sweating
- nausea and vomiting
40
investigations for renal colic (and what find):
- bedside? 3
- blood tests? 2
- imaging? 2
- dipstick (+ve for leukocytes, nitrates, blood)
- MSU (+ve for WBCs, RBCs or bacteria)
- pregnancy test (must do to rule out pregnancy before use ionising radiation)
- FBC (high WCC may indicate pyelonephritis or UTI)
- UandEs (high calcium or urate may indicate cause of stones)
- CT (rule out pregnancy first)
- USS (norm just in pregnancy)
nb composition of stone determines whether it is radio-opaque or not
41
Initial management of renal colic:
- bedside?
- medications?
- when to do more active treatments?
- fluids (IV or norm, more dehydrated, worse the symptoms)
- analgesia (NSAIDs are best - if not CI)
if evidence of stone plus infection then urgent treatment needed as high risk of septic shock
if conservative management not managing pain sufficiently then can ablate etc
42
Urinary tract infections:
- lower urinary tract symptoms? 7
- symptoms suggestive of upper UTI / pyelo? 3
- what signs to look out for?
- what's often the only symptom in the elderly?
LUTS
- urgency
- frequency
- feeling of incomplete emptying
- dysuria
- suprapubic pain
- haematuria
- smelly (purulent) urine
Upper UTI symptoms (in addition to LUTS)
- fever
- rigors
- loin or flank pain
LOOK FOR SIGNS OF SEPSIS!
confusion (often only symptom in the elderly!)
43
Who's UTIs most common in? 2
| - most common causative organism?
- women (esp sexually active ones)
- elderly
- e. coli (and other gram -ves)
44
Investigations for UTI:
- bedside lower? 2
- additional bloods for upper? 3
- other to consider? 1
- urine dip (not in over 65s!)
- MSU
- FBC
- UandE
- blood cultures
- consider pregnancy test (nb asymptomatic bacteraemia in pregnancy should be treated but not in anyone else, especially if have catheter in situ)
45
Management for UTI:
- abx if lower?
- abx if upper?
- other management?
lower:
- follow guidelines (trimethoprim, nitrofurantoin etc)
upper
- follow guidelines (norm cefuroxime)
lots of oral fluids (IV fluids if this not possible)
46
What are the things that you should always ask someone presenting with acute abdo pain about:
- local associated symptoms? 7
- systemic associated symptoms? 7
- PMHx? 3
also, if pain, always SOCRATES
- nausea
- vomiting (what? blood?)
- bloating
- bowel habits (incl when last BO and pass wind, blood?)
- difficulty or pain swallowing
- heart burn
- urination (incl colour changes)
AW FS FIN
- appetite
- weight loss
- fatigue
- sleep
- fever
- itch
- night sweats
- Have you ever had this before?
- Any chance you could be pregnant?
- any PMHx of (list GI probs) - also FHx of IBD
47
Symptoms of an acute ischaemic limb? 6
6Ps (regardless of the cause)
- pale
- perishingly cold
- painful
- pulseless
- parasthesia
- paralysis
nb If the ischaemia has developed in someone who has had a previously normal limb then all of these symptoms will be more pronounced because in those with more chronic arterial disease there will be some development of collateral circulations.
nb leg much more commonly affected due to better supportive collateral circulations in the arms
48
What are the two main mechanisms of acute ischaemic limb? 2
| list causes of each
TRAUMA
- compartment syndrome
- crush injuries
EMBOLI / THROMBI
- post MI
- AF
- prosthetic valves
- atrial myxoma
- vegetations
49
What risk factors and PMHx to ask about in acute ischaemic limb?
- diabetes
- hypercholesteraemia
- hypertension
- smoking
- AF
- Previous MI, stroke, TIA
50
Examination of acutely ischaemic limb:
- what look / test for in examination of leg? 5
- where else do you need to examine? what looking for?
"think about it that you are looking for the 6Ps"
ALWAYS COMPARE TO OTHER LEG!
- colour (pale)
- feel temperature (perishingly cold)
test pulses - using doppler if need to (pulseless)
- test nervous sensation (parasthesia)
- test motor function (paralysis)
CARDIAC EXAM (looking for possible sources of emboli)
- irregular pulse
- abnormal heart sounds / murmurs / valve clicks etc
51
investigations for acute ischaemic limb:
- bedside? 2
- bloods? 5
- imaging? 2
- ECG
- urineanalysis (check for mypoglobin = muscle damage)
- FBC
- UandE
- Creatinine kinase
- coag screen
- ABG
- CXR
- Cardiac / abdo USS (if thrombus suspected to still be in situ)
52
Initial management of acute ischaemic limb:
- immediate medication? 1
- definitive treatment? (incl timescale)
analgesia (norm IV opioid as v painful)
revascularisation within 6 hours - embelectomy or angiography
(to avoid permanent muscle damage and other stuff like rhabdo and renal failure)
(also correct the hypovolaemia if that's the cause)
53
What is the acronym for sepsis? what is the timescale?
BUFALO
- blood cultures (ideally before abx)
- urine output monitoring
- fluids
- antibiotics (broad spectrum)
- lactate (do ABG/VBG)
- oxygen (if unwell, 15L non-rebreath)
1 hour to get all this started
54
Cellulitis: features of history:
- what normally precedes the infection?
- features in history? 4 (which norm noticed first?)
wound or other injury to leg, so ALWAYS ASK (incl insect bites etc)
- though nb often won't have this
- pain (often first symptom)
- red
- swollen
- hot
55
What increases the risk of cellulitis following a wound / skin break? 6
- retention of foreign body in the wound
- haematoma
- devitalised tissue
- poor nutrition
- DIABETES
- decreased immubnity
56
What is the most common causative organism in cellulitis?
What should you always ask pts about when they get cellulitis
staph aureus (group A strep also common)
ask about previous MRSA infection (as this can cause cellulitis)
57
What should you look for when examining a patient with suspected cellulitis? 6
- examine extent of erythema, pain, swelling etc (will give an idea how far infection has spread)
- take swabs from any wound there is
- feel for pulses
- check neuro AND vasc supply is intact
- check temperature (and other obs)
- check regional lymph nodes
58
If see cellulitis in primary care, how should you treat?
- take obs
- give abx
- get them to go home and draw a line around area and say that you'd expect the area to start shrinking after 48 hours but to seek help if it grows
59
cellulitis:
- treatment normally?
- treatment if on face?
- treatment if pen allergic?
- who should you consider admitting? 4
- what should you always look for?
norm = flucloxacillin
face = co-amoxiclav
pen allergic = clarithromycin
- temp >38
- systemically unwell
- regional lymphadenopathy
- cellulitis is very widespread
look for signs of sepsis
- quite a high risk from cellulitis
60
What are the differential diagnoses for acute atraumatic leg pain?
- acutely ischaemic leg
- DVT
- cellulitis
- septic artritis
- gout
nb all of these are almost always unilateral!! - if bilateral pain, think more heart failure, venous eczema, chronic venous insufficiency, or peripheral vacular disease etc
61
DVT: presenting complaints / findings on exam? 5
- swelling in calf
- erythema
- pain
- warmth
- dilated superficial vessels
ALWAYS COMPARE TO OTHER LEG
62
DVT: risk factors to ask about in history? 8
what else should you ALWAYS ask about if suspect DVT?
- recent surgery
- immobility (recent injury or illness, long haul flight)
- COCP
- pregnancy
- dehydration
- IVDU
- previous DVT or PE
- active cancer (ask about if being treated for any med conditions first before asking about cancer specifically)
ALWAYS ask about any resp symptoms (for PE)
63
Investigations:
- 1st line?
- what to do following first line? 2
- routine bloods? 3
WELLS SCORE
- if low risk, do d-dimer
- --- if d-dimer high, do USS
- if high risk, do USS
- FBC
- UandE
- CRP
- potentially INR / clotting?
64
Management for DVT?
at least 3 months of treatment dose anticoagulation (norm DOACs - but can do warfarin w bridging LMWH)
if unprovoked, investigate for cancer
65
Gout:
- two most common sites?
- classical history?
- main presenting symptom?
- appearance of joint? 3
- what should you always ask?
- 1st MTPJ (base of big toe)
- knee
pain which is in ONE joint and there is no history of trauma
PAIN!!
