Intro week Flashcards
1
Q
What type of consent for blood transfusion
A
verbal informed consent
2
Q
Which transfusion can kill
A
ABO incompatible transfusions
3
Q
What type of antibody is anti-A and anti-B
A
IgM
4
Q
What happens in an ABO incompatible transfusion
A
Complelement activation results in lysis of antibody coated red cells. Causing haemolysis, shock and organ failure.
5
Q
How do you prevent ABO transfusion
A
2 independent checks are required. Taking the group and save sample is the step that involves the greatest risks.
6
Q
Measures implemented to reduce the risks associated with taking the G and S
A
2 independent G and S samples are required before blood is issued. Taken by different people at different time
7
Q
Steps for taking a blood sample
A
Complete all requests Take all equipment Identify patient using document, verbal, wristband Label samples at bedside Handwrite samples
8
Q
Absolute emergency blood
A
Emergency O negative red cells
9
Q
Main cause of morbidity in transfusion and how its prevented
A
Transfusion associated circulatory overload
Avoided by limiting number of bags of authorised at the same time
Reviewing patients
Use diuretics
10
Q
TACO checklist for transfusion
A
Heart failure LV dysfunction Diuretic Pulmonary oedema Resp symptoms Positive fluid balance
11
Q
Who is at risk of fluid overload
A
Low weight. Everyone needs weighing
12
Q
What are the 4 things of blood you can give
A
Red cells
Platelets
FFP
Cryoprecipitate
13
Q
TACO symptomns
A
Dyspnoea Wheezing Tightness Cough Cyanosis Tachypnoea Raised JVP Peripheral and pulmonary oedema Biltateral infiltrates on chest x ray
14
Q
How to avoid TACO
A
Give diuretics
Transfuse single units of red cells
15
Q
How to treat TACO
A
Diuretic
Morphine
Nitrate
16
Q
What does TACO stand for
A
Transfusion Associated Circulatory Overload
17
Q
What is generic prescribing
A
Once a drug is off patent, generic prescribing is more cost effective as does not use brand names
18
Q
Who has legal responsibility for the prescription
A
Whoever signs it
19
Q
Which sizings do you write out and which do you abbreviate
A
Write out micrograms and nanograms
20
Q
Types of prescribing
A
Acute prescriptions
Repeat prescriptions
Medication reviews
21
Q
Fever Pain score
A
Fever Purulence Attend within 3 days Inflamed tonsils No cough or coryza symptoms
22
Q
What antibiotic for tonsilitis
A
Phenoxymethylpenicillin for 10 days
23
Q
How do you structure a prescription
A
Drug
Size of tablets (preparation)
Dose
Supply
24
Q
Pen allergic tonsilitis treatment
A
Clarithromycin
25
How do you structure a controlled prescription
Name and form
Strength and dose
Total quanitity numbers (words)
26
How long do you prescribe for on a controlled presciption
A month
27
If its a dynamic/ new situation how long would you give for on a prescription
2 weeks
28
Measure of renal function used when prescribing DOACs
Creatinine clearance
29
Medication review questions
Indication
Monitoring up to date
Contraindications
Review suitability in context of patients current condition
30
Anticholinergic side effects
```
Arrythmias
Blurred vision
Confusion
Constipation
Dry eyes
Dry mouth
Postural hypotension
Urinary retention
?Dementia
```
31
Medical generalist definition
Doctors prepared to deal with any problem presenting to them, unrestricted by particular body systems and including problems with psychological or social causes as well as physical ones
32
Why are medical generalists needed
```
Ageing population
Comorbidities
Medical advances
Health inequalities
Patient expectations
```
33
Expert generalist principles
Managing complexity and uncertainty
Person centred care
Shared decision making
34
Three components of a good doctor according to GMC
Skills, Knowledge, Attitudes
35
Two types of decisions doctor make
Diagnostic decisions
| Treatment decisions
36
Whats bounded rationality
Concept that we work under constraints of limited information that we have a limited intellectual capacity and that we have a limited amount of time to make the decision
37
Biases which affect decision making
```
Affective state of clinician
Health of doctor
Workload
Time of day
Knowledge
Clinical familiarity
Tiredness
```
38
What makes a safe and legal prescription
```
Date
Idenitifiers
Name of drug
Formulation
Dose
Administration
Legible
etc.
