EMERGENCY MEDICINE Flashcards
(145 cards)
1
Q
ANAPHYLAXIS
what is it?
A
Anaphylaxis may be defined as a severe, life-threatening, generalised or systemic hypersensitivity reaction.
2
Q
ANAPHYLAXIS
what are the features?
A
Airway and/or Breathing and/or Circulation problems
Airway problems may include:
swelling of the throat and tongue →hoarse voice and stridor
Breathing problems may include:
respiratory wheeze
dyspnoea
Circulation problems may include:
hypotension
tachycardia
3
Q
ANAPHYLAXIS
what are the common airway features?
A
swelling of throat and tongue
hoarse voice and stridor
4
Q
ANAPHYLAXIS
what are the common breathing features?
A
respiratory wheeze
dyspnoea
5
Q
ANAPHYLAXIS
what are the common circulatory features?
A
hypotension
tachycardia
6
Q
ANAPHYLAXIS
what are the common causes?
A
food (e.g. nuts) - the most common cause in children
drugs
venom (e.g. wasp sting)
7
Q
ANAPHYLAXIS
what is the management for adults?
A
- IM adrenaline (500 micrograms for adults) + high flow oxygen
if no response repeat IM adrenaline after 5 mins + fluid bolus
8
Q
ANAPHYLAXIS
what is the management for children?
A
IM adrenaline
- <6m = 100-150 micrograms
- 6m - 6yrs = 150 micrograms
- 6-12yrs = 300 micrograms
9
Q
ANAPHYLAXIS
where should IM adrenaline be injected?
A
anterolateral aspect of the middle third of the thigh.
10
Q
ANAPHYLAXIS
what is refractory anaphylaxis?
A
respiratory and/or cardiovascular problems persist despite 2 doses of IM adrenaline
11
Q
ANAPHYLAXIS
what is the management of refractory anaphylaxis?
A
- seek expert help
- IV adrenaline infusion
- IV fluids
12
Q
ANAPHYLAXIS
what dose of adrenaline is required for the following age groups?
a) < 6 months
b) 6 months - 6 years
c) 6-12 years
d) adult (>12 years)
A
a) 100-150 micrograms
b) 150 micrograms
c) 300 micrograms
d) 500 micrograms
13
Q
ANAPHYLAXIS
what medication should be prescribed following initial stabilisation?
A
non-sedating antihistamines (loratadine, cetirizine)
14
Q
ANAPHYLAXIS
what test can establish if a patient has had true anaphylaxis?
A
serum tryptase levels - remain elevated for up to 12 hours
15
Q
ANAPHYLAXIS
what should happen following an initial episode of anaphylaxis?
A
- prescribe two adrenaline injectors
- give training on how to use them
- refer to specialist allergy clinic
16
Q
ANAPHYLAXIS
why is a risk-stratified approach to discharge used following anaphylaxis?
A
biphasic reactions can occur in up to 20% of patients
17
Q
ANAPHYLAXIS
when would fast-track discharge (after 2 hours) be considered?
A
- good response to single dose of adrenaline
- complete resolution of symptoms
- has been given an adrenaline auto-injector and trained how to use it
- adequate supervision following discharge
18
Q
ANAPHYLAXIS
when would discharge after 6 hours be considered?
A
- 2 doses of IM adrenaline needed, or
- previous biphasic reaction
19
Q
ANAPHYLAXIS
when would discharge after a minimum of 12 hours be considered?
A
- severe reaction requiring > 2 doses of IM adrenaline
- patient has severe asthma
- possibility of an ongoing reaction (e.g. slow-release medication)
- patient presents late at night
- patient in areas where access to emergency access care may be difficult
- observation for at 12 hours following symptom resolution
20
Q
ANIMAL BITES
what is the most common isolated organism in animal bites?
A
Pasteurella multocida
21
Q
ANIMAL BITES
what is the management?
A
- cleanse wound.
- Puncture wounds should not be sutured closed unless cosmesis is at risk
- CO-AMOXICLAV
- if penicillin-allergic then doxycycline + metronidazole is recommended
22
Q
HUMAN BITES
what are the most common organisms?
A
Streptococci spp.
Staphylococcus aureus
Eikenella
Fusobacterium
Prevotella
HIV and hep C should also be considered
23
Q
HUMAN BITES
what is the management?