- erythema
- swelling
- heat
have they had this before or is it first time? (could be either)
Ask about systemic symptoms, if they have them, unlikely to be gout
66
Risk factors for gout? 6
| ask about these in hx
- diet high in purines
- alcohol excess
- renal failure
- diuretics
- trauma
- leukaemia
67
investigations for gout:
- imaging?
- other?
and what they show
x-ray
- may show punched out lesions in the articular surfaces
aspiration of the joint
- tophi and negative bifringent crystals
68
initial management for gout:
- medications for acute flare? 2
- who to refer to?
- strong NSAIDs
- short course of steroids
get patient to go to GP
nb in hospital, if someone is already on gout meds, do not alter these!
69
septic arthritis:
- features of history? 3
- biggest risk factors? 3
- most common causative organism?
- VERY painful joint (often no palpation or movement of joint is tolerated)
- recent trauma to joint
- recent surgery to joint
- IVDU
staph aureus (though can be loads of others)
70
Investigations:
- bloods? 3
- imaging? 1
- others? 1
- FBC
- CRP
- blood cultures
- xray of joint (good for baseline)
- joint aspiration
71
Initial management of septic arthritis:
- two antibiotics to start? 2
- other medication? 1
- who to refer to? 1
IV flucloxacillin and benzylpenicillin
analgesia
refer urgently to orthopaedic team for joint irrigation / drainage
72
What are the possible clinical findings in MSK chest pain? 3
what should you always ask in chest pain histories to try and exclude MSK pain? 3
- tender to palpation of chest wall (esp tender to sternum)
- ask pt to put arms across chest and rotate thorax - if this elicits pain then more likely to be MSK in origin
- tell them to cough - does it hurt? (if so MSK or pleuritic pain)
- Have you ever had any joint problems? (rheum hx)
- have you had any trauma to the chest wall?
- Have you been coughing a lot or straining? - ask about occupation too
73
What should you always do when working up someone who you think might have MSK chest pain?
How do you manage MSK chest pain?
exclude other more sinister causes of chest pain
NSAIDs and paracetamol (just paracetamol if NSAIDs CI)
74
What is the definition of hypoglycaemia?
technically BM <3 (but treat if <4 and symptomatic)
in children it is below 2.5
75
Risk factors for hypoglycaemia (esp in diabetics)? 7
- tight glycaemic control
- insulin prescription error
- malabsorption
- injection into lipohypertrophy sites
- alcohol
- drug interactions between hypoglycaemic agents
- long duration of diabetes
nb hypos can also commonly happen at night
76
Initial signs/ features of hypoglycaemia? 7
- sweating
- pallor
- palpitations
- irritability
- hunger
- lack of coordination / awareness
- reduced conciousness
77
Who should you test for hypoglycaemia in?
everyone with reduced conciousness!!! (regardless if have diabetes or not!)
78
What are the three ways in which you can obtain a blood glucose in hospital? which is the most accurate?
- BM
- glucose on ABG
- blood glucose taken from venepuncture (most accurate, but also longest to get back, so do all 3!)
79
What is the management for hypoglycaemia in adults? 4
essentially a quick - acting carb, followed by a long acting carb
1) (10-20g glucose given PO or IV if unconscious, or IM/SC glucagon)
2) repeat BM after 10-15 mins, if still hypoglycaemic then repeat above
3) once BM in normal range, encourage toast or meal consumption to prevent going back into hypo
4) find out cause of hypo and refer back to GP / diabetes team to change meds if needed
80
common causes of delirium:
- systemic infection? 5
- intracranial infection? 2
- drugs? 6
- withdrawal? 1
- metabolic? 5
- hypoxia? 2
- vascular? 2
- head injury? 2
- epilepsy? 2
- nutritional? 3
Systemic infection
- Pneumonia
- UTI
- Malaria
- Wounds
- IV lines
Intracranial Infection
- Encephalitis
- Meningitis
Drugs
- Opiates
- Anticonvulsants
- Levodopa
- Sedatives
- Recreational
- Post-GA
Alcohol withdrawal (delirium tremens)
Metabolic
- Uraemia
- Liver failure
- Sodium or glucose
- Hb
- Malnutrition
Hypoxia
- Respiratory failure
- Cardiac failure
Vascular
- Stroke
- MI
Head injury
- Raised ICP
- Space occupying lesion
Epilepsy
- Non-convulsive status epilepticus
- Post-ictal states
Nutritional
- Thiamine
- Nicotinic acid
- B12 deficiency
81
What should you always try and ascertain when you think someone has delirium?
what their baseline cognitive function is
82
What should you do if you think someone has delirium:
- initial assessment? 1
- possible blood tests? 6
- possible other tests? 3
A-E assessment, including obs, to try and find out cause, especially looking for any signs of infection
- also review medications and notes
- FBC
- UandE
- LFT
- blood glucose
- ABG
- blood cultures / septic screen
- ECG
- LP
- Head CT
83
Management of delirium:
- most important thing? 1
- adaptions to reduce confusion? 5
- medication management? 2
identify and treat underlying cause
- nb may persist in the elderly (if >2 months, assess for dementia)
- ideally put in a side room or somewhere quiet with few disruptions
- ideally have same staff
- have family / friends with if possible
- have a large clock with time and date
- ensure have all aids (hearing, walking aids, glasses etc)
- minimise medication
- if disruptive, some sedation may be used (low dose haloperidol)
84
What type of hypersensitivity reaction is anaphylaxis?
type 1 hypersensitivity reaction
Previous exposure to allergen
- Leads to generation of IgE antibodies
- Which bind to Fc receptors on mast cells
Subsequent exposure to allergen
- Binds to IgE antibodies on mast cells
Triggers release of histamine and other inflammatory mediators resulting in:
- Massive vasodilation
- Hypotension
- Bronchoconstriction
85
Common allergies that cause anahylaxis:
- food? 2
- medication? 8
- other? 2
- nuts
- shellfish
- penicillin
- cephalosporins
- ciprofloxacin
- streptokinase (a thrombolytic)
- suxmethonium (and other muscle relaxants)
- aspirin
- nsaids
- IV contrast agents
- latex
- bee / wasp stings
86
When should people having a COPD exacerbation be considered for NIV?
decompensated type 2 respiratory failure i.e. pH <7.35 (H+ >45nmol/L) and pCO2 >6kPa.
On maximum medical therapy (and has been for 1 hour), nebulised salbutamol when required, corticosteroids, antibiotics if appropriate, controlled FiO2 (usually 28% venturi mask - aim for O2 saturation 86-90%),
and reversal of respiratory depressants.
Moderate to severe dyspnoea, RR >25bpm
87
absolute contraindications to NIV? 7
- respiratory arrest / need for immediate intubation
- facial trauma, burns, surgery, abnormalities
- fixed upper airway obstruction
- severe vomiting
- acute severe asthma
- pneumothorax (unless chest drain inserted)
- confirmed wish by the patient not to receive NIV in the event of a deterioration
88
hyponatraemia:
- normal blood sodium levels?
- medication causes? 3
- causes of fluid loss (replaced by hypotonic fluids)? 3
- other causes? 7
135-145 mmol/L
- diuretics
- LMWH
- ACEi
excessive fluid loss replaced by hypotonic fluids
- diarrhoea
- burns
- prolonged exercise
- polydipsia
- ecstacy ingestion
- SIADH (often caused by an underlying cancer!)