```
39
ASA status 1
Normal healthy patient
40
ASA status 6
Declared brain dead, organ retrieval
41
ASA status 2
Patient with mild systemic disease
42
ASA status 3
Patient with severe systemic disease
43
ASA status 5
Moribund patient, not expected to survive over 24 hours with/without surgery
44
ASA status 4
Severe systemic disease, constant threat to life
45
When do you add E to the ASA status
When it is an emergency
46
Why does surgery require muscle relaxation
For opening and closing the abdomen
47
What is surgical preoptimisation
```
HDU or POSU
Invasive BP monitoring
Urinary catheter
Central venous access
Inotropic support
Cardiac output monitoring
Broad aim is to maximum oxygen delivery perioperatively to supranormal levels
```
48
What is something that can be done for surgery preparation before surgical preoptimisation
Surgery school or Fit-4-Surgery. Where you improve lifestyle factors and improves long term outcomes
49
Preoperative measures
Oxygen
Fluids
Drugs
50
Types of premedication
Analgesia
Sedatives
Antiemetics
Antacids
51
Drugs omitted before elective
ACE and ARB
DOACs
Anti TNF (2 weeks)
Platelet inhibitors
52
How long should you have without aspirin before surgery
10 days
53
How long should you have without ACE and ARB before surgery
72 hours
54
Which NSAIDs are still used through surgery (COX2Inhibitor)
Parecoxib (as can be used IV)
55
Gastric effects of NSAIDs
Peptic ulceration. Prophylaxis with omeprazole/misoprostol.
56
Coagulation effects of NSAIDs
Reduced production of thromboxane (COX2-i)
| Increased bleeding time
57
Respiratory effects of NSAIDs
Asprin sensitive asthmatics
58
Renal effects of NSAIDs
Renal failure, fluid retention and hyperkalaemia
| As prostaglandin release
59
Who should you avoid NSAIDs in
Renal
Hyperkalaemia
Hypovoloemia
.....
60
Intraoperative measures
```
Oxygen
Fluid
Blood
Antibiotics
Anaesthesia
Analgesia
Muscle relaxation
```
61
Why shouldnt you give desflurane
Bad for the ozone
62
Whats the alternative to desflurane
Sevoflurane
63
What are desflurane and sevoflurane
Inhalational analgesia
64
Which IV analgesia is still used
Propofol
65
What is an alternative IV analgesia, other than Propofol
Ketamine
66
What are the two types of muscle relaxations
Depolarising and non depolarising
67
How do muscle relaxants work
mimic acetylcholine
68
Suxamethonium
Depolarising muscle relaxant
69
What is good about suxamethonium
Very rapidly acting
70
Non depolarising muscle relaxant
Rocuronium and atracurium
71
How do non depolarising muscle relaxants work
Competitive and therefore takes longer to work
72
What reverses neuromuscular block and muscle relaxants
Sugammadex
73
How does sugammadex work
Encapsulations relaxants and reverses
74
Post operative durgs
Analgesia
Blood products
Etc
75
Regional analgesia
Regional blocks: TAP blocks
| Epidural
76
In COPD which analgesia would be preferred
Epidural
77
What has changed about the trauma stats
Has gone from young men in RTC to older patients with falls
78
Trauma PRIMARY SURVEY (different to critically ill)
```
C= control catastrophic haemorrhage
A=airway with C spine protection
B= breathing with ventilation
C= circulation with haemorrhage control
D= disability: neurological status
E= exposure/environment
```
79
What is the acronym for trauma primary survey
C ABCDE
80
Initial assessment of trauma components
Preparation, triage, primary survey, resuscitation, adjuncts to primary survey
81
What happens after the primary trauma curvey
Next destination, definitive care, scans, surgery.
Secondary survey- life limiting
Tertiary survey- life changing (smaller things)
82
Types of trauma
```
Blunt injury (RTC, falls, assault)
Sharp injury
```
83
RTC injuries
Cervical spine injury
Blunt thoracic and cardiac injury
Hollow viscus perforation
Pelvic, acetabular an dfemur injuries
84
Common motorcycle injuries
Pelvis
| Everything
85
Assault injuries
Head injuries
| Beware stamp to abdomen/ chest
86
How do stab wounds resemble
Follows track of the knife better outcomes
87
Gunshot wounds
Depends on bullets and kinetics
| Bullet can tumble, cause displacement of tissues
88
Sports injuries
Splenic and renal injury in rugby
Open fractures motorcross
Fighting football
89
Primary injury in blast injury
Blast wave disrupts gas filled structures
90
Secondary injury in blast injury
Impact airborne debris (shrapnel)
91
Tertiary injury in blast injury
Trasmission of body (you are thrown)
92
Quarternary injury in blast injury
All other structures
93
Common preventable trauma deaths
Bleeding
Multiple organ dysfunction
Cardiorespiratory arrest
94
Trauma treatment key aims
Stop bleeding
Prevent hypoxia
Prevent acidaemia
Avoid traumatic cardiac arrest or treat
95
What pneumonic is used for handover in trauma
ATMIST
96
What does ATMIST stand for
```
Age
Time of incident
Mechanism of injury
Injuries found
Signs (observations)
Treatments
```
97
What tool is used to decide which hospital a patient goes to for trauma car
Yorkshire Major Trauma Triage tool
98
what is important when doing CABCDE
Do everything at once
99
Where are catastrophic trauma
Femoral
Axillary
Neck
100
Catstrophic bleeding treatment
```
Clear any clots
Direct pressure
More direct pressure
Indirect pressure
Tourniquet
Haeomstatic agents (ceelox)
```
101
How to apply tourniquet
Open band fully and place around limb, 2 to 3 inches above bleeding source. Twist rod until bleeding stops. Ensure bleeding stopped and no distal pulse.