A
co-amoxiclav
24
Q
BED BUGS
what is the causative organism?
A
Cimex hemipteru
25
BED BUGS
what is the management?
symptom control = topical hydrocortisone
definitive management = pest control, fumigation of house
26
BURNS
what is the immediate first aid for burns caused by heat?
1. remove the person from the source.
2. Within 20 minutes of the injury irrigate the burn with cool (not iced) water for between 10 and 30 minutes.
3. Cover the burn using cling film, layered, rather than wrapped around a limb
27
BURNS
what is the immediate first aid for burns caused by electricity?
switch off power supply,
remove the person from the source
28
BURNS
what is the immediate first aid for burns caused by chemicals?
brush any powder off then irrigate with water.
Attempts to neutralise the chemical are not recommended
29
BURNS
how do you assess the extent of burns?
Wallace's Rule of Nines:
- head + neck = 9%,
- each arm = 9%,
- each anterior part of leg = 9%,
- each posterior part of leg = 9%,
- anterior chest = 9%,
- posterior chest = 9%,
- anterior abdomen = 9%,
- posterior abdomen = 9%
Lund and Browder chart: the most accurate method
- the palmar surface is roughly equivalent to 1% of total body surface area (TBSA).
- Not accurate for burns > 15% TBSA
30
BURNS
what is a superficial epidermal (1st degree burn)?
- red and painful
- dry
- no blisters
31
BURNS
what is a Partial thickness (superficial dermal) (2nd degree burn)?
- pale pink
- painful
- blistered
- slow CRT
32
BURNS
what is a Partial thickness (deep dermal) (2nd degree burn)?
- white
- may have patched of non-blanching erythema
- reduced sensation
- painful to deep pressure
33
BURNS
what is a full thickness (3rd degree burn)?
- white (waxy) / brown (leathery) / black in colour
- no blisters
- no pain
34
BURNS
when should a patient be referred to secondary care?
- all deep dermal and full-thickness burns.
- superficial dermal burns of more than 3% TBSA in adults, or more than 2% TBSA in children
- superficial dermal burns involving the face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso, or neck
- any inhalation injury
- any electrical or chemical burn injury
- suspicion of non-accidental injury
35
BURNS
what is the management of superficial epidermal (1st degree burns)?
symptomatic relief - analgesia, emollients etc
36
BURNS
what is the management of superficial dermal (2nd degree) burns?
- cleanse wound
- leave blister intact
- non-adherent dressing
- avoid topical creams
- review in 24hrs
37
BURNS
what is the management for severe burns?
- IV fluids (calculated using Parkland formula)
- urinary catheter inserted
- analgesia
- conservative management
38
BURNS
what can be the result of smoke inhalation?
airway oedema
39
BURNS
when should early intubation be considered?
- deep burns to face or neck
- blisters or oedema to oropharynx
- stridor
40
BURNS
when do patients require fluids?
children = >10% burns
adults = >15% burns
41
BURNS
how do you calculate the fluids required for burns?
parkland formula
volume = %SA burnt x weight (kg) x 4
half of fluid should be administered within first 8 hours
42
BURNS
when should a transfer to a burns unit be considered?
- complex burns
- involving hand
- involving perineum
- involving face
- >10% burns in adults
- >5% burns in children
43
BURNS
how are circumferential burns to limbs managed?
escharotomy to divide burnt tissue to allow better blood flow + relieve compartment syndrome
44
ADVANCED LIFE SUPPORT
what are shockable rhythms?
ventricular fibrillation/pulseless ventricular tachycardia (VF/pulseless VT)
45
ADVANCED LIFE SUPPORT
what are non-shockable rhythms?
asystole/pulseless-electrical activity (asystole/PEA
46
ADVANCED LIFE SUPPORT
what is the ratio of chest compressions to ventilation?
30:2
47
ADVANCED LIFE SUPPORT
how would you use a defibrillator if the patient is not monitored?
single shock followed by 2 minutes of CPR
48
ADVANCED LIFE SUPPORT
how would you use a defibrillator if the patient is monitored?
three stacked shocks followed by CPR
49
ADVANCED LIFE SUPPORT
what is the first line way of delivering drugs?
IV
if IV access is not achieved then intraosseous (IO) is used
50
ADVANCED LIFE SUPPORT
when is adrenaline used?