- addison's disease
- renal impairment
- hepatic cirrhosis
- HF
89
Presentation of majority of people with hyponatraemia? 1
other symptoms if develop slowly? 3
other symptoms if rapid changes in Na levels or severe hyponatraemia? 6
majority are asymptomatic and picked up on routine blood tests
- especially if it's mild and has developed slowly
chronic, mild hyponatraemia
- gait instability
- falls
- concentration and cognitive deficits
```
rapid changes in Na levels or severe hyponatraemia
- vomiting
- drowsiness
- headache
- seizures
- coma
- cardio-respiratory arrest
(all dt cerebral oedema and raised ICP)
```
90
Management of hyponatraemia:
- if mild? 2
- if severe? 2
- when to admit (if see in primary care)? 3
mild
- restrict fluids and encourage increased salt intake
- find underlying cause if not clear (stop med, if think SIADH then consider 2WW for cancer, liver, heart, kidney failure etc)
severe
- give small amounts of IV 2.7% saline and keep rechecking
- find and treat underlying cause
nb Na <120mmol is associated with increased risk of brain herniation
admit if:
- acute onset or severe hyponatraemia (Na <125mmol)
- are symptomatic
- have signs of hypovolaemia
91
definition of hyperkalaemia?
serum potassium > 5.5mmol/L
| though norm don't do much until above 6mmol
92
ECG changes with hyperkalaemia? 5
Tall tented T waves
Small P waves
Wide QRS
Becoming sinusoidal
VF
93
Causes of hyperkalaemia:
- medication? 2
- iatrogenic? 2
- metabolic? 4
- artefact? 1
- ACEi / ARBs
- potassium-sparing diuretics
- excess K+ infusion
- massive blood transfusion
- oliguric AKI
- rhabdomyolysis
- metabolic acidosis
- addison's disease
- poor blood collection or processing (eg too long to get to lab -> haemolysis in tube -> high k)
94
management of hyperkalaemia:
- first thing? 1
- bedside test / monitoring? 2
- bloods? 4
- when is immediate treatment required? 2
- what should you always do immediately, regardless of how high? 2
A - E approach
- attach to a cardiac monitoring
- frequent obs
- FBC
- UandE
- LFTs
- glucose
treat if:
- >6mmol with ECG changes
- >6.5 mmol
- stop K raising meds (ACEi and K-sparing diuretics)
- treat underlying cause
95
What is the immediate management of hyperkalaemia? 4
incl doses!!!
what to do if this all fails?
1) calcium (to protect heart), either:
- calcium gluconate 30mls 10% IV over 2 mins
- calcium chloride 10mls 10% IV over 10 mins
2) insulin - 10 units IV over 10 mins
3) glucose, either:
- 50mls 50% IV over 10 mins
- 125mls 20% over 10 mins (less irritant - ideally do this)
in reality - give insulin and glucose together after the calcium
4) salbutamol nebulisers (5mg back to back)
then review!!
if not working = dialysis / kidney filtering
96
When should you start immediate treatment for hyperkalaemia? 2
treat if:
- >6mmol with ECG changes
- >6.5 mmol
97
pericarditis:
- history of the pain?
- other symptoms? 3
Sharp, central chest pain exacerbated by respiration (pleuritic) and lying down and made better by leaning forward
- can radiate to shoulders, jaw etc and back
- Fever
- nausea
- Dyspnoea (if big)
98
Pericarditis:
- main local finding on exam?
- other systemic signs? 4
pericardial rub on auscultation
- fever
- pale
- clammy
- SOB
99
Pericarditis:
- most common cause?
- other groups of cuases and most common example of each? 5
- what should you always ask about?
idiopathic
VIRAL (most common after idiopathic)
- cocksackie B
- echovirus
URAEMIC
- dt accumulation of toxins in advanced kidney disease
BACTERIAL
- staph aureus
FUNGAL
- candida albicans
IMMUNOCOMPROMISED
- HIV
Always ask about recent sore throat or cold as this often preceedes
100
Investigations if suspect pericarditis:
- bedside? 1
- bloods? 5
- imaging? 1
AND FINDINGS!
ECG
- ST elevation in all (or most) leads
- 'saddle sign'
- ABG/VBG
- blood cultures
- FBC
- UandE
- troponin
echo!!
101
Immediate management of pericarditis? 1
oral NSAIDs - aspirin or ibuprofen
102
What are the 4 reasons why you give fluids? and what are the indications for each?
What should you do before you prescribe any fluids?
RESUSCITATION
- if haemodynamically unstable (systolic BP <100, HR >90, cap refill >2s, cold peripheries, RR >20, NEWS >5, passive leg raising test positive)
- if known significant fluid losses occur (even if signs haven't become apparent yet) - eg major trauma
REPLACEMENT
- if deficit of specific electrolytes etc (eg sodium, potassium, glucose etc)
REDISTRIBUTION
- when fluid is in the wrong place, eg ascites
ROUTINE MAINTENANCE
- if patient is unable to swallow or consume fluids orally (eg vomiting, NBM dt surgery, unsafe swallow)
ALWAYS assess the patient YOURSELF before prescribing any fluids!
103
What should you look at when assessing someone's fluid status:
- history? 5
- clinical monitoring? 3
- examination? 9
- blood results? 2
what should you always do after giving fluids?
- ask about intake? any barriers to this?
- do you feel thirsty?
- ask about losses? vomiting? diarrhoea? urine colour? sweating?
- ask about PMHx?
- ask about what IV fluids have already had?
- NEWS obs
- fluid balance charts
- weight
- cap refill
- peripheries, cold?
- skin turgor
- pulse (thready?)
- JVP
- mucous membranes?
- central and peripheral oedema
- postural hypotension
- 45deg passive leg raise (if positive, are fluid responsive, is equivalent of a fluid challenge)
- FBC
- UandEs
ALWAYS REASSES to see the effects of the fluids
104
Where are the four places you should look for oedema?
- pulmonary
peripheral
- sacral
- legs
- abdomen
105
In resuscitation fluids:
- What sould you always do?
- what fluid used?
- what volume used? over how many minutes?
- what is the exception to this volume?
- when should you call for help?
A-E approach
crystalloid (saline or haartmans)
- 500mls over LESS THAN 15mins (squeeze bag!)
exception is severe heart failure, give 250mls instead
REASSESS, if still need resus fluids then give more in 250-500ml boluses - UP TO 2000ml - then call for help (in reality, norm ask for help before this!)
106
What is an example of redistribution fluids?
HAS (human albumin solution) for severe liver failure / ascites
- redistributes fluid from abdomen into blood
107
What are the three main types of fluids?
When each used?
CRYSTALLOID
- saline, haartmans
- loads of uses, resus and maintenance
COLLOID
- very few uses
- supposedly redistributes fluids into vascular space but doesn't work in distributive shock as large molecules seep out of leaky capillaries
- HAS is only one commonly used
- though technically blood products are all colloid too
BLOOD PRODUCTS
- if significant blood loss
- if significant anaemia
108
What are the NORMAL maintenance requirements for a person in 24hrs:
- fluid?
- sodium?
- potassium?
- glucose?
(nb these are all per kg, convert to what is for 70kg person too)
What are the two main ways of achieving this (for a 70kg person)? and what time periods over?
fluid = 1ml/kg/HOUR
- for 70kg = 1680ml/DAY
(in reality need about 2-3L a day when in hosp, as more ill than normal person)
potassium = 1mmol/kg/DAY
- for 70kg = 70mmol/DAY
(nb neat potassium only comes in 20mmol or 40mmol)
sodium = 1mmol/kg/DAY
- for 70kg = 70mmol/DAY
glucose = 50-100g/DAY
- for 70kg = same!
(5% glucose contains 5g/100ml - so a 500ml bag would be 25g)
"two sweet, one salt"
- beware of using this without reassessing and individualising management though!!!
method one
- 5% glucose 1L over 8 hours
- 5% glucose 500ml-1L over 8 hours
- haartmans 1L over 8 hours
method two
- 5% glucose 1L PLUS 40mmol potassium over 8 hours
- 5% glucose 500ml-1L PLUS 20mmol potassium over 8 hours
- 0.9% saline 1L over 8 hours
109
How much urine should someone produce per hour? (again, per kg and for 70kg person)
0.5ml/kg/HOUR
for 70kg person = 35ml/HOUR
110
When should you stop IV maintenance fluids? 2
1) when someone able to eat and drinking by themselves - keep reassessing for this!
2) if need for longer than 3 days, switch to nasogastric fluids or enteral feeding (though in reality, this may not happen)
111
Where can people loose fluids from / due to? 13
```
during surgery:
- evaporation from open body cavity
- suction
- any post-surgical drains
(nb normal fluid loss - not incl blood loss - during surgery is 600-900ml)
```
- urination
- vomiting
- NG tube suction (eg in obstructed bowel)
- diarrhoea
- high stoma output
- sweating (especially if have fever)
- through skin (burns)
- breathing (especially if hyperventilating)
bleeding
- external bleeding (also includes GI bleeding, meleana etc)
- internal bleeding (think about when, eg drain haemothorax in trauma)
112
What should all people given resus fluids have?
strict fluid input / output monitoring (normally with a catheter)
113
What differential diagnoses should you consider in the acutely breathless patient? 7
what are the things in the history and exam which may make each more or less likely?