If hasnt worked, add another tourniquet above
102
According to NICE what is the expected time frame for securing an airway in major trauma
45 minutes
103
Intubation absolute indications
Inability to maintain and protect own airway
Inability to maintain adequate oxygenation with less invasive manouevres
Inability to maintain normocapnia
Significant facial injuries
Detiorating conscious level
Seizures
104
Early tracheal intubation should be considered in the presence of
hypoxaemia or hypercapnia
Deep facial burns
Full thickness neck burns
105
Relative indications for intubation
Haemorrhagic shock
Agitated patient
Multiple painful injuries
Transfer to other area of the hospital
106
Airway and c spine management
Immobilise C spine
Give oxygen
Access airway (look, listen, feel)
Proceed to RSI/ intubation if indicated
107
Life threatening chest injuries ATOM FC
```
Airway obstruction or disruption
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest
Cardiac tamponade
```
108
Tension pneumothorax signs
```
Diminished breath sounsd
Hyperesonance
Distended neck veins
Deviated trachea
hypoxia
Tachycardia
Hypotension
```
109
What is the presentation of a tension pneuomthoarx
Air hungry, agitated
Hypoxia
Hypotensive
Tachycardic
110
Tension pneumothorax treatment
Needle thoracocentesis 2nd intercostal space midclavicular line
111
Massive haemothorax
Defined as over 1500mL blood
Reduced air sounds, hypo-resonant
Obtain IV access prior to decompression
Consider urgent thoractomy
112
Define open pneumothorax
Wound to chest wall communicating with pleural cavity
113
Open pneumothorax
More than 2/3 aperture of trachea
Air moves down pressure gradient into pleural space
Wound seals on expiration
Three sided occlusive dressing is the treatment
114
Flail chest
Fracture of 2 or more ribs broken in 2 or more places
Floating section ribs
Moves paradoxically during respiration
Ventilatory failure
115
What are the signs of cardiac tamponade
Becks Triad
- hypotension
- diminished heart sounds
- distended neck veins
116
Treatment for cardiac tamponade
Thoracotomy incise pericardium
117
Secondary survey injurieis
```
Simple pneumothorax
Aortic injuries
Diaphragmatic injuries
Fractured ribs
Lung contusion
Cardiac contusion
```
118
abdo bledding
```
Blunt force trauma
Signs can be subtle
Liver, spleen, retroperitoneal injuries
Perforation hollow viscus
CT in all but the most unstable patient
```
119
Indications for emergency laparotomy
Peritonism
Radiological evidence free air
GI haemorrhage
Resistant haemodynamic instability
120
What is a long bone
Bone that is longer than it is wide
121
Clinically important long bones
Femur
Humerus
Tibia
122
How do you treat circulation in trauma
Permissive hypotension. Aim for MAP 50
123
Why shouldnt you just pump them back full of fluid
Crystalloid doesnt carry oxygen
| They will get hyperchloraemic acidosis
124
Indications for fluid administration in trauma
Systolic under 90
Heart rate over 130
Reduced conscious level
Obvious massive ongoing blood loss
125
How to stop the bleeding
```
See catastrophic haemorrhage
Pelvic binder
Splint long bones
Permissive hypotension
Tranexamix acid
Emergent damage control surgery
Interventional radiology
Limit crystalloid
```
126
Neuro primary survey
AVPU
Pupillary size and response
Motor score of GCSE most predictive outcome
Sensory level if able
127
What is the primary injury
The incident
128
What is the secondary injury
Hypoxic injury/ hypoperfusion
129
What is cerebral perfusion pressure
mean arterial pressure - intracranial pressure
130
What is CPP
Cerebral perfusion pressure
131
Cushings triad in the presence of raised ICP
Hypertension
Bradycardia
Irregular breathing pattern
132
Head injury important things
Prevent secondary brain injury
Secure airway
Maintain normal ICP, glucose, oxygen and CO2
133
E assessment
Look for obvious limb threatening injuries
Keep patient war
Consider few bedside tests
134
How are elderly trauma patients different
Comorbidities
135
Respiratory differences in elederly
```
Respiratory muscle weakness
Kyphosis thoracic spine
Chest wall rigidity
Imparied central response to hypoxia
Reduced alvelolar gas exchange surface area
```
136
Cardiac output
CO=SVxHR
| Stroke volume is a product of preload, afterload and contractility
137
Cardiac differences in elderly
```
Total body water declines with age
Peripheral vasculature becomes rigid and non compliant
Myocardium replaced by fat and collagen
Autonomic and baroreceptor dysfunction
Atrial pacemaker atrophy
```
138
What are the cardiac responses to small changes in elderly
Bigger changes to smaller stimuli as systems bad
139
Normal elderly blood pressure
150
140
Low blood pressure in elderly
Hypotensive is under 110
141
Elderly drugs that arent good for emergencies
```
Sedatives
Anti HTN
opiates
Steroids
NSAIDs
Beta blockers
Anticoagulants
```
142
Spine injuries how do they differ in elderly people
Different normal posture
| Worse prognosis and mortality
143
Why are internal organ damage from external forces more common in the elderly
Protective cage (ribs) are week
144
Why does it seem like lots of people have UTI when old
Sterile bacteriuria much more common
145
Diagnostic criteria for UTI in elderly
```
New urinary symptoms or
Fever