- non-shockable rhythms = 1mg ASAP
- shockable rhythms = 1mg after 3rd shock
repeat adrenaline 1mg every 3-5 minutes
51
ADVANCED LIFE SUPPORT
when is amiodarone used?
- shockable rhythm: 300mg after 3 shocks
- further 150mg after 5 shocks
lidocaine can be used as alternative
52
ADVANCED LIFE SUPPORT
when should thrombolytic drugs be considered?
- if PE is suspected
if given, CPR should be extended for 60-90 mins
53
ADVANCED LIFE SUPPORT
following successful resuscitation, what is the target oxygen saturations?
94-98% - to avoid hyperoxaemia
54
ADVANCED LIFE SUPPORT
what are the reversible causes of cardiac arrest?
Hs + Ts
- hypoxia
- Hypovolaemia
- Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia and other metabolic disorders
- Hypothermia
- Thrombosis (coronary or pulmonary)
- Tension pneumothorax
- Tamponade - cardiac
- Toxins
55
ACID-BASE ABNORMALITY
what are the different causes of metabolic acidosis?
NORMAL ANION GAP
- GI bicarbonate loss (diarrhoea, ureterosigmoidstomy, fistula
- renal tubular acidosis
- drugs (acetazolamide)
- ammonium chloride injection
- addisons disease
RAISED ANION GAP
- lactate (shock, hypoxia)
- ketones (DKA, alcohol)
- urate (renal failure)
- acid poisoning (salicylates, methanol)
56
ACID-BASE ABNORMALITY
what are the causes of metabolic alkalosis?
usually GI/renal
- vomiting/aspiration
- diuretics
- liquorice, carbenoxolone
- hypokalaemia
- primary hyperaldosteronism
- cushings syndrome
- Bartter's syndrome
- congenital adrenal hyperplasia
57
ACID-BASE ABNORMALITY
what are the causes of respiratory acidosis?
Caused by inadequate alveolar ventilation, leading to CO2 retention
- COPD
- decompensation in other respiratory conditions (life-threatening asthma/pulmonary oedema)
- sedative drugs (benzodiazepines, opiate overdose)
- GBS
58
ACID-BASE ABNORMALITY
what are the causes of respiratory alkalosis?
caused by excessive alveolar ventilation, resulting in more CO2 than normal being exhaled.
- anxiety leading to hyperventilation
- PE
- salicylate poisoning
- CNS disorders (stroke, SAH, encephalitis)
- altitude
- pregnancy
59
ACID-BASE ABNORMALITY
what are the results for respiratory acidosis on an ABG?
low pH
raised CO2
60
ACID-BASE ABNORMALITY
what are the results for respiratory alkalosis on ABG?
raised pH
low CO2
61
ACID-BASE ABNORMALITY
what are the results for metabolic acidosis on an ABG?
low pH
low HCO3-
low base excess
62
ACID-BASE ABNORMALITY
what are the results for metabolic alkalosis on an ABG?
raised pH
raised HCO3-
raised base excess
63
ACID-BASE ABNORMALITY
what are the causes of mixed respiratory and metabolic acidosis?
cardiac arrest
multi-organ failure
64
ACID-BASE ABNORMALITY
what are the results for mixed respiratory and metabolic acidosis on ABG?
low pH
raised CO2
low HCO3
65
ACID-BASE ABNORMALITY
what are the causes of mixed respiratory and metabolic alkalosis?
- liver cirrhosis in addition to diuretic use
- hyperemesis gravidarum
- excessive ventilation in COPD
66
ACID-BASE ABNORMALITY
what are the results for mixed respiratory and metabolic alkalosis?
low pH
low CO2
raised HCO3-
67
ACID-BASE ABNORMALITY
what are the steps for interpreting an ABG?
1. how is the patient?
2. is the patient hypoxic (PaO2 should be >10 kPa)
3. what is the pH?
4. what happened to PaCO2?
5. what happened to HCO3-/base excess?
68
ACID-BASE ABNORMALITY
how can you remember different acid-base abnormalities results from ABGs?