ASTHMA ATTACK
- more likely: wheeze (widespread on auscultation), hx of asthma, young,
COPD EXACERBATION
- more likely: cough, increased sputum, hx of COPD or smoking,
PNEUMONIA
- more likely: slower onset, productive cough, fever, crackles in a distinct area
PE
- more likely: collapse, risk factors, pleuritic chest pain, tachycardia
- less likely: infective symptoms (though can get a mild fever), crackles
PNEUMOTHORAX
- more likely: trauma or hx of chronic lung disease, hyperresonant / reduced breath sounds in area
PULMONARY OEDEMA
- more likely: hx of heart failure / fluid overload, peripheral oedema, raised JVP, bibasal fine crackles, pinky frothy sputum, 3rd heart sound
METABOLIC ACIDOSIS (eg DKA, sepsis etc)
114
acute asthma
- initial symptoms? 3
- other features of history? 2
- breathlessness
- wheeze
- cough
- PMHx of asthma and/or atopy
- exposure to precipitant
115
What are the common precipitants of asthma attacks? 8
- cold air
- exercise
- emotion
- allergies
- smoking
- pollution
- nsaids
- b-blockers
116
What are the four categories of asthma attacks?
- how many features do you need to be in the next one up?
1) moderate exacerbation
2) acute severe asthma
3) life-threatening asthma
4) near fatal asthma
just need one feature of the category up to be classified in that higher category
117
Features of 'moderate exacerbation' of asthma? 3
- increasing symptoms
- peak flow 50-70% of best or expected
- no features of acute severe asthma (or worse)
118
Features of 'acute severe asthma'? 4
any one of:
- peak flow 33-50% of best or expected
- RR >25
- HR >110
- inability to complete sentences in one breath
119
Features of 'life-threatening asthma':
- clinical signs? 7
- measurements? 4
any one of:
- altered conscious level
- exhaustion
- arrythmia
- hypotension
- cyanosis
- silent chest
- poor respiratory effort
- peak flow <33% of best or expected
- SpO2 <92%
- PaO2 <8 kPa
- 'normal' PaCO2 (4.6-6)
120
Features of 'near-fatal asthma'? 2
- raised PaCO2
AND/OR
- requiring mechanical ventilation with raised inflation pressures
121
What things to monitor in someone having an asthma attack, to assess severity:
- clinical signs? 5
- obs / objective measurements? 6
- ability, or lack of, to speak in full sentences
- conscious level
- signs of respiratory distress (tripoding, accessory muscle, pursed lip etc)
- cyanosis
- auscultate chest
- peak flow
- repeat ABGs (for pao2 and paco2)
- RR
- O2 sats
- HR
- BP
(also ecg for arrythmias)
122
Management of acute asthma?
approach? 1
acronym? 7
- order you do it in reality?
other things to do? 3
what treatment side effect to be aware of?
A-E approach - esp assessing airway and breathing - looking for any signs of pneumothorax or pneumonia in addition to the asthma
O SHIT ME
- oxygen (high flow)
- salbutamol nebuliser 5mg
- hydrocortisone IV (or prednisalone PO)
- ipratropium bromide nebuliser
- theophylline (aminophylline instead)
- magnesium sulphate IV
- ESCALATE (do this a lot earlier)
- sit patient up
- check trachea is central in case of pneumothorax
- repeat ABG frequently!
in reality you:
- put on back to back salbutamol and ipratropium nebs driven by 15L oxygen
- examine airway and chest
- escalate to senior
- take blood gas
- give steroid PO or IV
- discuss with senior before giving aminophylline or magnesium
- keep reassessing (incl ABGs)
hypokalaemia from the salbutamol - monitor UandEs (also salbutamol will increase HR)
123
acute asthma:
imaging to consider? 1
who in? 5
consider CXR in:
- suspected pneumothorax
- suspected consolidation
- life-threatening asthma
- failure to respond to treatment
- requirement for ventilation
124
What bloods to do in someone having an acute asthma attack? 5
- ABG (repeatedly)
- FBC
- U and E (look at potassium)
- CRP
- blood cultures (if suspect infection)
nb don't delay treatment for any of these
125
features of history of someone with an acute exacerbation of COPD:
- PMHx/SHx? 3
- symptoms? 6
- two groups of questions to ask? 2
- diagnosis of COPD (some may have, others may not)
- any other lung conditions, esp asthma
- smoking history
- worsening SOB
- wheeze
- increased cough
- increased sputum (ask about colour and blood)
- chest pain
- fatigue
1) ask about INFECTIVE symptoms
- flu-like
- sore throat, running nose
- fever / rigors
- nausea
- myalgia
- headaches
2) ASK QUESTIONS ABOUT COPD SEVERITY (see other flash card)
126
What's the difference between dyspnoea and tachypnoea?
dyspnoea is the patients feeling of breathlessness
tachypnoea is the objective increase in respiratory rate
(can have both together or one without the other)
127
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?
128
What are the descriptors for each of the grades in the MRC dyspnoea scale? 5
MRC GRADE 0
- only get breathless with strenuous exercise
MRC GRADE 1
- SOB when hurrying on the level or walking up slight hill
MRC GRADE 2
- walk slower than people OF OWN age on flat dt SOB, or have to stop for breath while walking on flat at my own pace
MRC GRADE 3
- stop for breath after walking 100m (or a few mins) on the level
MRC GRADE 4
- too SOB to leave house OR am SOB when dressing / undressing
129
COPD exacerbation: Features of exam (go through order of a respiratory exam):
- end of bed? 6
- hands / arms? 3
- neck and face? 3
- inspect? 3
- palpate? 1
- percuss? 1
- auscultate? 1
- other? 1
- What else should you look at and monitor?
- tachypnoea
- talk in full sentences?
- change in colour (blue, pink, pale)
- tripoding
- pursed lip breathing
- accessory muscle use
- tar staining
- bounding pulse (CO2 sign)
- CO2 flap
- raised JVP (R heart strain)
- lymph nodes
- central cyanosis (under tongue)
- dilated veins on chest
- chest wall (barrel chest)
- accessory muscle use
- chest expansion
- percuss for signs of consolidation
auscultate
- listen for wheeze and/or crackles in area of consolidation
- often breath sounds are quite quiet dt emphysematous changes and poor inspiratory effort
- legs! for peripheral oedema
DON'T FORGET TO LOOK AT OBS TOO!!
130
investigations for COPD exacerbation:
- obs? 6
- bedside? 2
- bloods? 6
- imaging? 1
- RR
- O2 sats (and FiO2)
- HR
- BP
- temp (may be high if infective)
- ACVPU (really important to monitor!)
- ECG (looking for R heart strain)
- send sputum if purulent!
- ABG (repeat regularly)
- FBC
- UandE
- LFT (if need give abx)
- glucose
- theophylline
- CXR
(blood cultures if pyrexial)
131
Management of COPD exacerbation:
- things to always give/do? 4
- things to consider giving/doing? 4
- sit patient up
- O2 therapy (aiming for SpO2 of 88-92%) - if starting to be drowsy (hypercapnia) then put on 28% venturi and do ABG and titrate up
- salbutamol nebulisers 5mg (back to back if needed)
- oral steroids (30mg prednisalone stat) - or IV hydrocortisone
- consider adding nebulised ipratropium bromide
- consider antibiotics if think infective
- consider IV aminophylline or salbutamol
- consider NIV
132
What signs / findings do you look for to ascertain that this is an infective (as opposed to non-infective) exacerbation? 3
if infective, what antibiotics do you use?
- pyrexial
- purulent sputum
- evidence of consolidation on xray
treat as a CAP! - so use CURB-65 to determine abx
133
When should you consider starting NIV?
what are two main contraindications for NIV? what do you use instead?
If persisting hypercapnia despite an hour of optimal medical management (ie salbutamol, ipratropium, steroids, oxygen, abx if appropriate etc)
- vomiting
- reduced consciousness
use invasive intubation instead
134
pneumonia: features of history:
- local symptoms? 4
- systemic symptoms? 4
- SOB
- pleuritic chest pain
- productive cough (purulent sputum)
- haemoptysis
- confusion (esp elderly)
- nausea
- anorexia
- fever / sweats
135
pneumonia: features of exam:
- local? 3
- systemic? 4
- what should you always look for signs of?