with change in urinary character
or haematuria
or loin tenderness
```
146
Why is abuse common in elderly
Averbal
Dependent
vulnerable
147
Elder abuse definition
A single or repeated act or lack of appropriate action occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person
148
Why wouldnt you an MRI of a trauma patient
Takes 30 mins and you cant do anything when theyre in
149
FAST scan
Foccussed assessment with sonography in trauma
Pericardium, RUQ, LUQ, bladder
Looking for free fluid
But can only see more than 250ml and cant see retroperitoneal
150
Do you normally FAST scan or CT scan
Always CT unless too many patients
151
If you cant see lung markings and its dark whats going on on x ray
Pneumothorax
152
What is surgical emphysema
Air within the soft tissues
153
What causes a flat line on a chest xray
Fluid level
154
What is flail chest normally associated with
```
Pulmonary contusion (brusiing)
Pneumothorax or haemothorax
```
155
Widened mediastinum treatment
CT angio and transfer
156
Do you ever get just one pelvic fracture
No normally get two fractures as its a disk
157
What fracture is caused by AP compression to the pelvis
Open book fracture
158
Vertical shear force to the pelvis causes what fracture
Malgaigne or bucket handle fracture
159
Lateral compression causes what fracture
Lateral compression frature
160
What are the three C spine views
Lateral
Anterior posterior
Odonotoid peg
161
Whatre the 4 lines in the spine
Anterior vertebral line (straight)
Posterior vertebral line (straight)
Spino laminar line (straight)
Posterior spinous line (curved)
162
C1 fracture
Jefferson fracture
163
C2 fracture
Hangman fracture
164
Hyperextension flexure C345
Flexion teardrop fracture
165
Burst fracture
Dived into a swimming pool
166
Why does blood go dark then grey on CT
Acute and then when chronic and becomes fibrinated and changes colour
167
Subarachnoid bleed
Space between arachnoid and pia mater. Can cause hydrocephalus, midline shift and raised intracranial pressure
168
Subdural haematoma
Blood in space between the dura and arachnoid mater
Caused by traumatic tear to bridging veins
Crescent shaped
Crosses sutures
169
Extradural haemorrhage
Outer layer of dura and inner surface of skull. Biconvex.
| Middle meningeal artery
170
When is CT indicated
Haemodynamically instable
Mechanism of injury
Findings on Fast
Obvious severe injury
171
VQ mismatch causes
```
Pneumonia
Heart failure
COPD
Asthma
Lying down
Post Operative
```
172
Respiratory failure definition
pO2 less than 8
173
Normal partial pressure of oxygen
13
174
Normal partial pressure of carbon dioxide
5
175
Type 1 respiratory failure
Oxygen delivery is impaired. Breathe harder. Lower partial pressure of oxygen. Failure of ventilation but not oxygenation
176
If you breathe hard what happens to partial pressure of carbon dioxide
Partial pressure of carbon dioxide falls and then after you tire it goes back up
177
Type 2 respiratory failure
Obesity hypoventilation syndrome and COPD.
| Ventilation and perfusion are both impaired
178
What is high CO2 a sign of
Poor ventilation
179
What is the CO2 in Type 2 respiratory failure
High
180
What is the CO2 in Type 1 respiratory failure
Low/normal
181
Non invasive ventilation what can it be used for
Increasing expiratory pressure to prevent collapse of alveoli
182
When does gas exchange take place
During expiration
183
If you have a low oxygen and VQ mismatch what do you need
Expiratory positive airway pressure
184
If you have inadequate ventilation what do you need
Inspiratory positive airway pressuer
185
What is BIPAP made up of
Expiratory and inspiratory positive airway pressure
186
What is EPAP alone known as
CPAP
187
Type 1 respiratory failure (oxygen only problem) ventilation
BIPAP
188
Type 2 respiratory failure (oxygen and carbon dioxide problem) ventilation
CPAP)
189
When not to use Non Invasive Ventilation
Asthma (as gas trapping)
PTX
Agitation
Airway loss
190
Stage 1 AKI
Creatinine 1.5x baseline
| Urine output less than 0.5ml/kg/hr for more than 6 hours
191
Stage 2 AKI
2x baseline creatinine
| Urine output less than 0.5ml/kg/hr for more than 12 hours
192
Stage 3 AKI
3x baseline creatinine
Anuric 12 hours
Renal replacement therapy
urine output less than 0.3ml/kg/hr
193
Pre renal AKI causes
Sepsis shock
| Pressure optimisation
194
Renal AKI causes
Toxins
195
Post renal AKI causes
Obstruction
196
3 causes of shock which cause AKI
Hypovolaemic shock
Septic shock (leaky capillaries)
Cardiogenic shock
197
Treatment of hypovolaemic or septic shock
Fluid
198
How does pre renal failure affect ultrafiltration
K+ and H+ ions dont leave blood at the glomerulus causing acidosis and hyperkalaemia
199
How does septic shock affect the tubules
Acute tubular necrosis occurs
200
which toxin can cause acute interstitial nephritis
NSAIDs
201
Which drugs cause tubular toxicity
CT contrast
| Gentimicin
202
At the tubule whats happening to sodium
Moving into blood
203
At the tubule whats happening to potassium and hydrogen ions
Absorbed into tubule
204
How to treat the renal failure caused by a toxin
Stop the toxin
205
Causes of obstruction post renal
Stones and cancer
206
What is a CVVH machine
Renal replacement therapy on intensive care unit. Put heparin or citrate in to prevent clots.