ROME
Respiratory = Opposite
- low pH + high PaCO2 = resp acidosis
- high pH + low PaCO2 = resp alkalosis
Metabolic = equal
- low pH + low HCO3- = metabolic acidosis
- high pH + high HCO3- = metabolic acidosis
69
ACID-BASE ABNORMALITY
what does a high base excess indicate?
- higher amount of HCO3- in blood, due to primary metabolic alkalosis or compensated respiratory acidosis
70
ACID-BASE ABNORMALITY
what does a low base excess mean?
- low level of HCO3- in blood, suggesting metabolic acidosis or compensated respiratory alkalosis
71
FLUIDS THERAPY IN ADULTS
what are the requirements for maintenance fluids for adults?
- 25-30 ml/kg/day of water
- 1 mmol/kg/day of potassium, sodium + chloride
- 50-100 g/day glucose (to limit starvation ketosis)
72
FLUIDS THERAPY IN ADULTS
what factors should you consider when prescribing fluids?
- for obese patients use lower end of ranges when calculating volume of fluid required (25ml/kg/day)
- be more cautious in elderly, those with renal impairment, hear failure or malnourished patients at risk of refeeding syndrome
73
FLUIDS THERAPY IN ADULTS
who requires resuscitation fluids?
- hypotension (systolic BP<100mmHg)
- NEWS <5
- oliguria (urine output <0.5ml/kg/hr)
- prolonged CRT (>2s)
- raised lactate (>2mmol/L)
- tachycardia
- tachypnoea
74
FLUIDS THERAPY IN ADULTS
how would you give resuscitation fluids?
- 500ml bolus of 0.9% NaCl or Hartmanns over <15 minutes
- reassess patient
- give a further 250-500ml bolus of 0.9% NaCl or Hartmanns
- repeat until given 2 litres fluid. Then seek expert help
- if patient is complex, be cautious + use 250ml bolus
75
DEHYDRATION
what blood markers suggest dehydration?
- disproportionate increase in urea compared to creatinine
- raised albumin
- raised haematocrit
- sodium
76
DEHYDRATION
what are the clinical features?
- decreased JVP
- tachycardia
- weak pulse
- low BP and low pulse pressure
- decreased urine output
77
CARBON MONOXIDE POISONING
what is the pathophysiology?
- CO readily binds to Hb forming carboxyhaemoglobin
- this reduces Hb's oxygen carrying capacity
- O2 saturation decreases leading to early plateau in oxygen dissociation curve
78
CARBON MONOXIDE POISONING
what are the clinical features?
- headache
- nausea + vomiting
- vertigo
- confusion
- subjective weakness
severe toxicity = 'pink' skin + mucosa, hyperpyrexia, arrhythmias, extrapyramidal features, coma + death
79
CARBON MONOXIDE POISONING
what are the investigations?
- pulse oximetry (may be falsely high)
- venous/arterial blood gas
- carboxyhaemoglobin levels
- ECG
80
CARBON MONOXIDE POISONING
what are the typical carboxyhaemoglobin levels?
- <3% in non-smokers
- <10% in smokers
in CO poisoning
- 10-30% = symptomatic
- >30% = severe toxicity
81
CARBON MONOXIDE POISONING
what is the management?
- 100% high flow oxygen via non-rebreather mask for minimum 6hrs + until all symptoms have resolved
- hyperbaric oxygen (if very severe)
82
CARBON MONOXIDE POISONING
what are the target oxygen saturations?
100% oxygen saturations
83
LEAD POISONING
what is the pathophysiology?
lead poisoning results in defective ferrochelatase + ALA dehydratase function
84
LEAD POISONING
what are the clinical features?
- abdominal pain
- peripheral neuropathy (mainly motor)
- neuropsychiatric features
- fatigue
- constipation
- blue lines on gum margin
(consider in questions giving combination of abdominal pain + neurological signs along with acute porphyria)
85
LEAD POISONING
what are the investigations?
- blood lead level (>10 mcg/dL)
- FBC = microcytic anaemia
- blood film = basophilic stippling + clover leaf morphology
- raised serum + urine levels of delta aminoaevulinic acid
86
LEAD POISONING
what is the management?
- dimercaptosuccinic acid (DMSA)
- D-penicillamine
- EDTA
- dimercaprol
87
ORGANOPHOSPHATE INSECTICIDE POISONING
what is the pathophysiology?