- tachypnoeic
- dullness to percussion
- crackles on auscultation and / or reduced breath sounds (nb this is present in <25% of cases, have a high level of suspicion to do xray)
- tachycardic
- hypotensive
- febrile
- confused (esp elderly)
nb may also have enlarged lymph nodes
ALWAYS LOOK FOR SIGNS OF SEPSIS
136
What is the definition of pneumonia?
what's the difference between the definition of CAP vs HAP? what is the difference in management?
symptoms of pneumonia AND a CXR showing localised consolidation
- nb sometimes takes time for consolidation to show on xray, consider repeating or CT
HAP is if symptoms develop >48 hours after admission
use different abx as more likely to be caused by an atypical organism - also do additional swabs and cultures etc to look for organisms
137
Which organisms cause pneumonia:
- commonest? 1
- other common, esp if COPD? 1
- other common, esp following flu? 1
- common in alcoholics and diabetics? 1
- norm spread by air con? 1
- atypical pneumonia that typically affects young people? 1
- causes in immunocompromised? 3
say if each is typical or atypical!! - also what does this mean?
commonest cause of CAP
= strep pneumoniae (typ)
other common cause of CAP, esp if COPD
= haemophilus influenzae (typ)
other common, esp following flu
= staph aureus (typ)
common in alcoholics and diabetics
= klebsiella pneumoniae (atyp)
norm spread by air con
= legionella pneumophilia (atyp)
atypical young people
= mycoplasma pneumoniae (atyp)
immunocompromised
= pneumocystis jiroveci (esp in HIV) (atyp)
= mycobacterium tuberculosis (atyp)
= aspergillosis (fungal)
atypical basically means that it's not a 'typical' presentation of pneumonia, eg these bacteria may also have haemolytic or liver effects etc
- also treated with different abx!
nb 90% of pneumonia is caused by bacteria but a small proportion is fungal OR viral!!! (esp flu!)
nb also chlamydia is atypical
138
Investigations for pneumonia:
- ones to always do? (2 bedside, 3 bloods, 1 imaging)
- ones to consider? (2 bedside, 2 blood, 1 imaging)
= sputum sample
= nasal and throat swabs
= FBC
= UandE (need urea)
= LFT (for abx)
= CXR
- consider urinary pneumoccocal / legionella screen
- consider AMTS (to assess confusion)
- consider ABG (if sats drop)
- consider blood cultures
- consider CT if can't see consolidation on CXR (or CTPA if thinking PE)
139
What scoring system is used to indicate severity of CAP? What are the parameters for each aspect? (and way to remember)
CURB-65
- confusion (< 8 on AMTS or a drop from normal)
- urea (>7mmol)
- RR >30
- BP (systolic <90 or diastolic <60)
- age >65
"30, 60, 90"
score 1 point for each
140
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)
141
What abx should be used for HAP?
norm tazocin or similar (but look up trust guidelines)
142
Aside from abx, what other initial management of pneumonia should you consider:
- bedside? 2
- medications? 3
- oxygen, if hypoxic
- fluids, if dehydrated
- analgesia, if in pain
- anti-emetics, if nauseous
- VTE prophylaxis, esp if in for a while
143
Pneumothorax
- symptoms? 2
- symptom if severe? 1
- main three groups of causes?
- SOB
- unilateral pleuritic chest pain
- inability to talk in full sentences
- spontaneous in tall, young men
- secondary to chronic lung disease (literally any)
- secondary to trauma
144
pneumothorax:
- exam findings in simple? 4
- exam findings in tension? 4
- tachypnoea
- reduced expansion (on affected side)
- hyperresonant percussion
- reduced breath sounds on auscultation
TENSION
= worsening symptoms
= tachycardia
= hypotension
= tracheal deviation (a late sign)
145
Investigations for pneumothorax? (2 bloods, 1 imaging)
which should not be done for a tension?
- FBC (looking for infection)
- ABG
- ERECT CXR (not in tension)
146
Management of pneumothorax:
- for all?
- if simple?
- if tension? 2
oxygen for all
- titrate to sats (always ask about copd)
simple
- if small and primary can needle decompression or manage conservatively
- if large, needle decompression and, if no improvement or if secondary, chest drain!
tension
- needle decompression immediately
- chest drain immediately afterwards
nb needle decompression and aspiration are the same thing
147
anatomical markers for:
- needle decompression / aspiration? (what instrument do this with?)
- chest drain?
aspiration
= SECOND intercostal space, MID-CLAVICULAR line
= use a 16G cannula
chest drain
= FIFTH intercostal space just anterior to MID-AXILLARY line (nb nipple line in men)
nb needle decompression and aspiration are the same thing
148
Pulmonary oedema:
| - two groups of causes? with a brief mechanism for each
CARDIOGENIC
= left HF -> increased LV end-diastolic volume and pressure -> increased pulm capillary hydrostatic pressure -> fluid pushed into alveoli
NON-CARDIOGENIC
= basically any other cause that does not orginate from a problem with the heart
- mechanism can be dt increased capillary permeability, decreased plasma oncotic pressure, increased lymphatic pressure
149
Cardiogenic causes of pulmonary oedema:
- commonest? 3
- other causes? 6
= acute complication of MI or IHD
= long-standing HTN
= long-standing aortic / mitral valve disease
- arrhythmias
- acute myocarditis
- cardiomyopathy
- VSD
- failure of prosthetic valve
- negative inotropic drugs
150
non-cardiogenic causes of pulmonary oedema? 9
- ARDS
- IV fluid overload
- drowning
- hypoalbuminaemia
- acute kidney disease
- aspiration
- smoke inhalation (or other inhalational injury)
- allergic reaction
- neurogenic pulmonary oedema
nb cardiogenic causes of pulmonary oedema are much more common than non-cardiogenic causes
- so don't agonise over learning these - just be aware that there are non-cardiogenic causes too so look for them
151
symptoms of pulmonary oedema? 7
other systemic symptoms if is a cardiogenic cause? 3
what to always ask about?
- SOB (often unable to speak in full sentences)
- orthopnoea
- paroxysmal nocturnal dyspnoea
- cough (pink frothy sputum)
- wheeze
- fatigue (esp if caused by HF)
- chest pain
cardiogenic
- sweaty
- peripherally cool
- pale
ALWAYS ASK ABOUT ANY PRECIPITATING FACTORS - eg chest pain before or pmhx of heart or lung problems etc
nb can get pulm oedema very acutely or can develop over a long period of time
152
Signs of pulm oedema:
- general inspection? 3
- neck and peripherally? 3
- lung auscultation finding? 1
- possible heart auscultation finding? 1
- tachypnoea
- tachycardic
- wheeze
- raised JVP
- ankle oedema
- abdo oedema
- fine bilateral inspiratory crackles at bases
- 3rd and 4th heart sounds - gallop
153
investigations for pulmonary oedema:
- bedside? 2
- bloods? 5
- imaging? 2
what looking for in imaging
- ECG (recent or current MI, arrythmias etc) - find old ones to compare!
- attach to cardiac monitor
- ABG
- FBC
- UandE
- blood glucose
- troponin
- CXR (cardiomegaly, bat wing hilar shadows, kerly b lines, effusions, fluid in fissures)
- echo of heart (reduced LV ejection fraction)
154
management of pulmonary oedema:
- approach?
- acronym for initial management? 6 (which essential, which to consider)
- procedure to (norm) do for monitoring? 1
- intervention if pt is really breathless and medical management not working? 1
- definitive management? 1
- management if hypotensive? 1 (ie what complication are you concerned about in these pts?)
A-E approach
PODMAN
- Position = sit pt upright (always)
- Oxyen = high flow O2 with TIGHT-fitting face mask (always)
- Diuretics = IV furosemide (always)
- Morphine (consider if pt in pain)
- Anti-emetic (if giving morphine)
- Nitrates = consider giving sublingual GTN (if pt SysBP >90)
- catheterise patient and do a strict fluid input and output (also consider daily weights)
FIND OUT AND TREAT UNDERLYING CAUSE!
NIV
- use if med management not working
- positive pressure forces fluid back into capillaries
IF HYPOTENSIVE
= transfer to ITU for management of CARDIOGENIC shock (they will likely RSI intubate)
155
Differential diagnoses for chest pain:
- GI? 5
- cardiovascular? 4
- resp? 3
- other? 2
- oesophageal spasm
- oesophageal rupture
- GORD
- peptic ulcer disease
- pancreatitis
- ACS
- stable angina
- pericarditis
- aortic dissection
- pneumonia
- pneumothorax
- PE
- anxiety
- MSK pain / costochondritis
156
Going through socrates for chest pain, which features of each letter would make you think of which ddx?