207
Which drug predisposes you to renal failure
Linsopril (any ace inhibitor)
208
What causes pain worse than giving birth
Ureteric stone
| Gall stone
209
What investigation for a ureteric stone
CT
210
Is renal or respiratory correct of pH balances quicker
Resp takes hours, renal takes days
211
What does pO2 tell you on blood gas
respiratory failure?
212
What does pCO2 tell you on blood gas?
type 2 failure? respiratory acidosis or alkalosis
213
What does base excess tell you
Metabolic acidosis or alkalosis
214
What does pH tell you on blood gas
Compensated or decompensated
215
What can cause a metabolic acidosis and respiratory alkalosis that cancels out
aspirin overdose
216
If you have chronic respiratory acidosis
You get a chronically high HCO3 but normalish base excess.
| Kidney retains bicarb
217
Define sepsis
A life threatening organ dysfunction caused by a dysregulated host response to infection
218
Indications of organ dysfunction
```
Hypotension
Hypoperfusion (high lactate)
Hypoxia
Oliguria
Creatine high
Low platelets, high INR, high aPPT
```
219
What is septic shock
Sepsis and hypotension unresponsive to fluid
220
What SHEWS score should require a sepsis screen
SHEWS over 3
221
BUFALO, sepsis 6
```
Blood cultures
Urine output hoursly
Fluid challenge IV
Antibiotics broad spetrum
Lactate serum level
Oxygen high flow
```
222
Causes of coma
```
Seizure, infection, sol, cva
Low cardio output state
Hypoxia, hypercapnia, CO poisoning
Uraemia, hepatic encephalopathy, hypoglycaemia, hypo or hypernatraemia, hypothyroidism, hypothermia
Opiates, benzos, tricyclics and alcohol
```
223
AVPU
Alert
Voice
pain
unresponsive (despite painful stimuli)
224
GCS what order and whats it out of
EVM
| 456
225
Eyes GCS
4spontaneous
3speech
2pressure
1none
226
Verbal GCS
```
5orientated
4confused
3inappropriate words
2incomprehensible sounds
1none
```
227
Motor GCS
```
6obeys commands
5localises
4normal flexion to pain
3abnormal flexion to pain
2extension to pain
1none
```
228
What is normal flexion to pain
Hand goes above clavicle
229
What is abnormal flexion to pain
Slow and bunny rabbit like flexion, below clavicle
230
AVPU in GCS
15, 12, 8, under 8
231
Whatre you looking for on neuro exam
```
Tone
Power
Reflexes
Coordination
Sensation
Cranial nerves
```
232
Head injury, what scan
CT head and C spine
233
Neuro emergency, how often neuro obs
At least every half hour
234
Indications for intubation
```
Failure to maintain airway
Insecure aiway (low GCS)
Poor ventilation
Impending herniation (coning)
```
235
Why do you get 3rd nerve palsy in coning
Compression of occulomotor nerve
236
Cushings reflex
High ICP leads to ischaemia of vasomotor centre which causes hypertension and bradycardic
237
What does CPP =
MAP-ICP
238
How to minimise Intracranial pressure
Dehydration (mannitol), hypertonic saline
Reduction of cerebral blood volume
-head up 30 degrees
-hypercabia and hypoxia
239
What happens when arterial PCO2 rises to cerebral blood flow
Increases a lot
240
Instrumental values
Gain value over time
241
Right to die
Can refuse life saving treatment
242
Right to be killed
People who physiologically cant kill themselves require help
243
Paracetamol cautions
```
Liver impairment
Severe cachexia (less than 50kg= max 500mg QDS)
```
244
NSAIDs cautions
Renal impairment and platelet count
CI: GI bleed or ulcer history, asthma
Concurrent medications: warfarin, digoxin, steroids
245
Weak opioids
Codeine
Dihydrocodeine
Tramadol
246
Simple analgesia
Paracetamol and NSAIDs
247
Problem with weak opiods
Ceiling effect of analgesia. So if not effective, replace with a strong opioid rather than add to weak opiods
248
Strong opioids
```
Morphine
Diamorphine
Fentanyl
Oxycodone
Buprenorphine
```
249
Specialist palliative care opioids
Hydromorphone
Alfentanil
Methadone
Ketamine
250
What to consider before starting a strong opioid
```
Previous opioid experience
Previous side effects
Age and frailty
Comorbidities
Renal function
Patient concerns
Will they take them as prescribed
Are they driving
```
251
Opioids and driving
Dont drive whilst changing. If safe and steady then can drive
252
How many g of codeine = 1g of morphine
10
253
Max codeine converted into morphine
240mg codeine= 24mg morphine= 10mg BD
254
What can you use to translate opioid doses
Opioid conversion chart
255
Define background pain
Pain at rest, ongoing pain
256
Define breakthrough pain
Transient exacerbation. Can be predictable such as movement or unpredictable.