- inhibition of acetylcholinesterase leads to upregulation of nicotinic + muscarinic cholinergic neurotransmission
88
ORGANOPHOSPHATE INSECTICIDE POISONING
what are the clinical features?
SLUD
- salivation
- lacrimation
- urination
- defecation/diarrhoea
- hypotension
- bradycardia
- small pupils
- muscle fasciculation
89
ORGANOPHOSPHATE INSECTICIDE POISONING
what is the management?
- atropine
90
OVERDOSE
what are the clinical features of paracetamol overdose?
SYMPTOMS
- abdominal pain
- N+V
- RUQ pain
- confusion/coma
SIGNS
- jaundice
- reduced GCS
- evidence of self-harm
91
OVERDOSE
what are the investigations for paracetamol overdose?
- serum paracetamol (taken 4hrs post ingestion)
- LFTs
- clotting screen = deranged
- U&Es
- ABG = lactic acidosis if severe
92
OVERDOSE
what is the management of paracetamol overdose?
- activated charcoal if ingested <1 hour ago
- N-acetylcysteine (NAC) infusion over 1hr
- liver transplantation (as indicated by King's criteria)
93
OVERDOSE
when is NAC given in paracetamol overdose?
- timed plasma paracetamol concentration on or above treatment line on normogram
- doubt over ingestion time (regardless of paracetamol concentration)
- staggered dose (all tablets not taken within 1hr)
94
OVERDOSE
what is the criteria for liver transplant following paracetamol overdose?
- prothrombin time >100 seconds
- creatinine >300umol/L
- grade III or IV encephalopathy
95
OVERDOSE
what are the clinical features of salicylate (aspirin) overdose?
SYMPTOMS
- N+V
- abdominal pain
- SOB initially
- sweating later
- tinnitus
SIGNS
- epigastric tenderness
- hyperventilation
- kussmaul breathing
- pyrexia
- severe signs (confusion, seizures, reduced GCS)
96
OVERDOSE
what are the investigations for salicylate (aspirin) overdose?
- salicylate levels (taken at 2hrs post-ingestion if symptomatic or 4hrs if asymptomatic)
- ABG = respiratory alkalosis followed by metabolic acidosis
- U&Es = renal failure
- LFTs + clotting
- glucose levels
- ECG
97
OVERDOSE
what is the management of salicylate overdose?
ASYMPTOMATIC
- discharge if asymptomatic + no acid-base disturbance
SYMPTOMATIC
- activated charcoal if ingested within 1hr
- IV fluids
- urinary alkalinization with IV bicarbonate
- haemodialysis (if severe)
98
OVERDOSE
what are the clinical features of opioid overdose?
SYMPTOMS
- drowsiness (reduced GCS)
- coma
SIGNS
- miosis (constricted/small pupils)
- respiratory depression
- hypotension
99
OVERDOSE
what are the investigations for opioid overdose?
- pulse oximetry
- ABG
- blood glucose
- screen for co-ingestants
- ECG
100
OVERDOSE
what is the management of opioid overdose?
naloxone
101
OVERDOSE
what are the clinical features of benzodiazepine overdose?
SYMPTOMS
- drowsiness (reduced GCS)
- coma
SIGNS
- ataxia
- slurred speech
- respiratory depression
102
OVERDOSE
what is the management of benzodiazepine overdose?
1st line = supportive (airway management, IV fluids)
2nd line = flumazenil
majority of cases are managed supportively due to risk of seizures with flumazenil
103
OVERDOSE
what are the clinical features of TCA overdose?
SYMPTOMS
- dizziness
- dry mouth + eyes
- blurred vision
- urinary retention
- altered mental status
- seizures
SIGNS
- tachycardia
- hypotension
- mydriasis (dilated pupils)
- ataxia
- decreased bowel sounds
104
OVERDOSE
what are the investigations for TCA overdose?
- ECG
- FBC, U&Es, LFT
- serum TCA levels
- serum paracetamol + salicylate levels
to consider
- bladder scan
105
OVERDOSE
what is the management for tricyclic antidepressant (TCA) overdose?
- activated charcoal if ingested <1hr ago
- IV sodium bicarbonate
- benzodiazepines to manage seizures/agitation (diazepam or lorazepam)
- ICU support
106
OVERDOSE
what are the clinical features of lithium overdose?
