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Interpretation COPY Flashcards

1
Q

CT Head - Process

A

Demographics
Non-contrast // Contrast (only for vascular)

Work from OUT -> IN

  • Soft Tissue swelling? asymmetry?
  • Bone fracture
  • Periphery? bleed, atrophy
  • Paranchyma? hypo/hyperdense
  • Ventricles? Symmetry
  • Mid line shift??
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2
Q

What does atrophy look like on CT?

A

Obvious, pronounced sulci and gyri

Symmetrical left to right

May not be symmetrical front to back
e.g. fronto-temporal dementia only anterior

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3
Q

Who is at risk of subdural and why?

A

Elderly, alcholics

  1. More likely to fall
  2. Atrophied brain, cortical bridging veins are more stretched and easier to severe
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4
Q

Subdural: Appearance

A

Concave ‘sliver’ on brain periphery

May be hyperdense (acute bleed) or hypodense (chronic)

OR acute on chronic (hyper and hypo dense)

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5
Q

Subdural: Hx

A

Repeated falls

Fluctuating consciousness

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6
Q

Who gets extradurals and why?

A

Often younger patients

Trauma related as middle meningeal artery bleed

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7
Q

Extradural: Appearance

A

Convex ‘eggtradural’ on periphery

Hyperdense, acute blood (high pressure bleed)

Within suture lines (between skull and dura)

May be midline shift

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8
Q

Extradual Hx

A

Traumatic incident with lucid interval

Then LOC, decreased GCS

e.g. rugby player took blow to head, carried on playing, dropped dead in changing room after match.

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9
Q

Extradural Mx

A

A to E, senior, refer neurosurgeons

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10
Q

SAH Mx

A

A to E, senior, refer neurosurgeons

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11
Q

Hypodense Brain Tissue: Causes

A

Ischaemia

Oedema

Old bleed

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12
Q

Hyperdense Brain Tissue: Causes

A

Acute bleed

Tumour

Calcification (often choroid plexus in ventricles)

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13
Q

SAH Risk Factors

A

Family history
HTN
PCKD

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14
Q

How to tell if old blood OR ischaemia/oedema on CT?

A

Old bleed will be much more defined than ischamia/oedema

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15
Q

SAH on CT

A

Could be central area of hyperdensity in the circle of willis area

May be midline shift

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16
Q

What anticoagulant?

Arterial vs Venous clot

A

Arterial e.g stroke, MI

  • Due to platelet aggregation
  • Give antiplatelets: aspirin, clopidogrel, ticagrelor

Venous e.g. DVT, AF clots

  • More to do with clotting factors and cascade
  • Give warfarin, DOAC
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17
Q

Ischaemic Stroke on CT

A

Initial CT Head may be normal
— Primarly to rule out haemorrhage

CT head 2-3 days later will show ischamia

  • Hypodense area in parenchyma
  • Asymmetrical
  • May be midline shift
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18
Q

Initial Ischaemic Stroke Management

A

A to E

NBM until pass swallow assessment

CT Head to rule out haemorrhage

Aspirin 300mg Oral/600mg PR if unsafe swallow

CALL STROKE TEAM
- Consultant will make decision RE thrombolysis

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19
Q

Stroke Medical Management

A

Aspirin 300mg for 14 days

then

Clopidogrel 75mg for life

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20
Q

Mx If CT head shows haemorrhagic stroke?

A

A to E
Swallow assessment and NBM
Refer neurosurgeons

DO NOT GIVE ASPIRIN

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21
Q

Definitive rx for Ischaemic stroke

A

Thrombolysis if <4.5 hours (Stroke consultant to decide)

NEW Rx:
<4 hours, possibly PCI for brain
= mechanical thromolectomy
- discuss with stroke

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22
Q

When is midline shift significant?

A

ALWAYS

there is no such thing as a minor midline shift!!!

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23
Q

Why would you do an AXR?

A

Obstruction (main)

Perf - but probably would do erect CXR, abdo CT instead

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24
Q

Good Xray?