SITE
- central? (cardiac cause)
- epigastric? (GI cause)
- unilateral? (resp cause)
ONSET
- following trauma? (pneumothorax)
- following a specific movement? (MSK?)
- on exertion? (ACS/cardiac)
- gradual onset? (pneumonia)
- sudden onset? (not pneumonia)
- had before? (REALLY HELPFUL Q TO ASK!)
CHARACTER
- crushing? (ACS)
- sharp pain? (PE, pneumothorax, pericarditis)
- tearing? (dissection)
- band-like? (anxiety)
RADIATION
- neck, shoulders, jaw? (ACS)
- back? (dissection, pericarditis, oesophageal rupture, pancreatitis)
ASSOCIATED SYMPTOMS
- breathless (any resp)
- nausea (ACS, anxiety)
- sweaty/clammy (ACS, anxiety)
- cough (pneumonia, PE)
- collapse (dissection, PE)
- acid in mouth? (GORD, PUD)
- palpitations? (anxiety)
- feeling of doom? (ACS, anxiety)
- fever? (PE, pneumonia, pericarditis)
TIMING
- see onset
EXACERBATING / RELIEVING FACTORS
- made worse by exertion / better by rest? (angina, ACS)
- worse by breathing in? (pleuritic - any resp)
- better by sitting forwards and worse by lying down? (pericarditis)
- affected by eating? (GORD, PUD, oesophageal spasm)
- worse by certain movements and/or palpation? (MSK)
157
When taking a history for chest pain, what risk factors / PMHx should you ask about:
- risk factors for angina / ACS? 5
- risk factors for PE? 4
- risk factors for dissection? 2
- recent PMHx for pneumonia / pericarditis? 3
- PMHx HTN (this also for dissection)
- PMHx hyperchlorestaemia
- PMHx MI / stroke / angina
- PMHx diabetes
- smoking
- recent immobilisation
- surgeries
- active cancer
- pregnancy
- connective tissue disorders (ehlers danlos, marfans)
- cocaine use
- recent viral URTI (pericarditis)
- fever, cough, rigors, SOB
158
What FHx should ask about in chest pain?
any FHx of stroke, heart attack
159
ACS
- description of chest pain?
- associated symptoms? 6
- acute
- central
- crushing
- radiating to jaw, shoulder, arm, neck (norm L)
- came on during exertion and eased by rest (or pain still ongoing)
(pt may have previously had angina and presenting with similar pain - if so, ask what's different this time?)
- sweating
- nausea and vomiting
- palpitations
- anxiety / feeling of doom
- pallor
- may be SOB
160
- symptoms of silent MI? 3
| - who get's silent MIs? 2 (why?)
- nausea
- feeling of indigestion or vomiting
- dyspnoea
ie no chest pain
- diabetics
- elderly
dt neuropathy so they don't feel 'pain' from the heart
HAVE A HIGH DEGREE OF SUSPISION TO DO ECG / TROPONIN IN ELDERLY AND DIABETICS!
161
Findings on examination for ACS:
- most common finding?
- other findings? 4
- what might they have signs of if is a large MI?
very little - main point of exam is to exclude other causes of chest pain
- sweaty
- grey
- SOB
- tachycardic (may also have low BP)
May have signs of heart failure, pulm oedema etc
162
Investigations for ACS:
- bedside? 2
- bloods? 3
- imaging to consider? 2
- ECG
- continuous cardiac monitoring
- TROPONIN
- FBC
- UandE
- consider CXR (if suspect other cause of chest pain)
- consider echo (if suspect secondary HF)
163
When should troponin be done? 2
when do levels peak following an MI? 1
- ASAP
- 4-6 hours after symptom onset
levels peak after 3-12 hours of start of symptoms (if no elevation after 6 hours then very unlikely to be MI)
164
What is the initial management of ACS acronym? 8 (ie before get troponin back)
which of these are done always and which to consider?
what should you always consult?
ROMANCEF
- Reassurance
- Oxygen (ONLY IF sats <96%)
- Morphine AND Metoclopramide
- Aspirin 300mg
- Nitrates (sublingual GTN or longer-acting, only if not hypotensive)
- Clopidogrel 300mg OR ticagrelol 180mg
- Escalate to cath lab (if STEMI)
- Fondaparinux (consider)
also consider beta blocker! (again only if not hypotensive)
CONSULT TRUST GUIDELINES FOR MANAGEMENT OF EACH TYPE
165
Difference between STEMI, NSTEMI and unstable angina?
What is definition of ST elevation?
who should receive immediate PCI?
STEMI
- ST elevation in 2 or more leads
- rise in troponin
NSTEMI
- no ST elevation
- rise in troponin
UNSTABLE ANGINA
- no ST elevation or troponin rise
- but continued cardiac chest pain at rest
ST elevation = elevation of ST segment by >1 small square from PR baseline
STEMI gets immediate PCI
NB BE AWARE THAT UNSTABLE ANGINA MAY BECOME A STEMI - KEEP REASSESSING!!
166
What drugs should everyone be started on (if not already on) following ACS for lifelong?
(if not contraindicated)
which one drug should be used for first year after ACS?
- ACE inhibitor
- Beta blocker
- Statin
- GTN spray
- Aspirin
clopidogrel / ticagrelol for first year following
167
What are the two signs of STEMI on an ECG?
ST elevation
OR
NEW LBBB
168
Aortic dissection:
- risk factors? 3
- features of chest pain?
- other symptoms? 3
- connective tissue disorder (ehlers danlos, marfans)
- HTN
- smoking
- sudden
- tearing
- radiating to back
- collapse (15%)
- acute limb ischaemia
- acute paraplegia
169
Aortic dissection:
- possible findings on examination? 6
- what to look for signs of?
nb exact findings depend on location of dissection
- pale
- different BP in arms (by systolic of >20mmHg)
- different pulses in each arm
- aortic regurg murmur
- new neurological weakness
- difference in perfusion (eg a new ischaemic limb - inspect both arms)
LOOK FOR SIGNS OF SHOCK (high HR, low BP)
170
Investigations for aortic dissection:
- bedside? 3
- bloods? 4
- imaging? 2
- definitive imaging if pt stable?
- measure BP in both arms
- ECG
- continuous cardiac monitoring
- CROSS MATCH 10 UNITS
- coagulation
- FBC
- UandE
- CXR (may get widened mediastinum but rare)
- Trans-oesophageal echo (TOE)
- CT angiography (if pt stable)
171
Mangement of aortic dissection:
- approach?
- what need very fast?
- bedside? 2
- meds? 2
- who to escalate to and where to go?
- who needs surgery?
A-E approach
need IV access fast!
- oxygen
- fluids (bloods and crystalloid)
- analgesia (morphine)
- labetolol or CCB or beta blocker infusion to keep BP low
escalate to cardiothoracic team and HDU/ITU fast!
If type A (involving ascending aorta) or type B (NOT involving ascending aorta) but:
- compromised blood flow
- severely dilated aorta or risk of rupture
- HTN or pain cannot be controlled by meds
172
ECG territories and features of the four types of STEMI?
| and arteries!!
ANTERIOR (also septal)
= left anterior descending (LAD)
- V1-V4
LATERAL
= left circumflex OR LAD
- I, aVL, V5-V6
INFERIOR
= right coronary artery (RCA) OR left circumflex
- II, III, aVF
- nb normally reciprocal ST depression in I, aVL
POSTERIOR
= posterior descending artery (PDA)
- ST DEPRESSION in V1-V4 (confirm by doing a posterior ECG - stick leads on back)
(nb don't really get ST elevation in aVR)
REMEMBER any NEW LBBB = STEMI too!!!
173
If find someone collapsed and suspect arrest, what three things should you check before calling resus? 3
What is the bleep for resus?
- responsive, call name and shake
- check for breathing
- check for carotid pulse
2222
174
What should you start immediately if someone has no pulse?
- what monitoring / equipment should you attach? 3
CPR 30:2
- defibrillator
- cardiac monitor
- get airway in (igel or IV) and connect to oxygen
175
After 2 mins of CPR in cardiac arrest, what should you stop and do?
you will find one of 3 things? what are these? and what should you do with each?
stop CPR and do a rhythm check
- check carotid pulse
- check femoral pulse
- check if shockable rhythm
1) shockable -> 1 shock then continue with CPR
2) non-shockable -> continue with CPR
3) return of spontaneous circulation (ROSC) -> A-E approach
176
What are the two shockable rhythms?
what are the two unshockable rhythms?