257
What is modified release morphine
For background pain. Lasts 12 hours. MST or Zomorph
258
What is immediate release morphine
For breakthrough pain. Oramorph
259
Is oxycodone or morphine stronger
Oxycodone is twice as potent
260
How to prescribe opioids
Always start low
Titrate dose according to pain and PRN usage
Be ready for side effects
261
What should you also prescribe for opioid side effects
PRN antiemetic: Haloperidol
| Stimulant Laxative
262
Common opioid side effects
Constipation
Nausea
Sedation
Dry mouth
263
Less frequent opioid side effects
Psychomimetic effects
Confusion
Myoclonus
264
Rare opioid side effects
Allergy
Respiratory depression
Pruritis
265
When should you give fentanyl or buprenorphine patches
For stable opioid responsive pain.
266
Indications for buprenorphine patches
Intolerable side effects
Oral route difficulties
Renal impairment
267
How long does it take for buprenorphine patches to work
1-3 days
268
What to be cautious of with opioid patches
Hairless, dry, non inflamed
Avoid heat as increases rate of absorption
Adhered fully
269
Should you use fentanyl as a first strong opioid
Never! its too strong
270
Antidepressants as analgesics
Amitryptilline, duloxetine
271
What are used for neuropathic pain
Antidepressants, anti epileptics
272
Are injectable or oral doses stronger
Injectable are twice as strong
273
Renal impairment and opioids
Fentanyl buprenorphine more renal friendly
| Reduce dose or frequency
274
What to make sure is on an opioid prescription
```
Minimum interval
Max in 24 hours
Always check allergy status
Separate prescription for PO vs SC
Is it modified release or immediate release
```
275
General medical palliative emergencies
```
Fits
Cardiac arrest
DKA
Anaphylaxis
Opioid overdose
```
276
More common palliative care emergencies
```
Neutropenic sepsis
Superior vena cava obstruction
Stridor
Malignant hypercalcaemia
Metastatic spinal cord compression
Opioid overdose
Massive Haemorrhage
```
277
Neutropenic sepsis, who gets it
Following chemotherapy
Bone marrow infiltration causing pancytopenia
Haematology patients
278
Neutropenic sepsis signs and symptoms
High temperature
| Clinical infection
279
How is neutropenic sepsis diagnosed
Pyrexia over 38 degrees
Signs of sepsis
Low neutrophil count
280
Neutropenic sepsis treatment
```
IV access
Broad spectrum antibiotics
Close observation
Fluid resus
Investigations
```
281
Superior vena cava obstruction who gets it
Lung cancer tumour, involving the right upper lobe or mediastinum
282
SVC obstruction symptoms
Facial swelling
Conjunctival and arm oedema
Breathlessness
Distended veins in chest
283
SVC obstruction investigations
CT chest
284
Treatment of SVC obstruction
Dexamethasone 16mg OD (for tumour oedema)
Consider anticoagulation
Stenting
Radiotherapy
285
Stridor define
Noisy harsh inspiratory sounds (turbulent air flow)
286
Stridor who gets it
Head and neck tumours
| Lung and upper GI tumours
287
Signs and symptoms of stridor
Noisy breathing on inspiration
Harsh breath sounds
Breathlessness
288
Diagnsois of stridor
ENT endoscope
Upper airway imaging
Clinically
289
How is stridor managed
```
Oxygen
Dexamethason 16mg OD
Tracheostomy
Stenting
Radiotherapy
```
290
Who gets malignant hypercalcaemia
```
Bone cancer mets
Breast
Lung
Kidney
Thyroid
Prostrate
```
291
Signs and symptoms of malignant hypercalcaemia
acute
-thirst, confusion, constipation, global detioration
Chronic
-depression, abdominal pain, constipation, calculi
292
Diagnosis of malignant hypercalcaemia
Correct calcium blood test
293
Malignant hypercalcaemia treatment
IV fluids most important
IV bisphosphonates
Denosumab
294
Massive haemorrhage who gets it
Head and neck cancer
Lung or GI cancer with history of bleeding
Herald bleed (bleed settled)
295
Signs and symptoms of massive haemorrhage
Sudden large volume blood
| Rapidly loses consciousness
296
Massive haemorrhage management
Stop anticoagulation
| Dependent on ceiling of care
297
Palliative massive haemorrhage treatment
Dark towels
Remain with them
Midazolam
298
Opioid overdose, who gets it
Patient on strong opioids
| Sudden improvement in condition or pain
299
Opioid overdose symptoms
```
Reduced conscious level
Reduced respiratory rate
Myoclonic jerks
Pinpoint pupils
Confusion
Hallucinations
```
300
Opioid overdose treatment
```
Naloxone
-400mcg stat in emergency
-smaller amounts in palliative
Close observations
Dose reduction
```
301
What is half life of methadone
Long and variable
302
What is half life of naloxone
Short
303
Palliative opioid overdose
They get varying pain and respiratory rate so dont bother giving nalaxone
304
Metastatic spinal cord compression
Bone mets in spine.