A

Diagphragm -> hernial orifices

Should be able to see psoas muscle
- if not, ? AAA rupture

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25
SBO?
``` Dilation <3cm Valvular coniventes (all the way across) ```
26
3, 6, 9 rule for bowel size
Small < 3cm Trans. colon <6 cm Caecum <9cm
27
LBO?
Haustra not all the way across
28
Signs of inflammation in LB Usual cause?
Thumprinting - thickened bowel wall Lead pipe colon - smooth, featureless TMC - Smooth, featureless, +++ size - risk of perf Cause = IBD
29
Cause of concurrent LBO and SBO?
Incompetent ileocaecal valve
30
Volvulus?
Sigmoid - towards RUQ, coffee bean sign - Common, elderly, rx with flatus tube Caecal - toward LUQ, rarer
31
Signs of perf?
Wrigler's sign | - double wall sign, gas on inside and out of bowel
32
Common surgical clips?
RUQ, cholystectomy clips
33
ECG placement
4th intercostal space for V1 Ride Your Green Bike R = RA, Y = LA, G = LF, B = RF
34
Rate?
Count complexes on rhythm strip
35
Rhythm?
Irregular = likely AF!
36
P waves - Absent? - Shape?
Absent = AF Triangular + tall = p pulmonale - indicative of large right atrium - usually due to lung disease causing pulm. hypertension Bifid = p mitrale - indicative of large left atrium - usually mitral valve regurg/stenosis
37
Axis?
Look at V1 and V3 LAD = leaving: +ve in V1, -ve in V3 RAD = reaching: -ve in V1, +ve in V3
38
PR interval? - Normal? - What does length indicate?
should be 3-5 small sq < 3 = accessory pathway e.g. WPW >5 = heart block
39
3 Features of WPW on ECG
Delta wave (slurred upstroke) Short PR Broad QRS
40
Mnemonic for Reciprocal changes
PAILS ST depression in the area after e.g. Posterior STEMI = ST depression in ant. leads
41
Narrow QRS?
< 3 sqs - ALSO NORMAL! usually atrial problem if tachy
42
Broad QRS?
> 3 sqs, never normal ventricular cause // pathway obstruction
43
To work out if LV Hypertrophy?
Count the squares of the deepest S wave in V1 Tallest R wave in V5 or V6 If total = >35 then the pt has LVH
44
Causes of small voltage QRS?
Tamponade, pericardial effusion? OBESITY!!
45
Cause of QRS Alternans?
Pericardial effusion Heart is mobile in fluid filled sack Height of QRS alternates from smaller to larger regularly
46
Causes of Broad QRS?
VT, VF BBB Hyperkalaemia Drug OD Pacemaker (see pacemaking spikes, talk to senior)
47
VT w/ a pulse?
Unstable = DC shock, need anaesthetist Stable = amiodarone - 300mg over 20 mins - 900mg over 24 hours (infusion)
48
Signs of instability in arrhythmia?
Shock MI HF Syncope MUST BE DUE TO THE ARRHYTHMIA
49
Unstable Tachy?
DC shock (need anaesthetist)
50
Broad complex Stable Tachy?
Reg: VT w/pulse - amiodarone 300mg Irreg: AF with block, need senior
51
Shockable Rhythms
Pulseless VT VF
52
Non-shockable rhythms
Aystole PEA
53
Risk of Amiodarone
Prolongs QT, be wary if patient already has long QT
54
Narrow Complex Stable Tachy?
Reg: SVT - carotid sinus massage, - blow syringe, - adenosine 6mg, 12 mg, 12mg Irreg: AF - Beta blocker (caution: asthma) - Digoxin (caution: HF)
55
Cautions in asthmatics?
Beta-blockers = ABSOLUTELY NOT Adenosine = DON'T YOU DARE high risk of bronchospasm
56
J wave
Osborne wave, usually in hypothermia Homeless, old with long lie May have shivering artifact (e.g. tremors)
57
ST Elevation: Causes
INFARCT! - SAH (due to raised ICP) - LBBB - Pericarditis (saddle shaped) - Brugades (v1-v3: sudden death) - ventricular pacemakers
58
ST Depression: Causes
``` Hypokalaemia Digoxin (dali reverse tick sign) RBBB Reciprocal change in infarct (PAILS) Vent. pacemaker ```
59
LBBB on ECG
With LAD = likely LBBB Need to check old ECG - If new, rx as STEMI
60
Leads and areas?
V1-V4 = anterior V5-V6, I and AvL = lateral II, III, avF = inferior
61
LBBB vs RBBB
LBBB = WiLLiaM (look at V1 and V6) - Pathological RBBB = MaRRow (look at V1 and V6) - may be a normal varient
62
Bad lead to have in ST elevation?
aVR - means very proximal infarct, not a good prognostic sign