SYMPTOMS
- acute confusion
- N+V
- polyuria secondary to nephrogenic DI
SIGNS
- coarse tremor
- hyperreflexia
- seizures
- reduced GCS
- ataxia
107
OVERDOSE
what is the management of lithium overdose?
- mild-moderate = volume resuscitation with saline
- haemodialysis in severe cases
108
OVERDOSE
what is the management of warfarin overdose?
vitamin K
109
OVERDOSE
what is the management of heparin overdose?
protamine sulphate
110
OVERDOSE
what are the clinical features of beta-blocker overdose?
SYMPTOMS
- dizziness
- syncope
- fatigue
- SOB
SIGNS
- bradycardia
- hypotension
- reduced GCS
- features of hypoglycaemia
111
OVERDOSE
what is the management of beta-blocker overdose?
1st line
- activated charcoal if ingested <1hr ago
- atropine (if symptomatic + bradycardic)
- IV fluids (0.9% NaCl + dextrose)
- IV glucagon (if severe + refractory)
- airway management
2nd line
- intralipid
- high dose insulin
- benzodiazepines
112
OVERDOSE
what is the management for ethylene glycol overdose?
fomepizole
113
OVERDOSE
what is the management for methanol poisoning?
fomepizole or ethanol
haemodialysis
114
OVERDOSE
what are the clinical features of iron overdose?
SYMPTOMS
- abdominal pain
- N+V
- diarrhoea
- dizziness
SIGNS
- abdominal tenderness
- haematemesis
- haematochezia
- tachycardia
- hypotension
115
OVERDOSE
what is the management of iron overdose?
desferrioxamine
116
OVERDOSE
what is the management of cyanide poisoning?
hydroxocobalamin
117
SEPSIS
what is it?
life-threatening organ dysfunction caused by deregulated host response to an infection
118
SEPSIS
what are the potential causes?
CHEST
- pneumonia
UROSEPSIS
- UTI
- pyelonephritis
- STI
INTRA-ABDOMINAL
- cholecystitis
- cholangitis
- diverticulitis
- colitis
- appendicitis
- PID
- surgical wound infection
CNS
- meningitis
SKIN
- cellulitis
- necrotising fasciitis
MSK
- osteomyelitis
- discitis
- septic arthritis
CARDIAC
- infective endocarditis
- myocarditis
SEPSIS OF UNKNOWN ORIGIN
119
SEPSIS
what are the risk factors?
- age >65
- immunocompromised
- haemodialysis
- indwelling lines or catheters
- surgery or invasive procedure
- IVDU
- alcohol dependence
- pregnancy
- breached skin integrity
120
SEPSIS
what are the clinical features?
SYMPTOMS
- malaise
- N+V
- diarrhoea
SIGNS
- altered mental status (reduced GCS)
- increased CRT
- pyrexia
- tachycardia
- reduced urine output
- respiratory distress
- profound hypotension (not responsive to fluids)
121
SEPSIS
what tools can be used to assess sepsis?
SOFA
qSOFA (GCS<15, increased resp rate >22, reduced systolic BP <100mmHg) score >2 indicates risk of mortality
NICE have own risk stretegy tool
122
SEPSIS
what are the investigations?
- urinalysis
- sputum, urine, stool samples
- ABG
- FBC = leukocytosis
- CRP = raised
- U&Es = pre-renal AKI due to hypovolaemia
- LFTs
- clotting screen
- blood cultures
to consider
- CXR
- CT scan
123
SEPSIS
what is the immediate management for suspected sepsis?
SEPSIS 6 (BUFFALO)
IN
- oxygen (titrate to 94-98%)
- IV fluids (crystalloid bolus 500ml over 15 mins + reassess)
- broad-spectrum antibiotics (CO-AMOXICLAV with GENTAMICIN)
OUT
- measure lactate
- blood cultures
- urine output
124
SEPSIS
when should a fluid bolus be given?
bolus given if lactate >2 or systolic BP is <90mmHg
30ml/kg/hr for first 3hrs if hypotensive
125
SEPSIS
what further measures can be taken if the patient requires organ support?