305
Metastatic spinal cord compression investigation
MRI
306
Metastatic spinal cord compression treatment
Dexamethasone
| Surgery
307
Metastatic spinal cord compression symptoms
Neurological symptoms at and below that level
Paraesthesia and weakness
Change in bowel and bladder
308
Approaching end of life definition
Advanced
Progressive
Incurable conditions
Likely to die within 12 months
309
Approaching end of life caer
Optimise symptoms and quality of life
Plan for the future and ongoing decline
Communicating your assessment to the patient
310
Advanced care planning
Discussion with patients and those important to them about their wishes and thoughts for the futures. Ensure Quality of Life is preserved
311
Formal advance care planning
What they want to happen
What they dont want to happen
Who will speak for them
312
What they want to happen document
Advanced statement of wishes
313
What they dont want to happen document
Advance decision to refuse treatment
314
Who will speak for them document
Lasting power of attorney for health and welfare
315
DNACPR
CPR is a medical treatment and therefore decision
| Unethical to offer futile medical treatments
316
Signs and symptoms of dying
Oral intake
Respiratory effort
Conscious levels
Observations
317
Stages of dying
```
Disease relentless
Change underway
Recovery less likely
Dying begins
Actively dying
```
318
Recognising dying outlook
Anyone on team may recognise
| Senior clinician needs to be involved to assess the reversibility
319
Recognising dying
```
Recent change
Organ failure
Function decline
Treatment ineffective
Anyone recognised dying
```
320
Signs of dying
```
Weight loss and appetite
Fatigue and sleeping
Detiorating mobility
Social withdrawal
Changes in consciousness
Struggling with medications
Detiorating ADLs
Pulse strength, change in colour, mottled skin
Respiratory changes: noisy secretions, laboured breathing, cheyne stokes resp
```
321
Five prioirties of care of the dying
```
Communication
Involved
People important to the dying person
Individual compassion
Recognised dying
```
322
What is something important to do when communicating about dying
Document it
323
How to communicate about dying
Be specific and best recommendating
Use SBAR
Recommend ceilings of care and specific planning
324
Symptom control in dying person
Daily reviews still
Keep listening and talking, meeting families
Preemptive prescribing for key symptoms
325
5 key symptoms of dying
```
Pain
Breathlessness
Respiratory secretions
Nausea/ vomiting
Distress/ agitation
```
326
Preemptive medications
```
Subcut injections or syringe driver
Morphine (pain and breathlessness)
Buscopan (secretions)
Midazolam (agitation)
Haloperidol (nausea)
```
327
Preemptive for pain
Morphine hourly
328
Preemptive for breathlessness
Morphine hourly
329
Preemptive for secretions
Buscopan hourly
330
Preemptive for agitation
Midazolam
331
Preemptive for nausea
Haloperidol
332
Non pharmacological treatment of breathelssness
Sit up
| Open window
333
Nutrition and hydration
Reduced intake is normal
Fundamental and instinctive nurturing act
Cultural, faith and ethical
334
Nutrition and hydration things to do
Mouth care to prevent feeling of thirst
Support oral food enjoyment
Regularly review symptoms
335
Bereavement help
Good communication
Discuss events following death
Following bereavement support
Counselling through GP referral
336
Immediate treatment for hyponatraemia
3.0% normal saline 150ml bolus over 20 mins
337
What can be a consequence of over quickly treatment of hyponatraemia
Osmotic demyelination when water rushes out.