63
LAD + RBBB
Bifasicular block
64
Most likely STEMI to cause arrhythmia?
Inferior - NEED telemetry
65
Hyperacute T waves
Pre-ischaemic change in early MI Tall and broad Asymmetrical Usually follows lead pattern of infarct e.g. inferior = I, II, avF
66
Tall-tented T waves
High K+ | Tall and symmetrical
67
Biphasic T waves
Ischamia (STEMI) = - up then down Hypokalemia - down then up (U wave)
68
Risk in Long QT? Causes?
Cardiac arrest - due to torsades de pointes Low temp, low K+, low Ca2+, drug overdose
69
Prolonged QT
Male: >440 Female: >460
70
Risk in short QT? Causes?
Sudden death Congenital, hypercalcaemia
71
Bradycardia Unstable
Shock, MI, syncope, HF Atropine Pacing
72
Bradycardia Stable Rx
Risk of asystole - Treat as unstable - Atropine - Pacing Low Risk - Observe
73
Low Risk
First degree | Mobitz type 1
74
High Risk of Aystole
>3 seconds ventricular pause Mobitz Type 2 Complete Heart Block
75
Mobitz Type 1 (Wenkebach)
Clumping of QRS complexes PR increases until 1 is dropped If asymptomatic = observe Symptomatic (rare) = atropine and pacing
76
Mobitz Type 2
Ratio e.g. 2:1 No lengthening of PR
77
When to do an ABG?
ONLY if worried about ventilation e.g. high RR, low O2 sats otherwise DO A VBG!
78
When to do an ABG in asthma?
ONLY if life threatening or deterioration Don't want to stop people coming back to A&E as scared of ABG
79
Process for ABG interpretation
pH does CO2 account for pH? HCO3 O2 - check amount of o2 patient is using Lactate Hb Electrolytes
80
Metabolic Acidosis with low Bicarb cause? ABG?
Renal Failure // AKI Very low bicarb Low CO2 to try and compensate (due to increased HCO3- excretion) Raised anion gap
81
Chronic Resp acidosis?
e.g. COPD pH low, or may be compensation High CO2 high bicarb to comp
82
Lactic Acidosis Causes ABG?
Seizure Bowel ischameia Sepsis Metformin - due to anaerobic resp low pH, norm CO2 + bicarb, high lactate
83
Metabolic Acidosis ABG
e.g. DKA low pH, low CO2 (comp), low bicarb Normal anion gap
84
AKI Staging and meaning
I = risk II = intermediate III = failure
85
Drugs to omit in AKI
ACEi/ARB NSAIDs Metformin Diuretics
86
Drugs to Keep in AKI
Aspirin 75mg (not damaging to kidneys)
87
Drugs to dose review in AKI
ALL Abx, opiates, insulin, digoxin, benzos, lithium
88
How to assess Fluid Balance
Inspection: vomit bowls, stoma, catheter, blood loss - Is the patient drowsy, well? Hands: temp, perfused, CRT, turgor Pulse: high HR? BP: both arms lying and standing - postural drop indicates poor fluid status before lying BP will drop Face: mucous membranes? Neck: Raised JVP? Chest: Central cap refill, listen to bases of lungs for overload Sacrum and legs: Check for fluid overload
89
Process for AKI?
ABCCDD ``` Assess fluid balance Bloods Catheter (monitor fluid balance) Cannula (push oral or give IV fluids) Drugs: REVIEW Dialysis? senior decision ```
90
Bloods in AKI?
Daily U+Es - creatinine - K+ VBG - Check bicarb Calcium and phosphate FBC - Check Hb (norm. anaemia, not acute change)
91
ALT:ALP ratio
Is it hepatic or biliary tree? ALT ++++ in damage to hepatocytes ALP ++++ in damage to CBD e.g. obstructive pathology - also raised in bone conditions e.g. paget's - also high in pregnancy READ Hx
92
Why is ALT not a good marker of function?
Produced by destruction of hepatocytes If you have no hepatocytes left e.g. cirrhosis than ALT may be decievingly low even if function is bad
93
How to measure liver function?
Synthetic function - Low albumin - Clotting - high PT (>30 secs) = bad - BM: low if non-functioning liver
94
What else is AST found in?
Muscles | - Will be high in rhabdomyolysis
95
Acute inflammatory markers?
Positive - CRP, WCC, platelets, Iron Negative - Albumin Don't do ESR acutely - ONLY RHEUM!
96
Hypocalcaemia?
CATs go Numb on a LONG QT Convulsions Arrythmias Tetany Numbness Long QT

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