SHOCKABLE
- pulseless VT
- VF
UNSHOCKABLE
- asystole
- PEA (pulseless electrical activity)
basically if it's pulseless and NOT VT then is PEA
177
When should you do continuous compressions? (as opposed to 30:2)
do continuous compressions as soon as advanced airway (igel or IV) is in place
178
What are the reversible causes of cardiac arrest? 8
4 Hs and 4 Ts
- Hypovolemia
- Hypothermia
- Hyper or hypokalaemia (or other metabolic)
- Hypoxia
- Tamponade (cardiac)
- Tension pneumothorax
- Thrombus (PE or coronary)
- Toxins
179
During compressions in cardiac arrest what should be done:
- examination? 2
- bloods? 1
- bedside given? 1
- medication given? 1
- other? 2
why should these things be done?
- resp exam
- cardiac exam
to exclude pneumothorax, tamponade etc
- ABG (to check electrolytes incl K)
- give fluids (correct hypovolemia)
- give adrenaline IV every 3-5 mins
- go over 4Hs and 4Ts and rule in / out each and treat appropriately
CHECK OXYGEN IS CONNECTED!
180
How do you take a history from someone who has collapsed?
| - questions to ask?
In anyone that collapse it is always a good idea to structure a history chronologically:
BEFORE
- What were they doing before they collapsed (exertional is a sign of potential cardiac source)
- Any palpitations
- Chest pain
- Breathlessness
- Headache
- Nausea or vomiting
- When was the last time they ate/drank?
- Any illegal drunks or alcohol
- Any past history of collapse?
- Did they have any funny tastes or sensations before they collapsed?
- Did they go pale and clammy?
- Any weakness in their arms or legs?
- Any facial droop
DURING (get a collateral if poss)
- Did they lose consciousness (If so how long for)
- Did they hit their head
- Were they incontinent
- Did they bite their tongue? (tip or side)
AFTER
- Are they sleepy or drowsy? (for how long?)
- Any chest pain or breathlessness?
181
What are the 7 features of alcohol dependence?
1) increased TOLERANCE (have to drink more to achieve same effect)
2) WITHDRAWAL symptoms
3) RELIEF from, or avoidance of, withdrawal from further drinking
4) PRIMACY of drinking over other activities
5) narrowing of drinking REPERTOIRE
6) persistent desire or unsuccessful efforts to CUT DOWN on alcohol use
7) use is continued despite knowledge of alcohol-related HARM
182
Alcohol withdrawal
| - when do symptoms occur?
symptoms occur within 12 hours of stopping, or considerably reducing alcohol intake (symptoms occur before alcohol is completely removed from the blood)
peak symptoms is on day 2
significant improvement by day 4/5
183
alcohol withdrawal:
- common symptoms? 10
(excluding the 3 serious acute complications)
what are these all mainly due to?
- anxiety
- restlessness / agitation
- headache
- insomnia
- tremor
- sweating
- anorexia
- nausea / retching / vomiting
- palpitations
- visual, auditory or tactile hallucinations (alcohol hallucinosis)
these are basically due to GABA no longer being stimulated and so nervous system is just over excited!
184
What are the THREE serious acute complications of alcohol withdrawal?
list symptoms/signs of each
```
WITHDRAWAL SEIZURES (24-48 hrs after alcohol stopped)
- generalised tonic clonic seizures
```
```
DELIRIUM TREMENS (48-72 hrs after alcohol stopped and norm lasts 2-3 days)
- hallucinations
- delusions
- severe tremor
- agitation
- clouding of consciousness
- confusion and disorientation
- fever
nb wernicke-korsakoff is a complication of this
```
WERNICKE-KORSAKOFF SYNDROME (dt thiamine deficiency)
- opthalmoplegia
- nystagmus
- ataxia
- confusion
- polyneuropathy
Korsakoff's psychosis characterised by profound retrograde and anterograde amnesia
CAN ALSO GET KETOACIDOSIS (as in DKA)
185
Questions to ask patient who is withdrawing from alcohol about their alcohol history? 4
- other questions? 3
- quantity of normal alcohol intake
- duration of use
- time since last drink
- any previous attempts at withdrawal
- PMHx incl psychiatric
- DHx incl recreational
- SHx - living situation, employment, support network
SOCIAL HISTORY IS SO IMPORTANT IN THESE PATIENTS
186
Possible signs on examination in alcohol withdrawal:
- obs? 3
- general inspection? 3
- what 3 examinations should you perform? (possible findings on each)
- fever
- tachycardia
- hypertension
- sweaty and clammy
- tremor
- ataxia when walking
1) MENTAL STATE
2) NEUROLOGICAL (incl cerebellum)
3) GI
- anxiety
- restlessness / agitation
- visual or tactile hallucination
- delusions
- nystagmus or opthalmoplegia (wernickes)
- ataxia
- hyper-reflexia
- polyneuropathy
- enlarged liver or signs of liver failure (palmar erythema, spider naevi, jaundice etc)
187
investigations for alcohol withdrawal:
- bedside? 2
- bloods? 4
- ECG
- monitor obs closely
- FBC (macrocytic anaemia)
- UandE (dehydration)
- LFT (liver)
- amylase / lipase (pancreas)
- ABG (looking for metabolic acidosis)
- repeat glucose
188
Alcohol withdrawal:
| Who should you consider admitting into hospital?
- alcohol withdrawal seizures
- presence of autonomic over-activity
- suspected wernicke's encephalopathy
- failed detoxification at home
- previous delirium tremens
- < 18 years
- concerns about pt safety (lives alone, psych problems etc)
189
Management of alcohol withdrawal:
- two main medications? (and alternative for one)
- other things to consider? 4
CHLORDIAZEPOXIDE
- over 5 days with reducing dose
- higher/longer doses if severe dependence or high risk delirium tremens or seizures
- DIAZEPAM is alternative
PABRINEX
- thiamine supplement
- to prevent / treat wernickes encephalopathy
- beware of anaphylaxis
- correct electrolyte abnormalities
- give fluid if dehydrated (also encourage oral intake)
- get a psych consult (if relevant)
- give prophylactic carbamazepine (if pmhx of withdrawal seizures)
190
what are the four types of heart block? features?
which is most likely to present with collapse?
FIRST DEGREE AV BLOCK
- increased PR interval
- (no dropped beats)
SECOND DEGREE - MOBITZ TYPE I / WENKEBACH
- PR interval gets progressively longer until it drops a QRS beat and then returns to short and gets longer again etc
- regularly irregular
SECOND DEGREE - MOBITZ TYPE II
- fixed PR interval but every now and then a QRS beat is dropped
THIRD DEGREE (COMPLETE) AV BLOCK
- no association between P waves and QRS complexes
- P waves norm more frequent that QRS
- can also get escape rhythms which give narrow QRS complexes
- more likely to present with collapse
191
Complete heart block
| - symptoms? 7
- fatigue
- dizziness
- confusion
- chest pain
- impaired exercise tolerance
- dyspnoea
- COLLAPSE (?exertional)
192
complete heart block: investigations:
- bedside? 2
- bloods? 3
- ECG
- cardiac monitoring
- FBC
- UandE
- Troponin
193
complete heart block: findings on ECG? 3
- dissociation between P waves and QRS complexes
- QRS complexes relatively narrow
- possible evidence of previous or ongoing ischaemia
194
complete heart block: management? 2
review all medications
- digoxin toxicity and other drugs can cause too so ask about these in history etc
refer to cardiology (most will need pacemaker)
195
DKA:
- symptoms? 9
- what symptoms to ask about?
- polyuria
- polydipsia
- abdo pain
- vomiting
- diarrhoea
- SOB (compensating for acidosis)
- confusion / altered conscious
- collapse (esp think about if young person!)
- recent history of weight loss
ASK ABOUT ANY INFECTIVE SYMPTOMS
196
DKA:
- obs? 3
- other signs? 4
- high RR (kussmaul breathing if late)
- high HR
- hypotension (dt dehydration)
- decreased skin turgor
- dry mucous membranes
- altered consciousness
- smell of acetone on breath
197
DKA: two mechanisms that lead to the acidosis?
low cellular sugar -> breakdown of fat -> ketones -> acidosis
high blood sugar -> diuresis -> dehydration -> anaerobic -> lactate -> acidosis
LONGER DESCRIPTION:
During periods of starvation the liver works to release glucose - it does this with glycogenolysis and gluconeogenesis from fats and proteins. When there is no insulin the body can improperly recognise starvation and start drawing on these reserves too early.