- central venous catheter
- inotropes + vasopressor support (NORADRENALINE or DOBUTAMINE) to maintain MAP>65mmHg
- intubation + ventilation
- renal replacement therapy
126
SHOCK
what is it?
hypoperfusion of organs and peripheral tissues due to circulatory insufficiency
127
SHOCK
what are the different types of shock?
hypovolaemic = fluid loss
distributive = excessive vasodilation
cardiogenic = cardiac dysfunction
obstructive = mechanical obstruction to blood flow
128
SHOCK
what are the causes of hypovolaemic shock?
- haemorrhage
- burns
- diarrhoea and vomiting
- DKA
129
SHOCK
what are the causes of distributive shock?
- sepsis
- anaphylaxis
- neurogenic shock (injury to CNS causing autonomic disruption)
130
SHOCK
what are the causes of cardiogenic shock?
- MI
- arrhythmias
- valvulopathies (e.g. acute mitral regurgitation)
- overdose of meds (e.g. beta blockers)
131
SHOCK
what are the causes of obstructive shock?
- pulmonary embolism
- cardiac tamponade
- tension pneumothorax
- acute superior or inferior vena cava obstruction
132
SHOCK
what are the clinical features?
features vary depending on cause
- cool peripheries = hypovolaemic shock
- warm peripheries = distributive shock
SIGNS
- hypotension
- tachycardia
- tachypnoea
- altered mental status (e.g. confusion)
- reduced urine output
133
SHOCK
what are the investigations?
- ECG
- blood gas
- blood cultures
- crossmatch (if haemorrhage)
134
SHOCK
what is the management?
- high flow oxygen via non-rebreather mask
- IV fluid boluses
- blood transfusion
- inotropic support
- intubation + ventilation
treat the underlying cause
135
TOXIC SHOCK SYNDROME
what is it?
life-threatening condition caused by toxins released by staphylococcal or streptococcal bacteria
classically associated with tampon use + cellulitis
136
TOXIC SHOCK SYNDROME
what are the causes?
staphylococcal TSS = methicillin-sensitive (MSSA) or methicillin resistant (MRSA)
streptococcal TSS = group A strep (s.pyogenes)
137
TOXIC SHOCK SYNDROME
what are the clinical features?
- fever
- rash (generalised erythema, resembles sunburn)
- desquamation, especially on hands and feet
- hypotension
- nausea + vomiting
- diarrhoea
- myalgia + muscle weakness
- confusion + disorientation
- dizziness
- headache
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TOXIC SHOCK SYNDROME
what are the investigations?
- swabs for microscopy, culture + sensitivities (throat/wound/vaginal)
- blood gas
- urinalysis
BLOOD TESTS
- blood cultures
- FBC = high WCC
- U&Es
- LFTs
- CRP
- coagulation screen
- creatinine kinase
- group and save
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TOXIC SHOCK SYNDROME
what is the management?
- IV antibiotics (LINEZOLID or CLINDAMYCIN) with (PENICILLIN/CEPHALOSPORIN/VANCOMYCIN)
- remove focus of infection
- IV fluid boluses
- catheterise
- correct coagulopathy or deranged glucose or electrolytes
- steroids/IVIG occasionally required
- Intensive care usually required
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SURGICAL SITE INFECTIONS
what are the most common causative organisms?
- orthopaedic surgery = s.aureus
- abdominal surgery = e.coli
- other = pseudomonas aeruginosa
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SURGICAL SITE INFECTIONS
what are the risk factors?
- advanced age
- frailty
- co-morbidities
- complexity of surgery
- immunosuppression
- smoking status
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SURGICAL SITE INFECTIONS
what are the clinical features?
- fever
- localised pain
- erythema +/- signs of spread from wound
- discharge from wound
- abscess +/- sinus formation
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SURGICAL SITE INFECTIONS
what are the investigations?
- observations and NEWS scoring
- wound swab
BLOODS
- FBC, U&Es, CRP
- sepsis 6: blood cultures, urine output, lactate
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SURGICAL SITE INFECTIONS
how can they be prevented pre-operatively?
- optimise co-morbidities
- shower with soap prior to surgery
- avoid hair removal (or use electronic clippers)
- patients and staff wear appropriate clothing
- reduce traffic through theatre
- laminar air flow
- antibiotic prophylaxis
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SURGICAL SITE INFECTIONS
how can they be prevented intra-operatively?
- hand decontamination
- sterile gowns and gloves
- wound closure in layers
- dressings