Lack of insulin leads to a release of free fatty acids from adipose tissue so glucose can be drawn from it. In the breakdown of FFAs ketone bodies are produced - ketone bodies have a low pH and so cause a state of METABOLIC ACIDOSIS
The increase in plasma glucose leads to an increase in DIURETUC OSMOSIS and a high loss of sodium and water (this also explains some of the symptoms)
198
DKA:
what three things do you need to know to make a diagnosis?
give values!
DIABETIC
- known?
- high blood sugar? (20% of diabetics present in DKA)
= capillary glucose >11mmol/l
KETONES
- use fingerprick test (or urine, but less good)
= capillary ketones > 3mmol/l (or urine ketones ++)
ACIDOSIS
- do VBG or ABG
- is there acidosis?
= pH <7.3 (+/- low bicarb)
199
What are the four I's of causes of DKA in KNOWN diabetics? 4
INFECTION
- UTI, URTI, skin infection
INTERCURRENT ILLNESS
INFARCTION
- MI, stroke, GI tract, peripheral vascular
INSUFFICIENT INSULIN
200
investigations for DKA:
- bedside? 5
- bloods? 6
- imaging to consider? 1
- urineanalysis (glucose and ketones, also infection)
- pregnancy test in women of child-bearing age
- ECG (potassium)
- fingerprick glucose
- fingerprick ketones
- ABG
- glucose (must get this as well as one from ABG)
- FBC (raised WCC)
- UandE (high Na dt dehydration)
- LFTs (biliary infection)
- consider blood cultures
- consider CXR
201
management of DKA
- approach?
- what do you follow?
- bedside things to remember?
- acronym to remember key aspects of management? 4
- basic process of correcting the DKA?
- definitive treatment?
A-E approach and REASSESS
- remember to keep monitoring on!
follow trust guidelines on DKA management
basically your A-E, but don't forget:
- high flow oxygen (may need airway if reduced consciousness)
- catheterisation and fluid chart
KIDS
- potassium
- insulin
- dextrose
- saline
FLUIDS
```
Give bolus until BP has responded then…
- 1L over 1hr
- 1L over next 2hrs
- 1L over next 2hrs
- 1L over next 4hrs
- 1L over next 4hrs
- 1L over next 6hrs
INSULIN fixed-rate infusion using an IV pump at 0.1U/kg/hr (in cannula in opposite arm to fluids)
- May need to give potassium as the therapy (insulin) will drive potassium into the intracellular compartment (Consider adding to second bag / alternate bags)
```
TREAT UNDERLYING CAUSE (ie infection etc)
202
What is hyperglycaemic hyperosmolar state?
normally caused by? 6
high blood sugar -> dehydration (aka high blood osmolality) WITHOUT significant ketoacidosis
- norm in type 2 DM
- takes days to weeks to develop
- mixed picture of DKA and HHS may occur
- sugary food
- non-compliance with diabetes treatment
- infection
- acute illness
- steroids
- new diagnosis of DM
203
What two things do you need to make a diagnosis of HHS?
How does HHS present?
RAISED PLASMA OSMOLALITY
- >340mOsmol/kg
HIGH GLUCOSE
- >30mmol/l
nb don't learn values
PRESENTS BASICALLY THE SAME AS DKA!
204
investigations for HHS:
- bedside? 4
- bloods? 6
- imaging to consider? 1
basically the same as DKA as want to exclude DKA!
- urineanalysis (glucose and ketones, also infection)
- pregnancy test in women of child-bearing age
- ECG (potassium)
- fingerprick glucose
- fingerprick ketones
- ABG
- glucose (must get this as well as one from ABG)
- FBC (raised WCC)
- UandE (high Na dt dehydration)
- LFTs (biliary infection)
- consider blood cultures
- consider CXR
205
Management of HHS:
- approach? 1
- specific management? 2
- things to monitor / consider? 3
A-E approach
- 1L 0.9% saline over 30 mins (effectively 2 fluid challenges
- if glucose still raised, start on sliding scale of insulin and give more fluids
- if hypoxic, give O2
- if low potassium, give K
- reassess for signs of DKA
- monitor hydration status / urine output
REASSESS!
206
What are the things that can cause secondary brain injury? 8
how do you prevent against these?
1) HYPOXIA
- adequate oxygenation (actually over-oxygenate them as high CO2 -> vasodilation -> increased ICP)
2) HYPOGLYCAEMIA
- monitor blood glucose and correct if needed
3) HYPOPERFUSION
- keep BP (use MAP) high using fluids etc
- control bleeding elsewhere
4) SEIZURES
- treat status epilepticus with benzos and propofol if needed
5) RAISED ICP
- raise head of bed
- monitor for signs
- get neurosurgeons involved to relieve pressure
6) INFECTION
- if any penetrating injury, give abx (also tetanus)
7) INTRACRANIAL HAEMATOMA
- review medications and remove / correct for any blood thining
8) ACIDAEMIA
- monitor blood gases for any sort of acidosis (esp lactic) and treat
207
symptoms of a head injury? 7
additional questions to ask about the injury? 7
- impaired consciousness
- amnesia
- nausea and vomiting (>3 times is significant)
- head ache
- rhinorrhea
- otorrhoea
- diplopia
1) mechanism of injury (how much energy)
2) WHEN injury occured
3) any LOC? (is LOC, implies at least moderate head injury) amnesia? seizure?
4) any previous head injuries
5) significant PMHx (arryhtmias, seizures, epilepsy, diabetes)
6) DHx alcohol, regular meds, any blood thinners?
7) SHx home situation for discharge
208
Cushings triad?
what does it indicate?
what is another sign that can be used alongside this?
- increase in BP
- bradycardia
- irregular breathing
indicates RAISED ICP and IMMINENT HERNIATION
sudden diuresis (dt compression of pituatory gland which secretes ADH)
209
Possible examinations in head injury:
- what score to use?
- other examinations to do? 4
what to always be aware of when examining a person post-head injury?
what else to examine for if have head injury?
GCS score
- cranial nerve exam (especially pupils - fixed and dilated is a bad sign!)
- cerebellar exam
- LL neuro
- UL neuro
esp looking for any focal neuro signs also any signs of basal skull fracture
always consider C-SPINE INJURY
- immobilise c-spine until have a clear CT scan
ANY OTHER INJURIES ELSEWHERE?
210
Acronym for cerebellar signs? 6
DANISH
- Dysdiadokinesia
- Ataxia
- Nystagmus
- Intention tremor
- Slurred / staccato speech
- Hypotonia
211
Signs basal skull fracture?
- bilateral periorbital bruising (panda eyes)
- haemotympanum (blood in middle ear - pain, sense of fullness in ear, hearing loss)
- subconjuctival haemorrhage
- CSF, ottorhoea or rhinorrhoea
- battle's sign (bruising over mastoid process)
212
investigations / management of head injury:
- approach?
- bedside? 3
- bloods? 4
- imaging to consider? 2
- medication to consider? 1
- who to consider referring to? 3 (when to refer)
A-E approach
- raise head of bed
- BM glucose
- FUNDOSCOPY
- FBC
- UandE
- VBG/ABG
- glucose
- CT head
- CT c-spine
- abx if compound fracture (cefuroxime)
- anaesthetist (if GCS <8)
- neurosurgery
- ICU
213
Criteria for CT head in ED following head injury? 7
What should you make sure when sending someone for CT head post-head injury
MUST KNOW THESE!!!!
- GCS <13 on initial assessment
- GCS <15 at 2 hours post-incident
- suspected open or depressed skull fracture
- any sign of basal skull fracture (haemotympanum, panda eyes, CSF leaf from ear or nose, battle's sign)
- post-traumatic seizure
- focal neurological deficit
- more than one episode of vomiting
(also if suspision of non-accidental injury, esp in children)
MAKE SURE THERE IS A RADIOLOGIST TO INTERPRET SCAN ASAP - provisional written report in <1 hour
214
What should all patients be given following any head injury? 2
written (and verbal) advice and safetynetting, including:
- responsible adult should stay with them for 24hrs
- symptoms to look out for
- contact details of hospital services in case of delayed complications