338
Max raising of sodium in a day
10mmol
339
Hyponatraemia endocrine causes
Adrenal insufficiency
340
Weight loss and hyponatraemia
Adrenal insufficiency, addisonian crisis
341
How do cortisol and TSH interact
Cortisol inhibits TSH. So adrenal insufficiency can present as hypothyroid
342
Fluid overloaded hyponatraemia causes
Low urine sodium
Congestive cardiac failure
Nephrotic syndrome
Cirrhosis and liver failure
343
Causes of normovolaemic hyponatraemia
SIADH
344
Causes of dehydrated hyponatraemia
Vomiting and diarrhoea
Burns
Pancreatitis
345
Fluid overloaded or normovolaemic hyponatraemia treatment
Fluid restriction
| 750-1000ml/24hrs
346
Dehydrated hyponatraemia treatment
Saline replacement
347
What drugs can cause high urine sodium
Diuretics
Addisons
Cerebral salt wasting
Salt wasting nephropathy
348
What causes SIADH
Tumours
Respiratory
Drugs
CNS
349
How do you treat adrenal insufficiency
Saline replacement and hydrocortisone
350
How much hydrocortisone do you give to treat adrenal insufficiency
100mg IV/IM
351
When do you do a short synacthen test
Testing for addisons
352
If ACTH is high but cortisol is low what does this suggest
A primary problem as the adrenal is not responding to the high ACTH levels
353
Primary causes of adrenal insufficiency
```
Adrenalitis
Haemorrhage
Infiltration
Bilaterla adrenalectomy
Drugs
Inhertied causes
```
354
Secondary causes of adrenal insufficiency
Pituitary/hypothalamic
| Long term glucocorticoid usage
355
Whats the treatment for phaechromocytoma
Alpha blocker
356
What is pituitary apoplexy
Infarction/ haemorrhage into tumour
357
Causes of hypercalcaemia
```
Primary hyperparathyroidism
Malignancy
Lithium
Thyrotoxicosis
High vit d
```
358
3 roles of the liver
Synthesis
Detoxification
Storage
359
What does the liver synthesise
Protein
Clotting factors
Bile
Glycogen
360
What does the liver detoxify
alcohol
Drugs
Ammonia
Bilirubin
361
What does the liver store
Energy
Vitamins
Minerals
362
Define ALF
Complex multisystemic illness which occurs after an insult to the liver.
363
What are the five requirements for ALF
```
Jaundice
Coagulopathy
Hepatic encephalopathy
Absence of chronic liver
Within 12 weeks
```
364
Hyper acute ALF defintion
Jaundice to encephalopathy within 7 days. Best prognosis
365
Acute ALF definition
Jaundice to encephalopathy within 8-28 days
366
Sub acute ALF definition
Jaundice to encephalopathy in 29days- 12 weeks (worse diagnosis)
367
Most common cause of ALF in the UK
Paracetamol
368
Most common cause of ALF in developing countries
Viral hepatitis
369
Drugs which cause ALF
```
Paracetamol
Rifampicin
NSAIDs
Sodium Valproate
Carbamazepine
Ectasy
```
370
Which hepatitis' are viral
A, E and B
371
Rare causes of ALF
```
Ischaemic hepatitis
AI hepatitis
Wilsons
Fatty liver of pregnancy
Budd Chairi
Amanita phalloides mushrooms
```
372
Causes of hyperacute ALF
Paracetamol
Drugs
Viral hepatitis
373
Causes of acute hepatitis
Viral hepatitis
| Ischaemic hepatitis
374
Causes of subacute hepatitis
Seronegative hepatitis
| Autoimmune hepatitis
375
What are the three aspects of palliative care
Physical
Psychological
Spiritual
376
Define palliative care
An approach which improves the quality of life of patients and their families facing problems associated with life threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems
377
Steps of palliative care
Supportive care then end of life care then terminal care then bereavement support
378
Main specialties treated by palliated care
```
Oncological
Neurological
Respiratory
Cardiac
Renal
Vascular
```
379
Focus of palliative care
Patient centred goal, needs realism, honesty, hope, enablement approach
380
Hospice MDT
```
Nursing
AHP
Chaplain
Psychocologist
Physio
Social Worker
Well being therapy
Doctor
```
381
Symptoms of cancer
```
Fatigue and weakness
Pain
Appetite, nausea and bowel problems
Breathing problems
Sexuality and intimacy issues
Problems with body image
```
382
Side effects of cancer treatment
All cancer symptoms
| fatigue, weakness, pain, GI, breathing, sexual
383
Common causes of nausea and vomiting in palliative patients
Morphine
Constipation
Hypercalcaemia
Chemotherapy
384
3Bs of nausea causes
Bowels
Brain
Biochemical
385
Bowel causes of nausea
Mucositis, constipation, infection, gastric stasis, bowel obstruction
386
Brain causes of nausea
Raised intracranial pressure
| Breast cancer mets
387
Biochemical causes of nausea
Medications, hypercalcaemia, hypomagnesaemia, uraemia, infection
388
Antiemetic for bowel cause
Odansetron
| Metoclopramide
389
Antiemetic for biochemical cause
Levomeopromazine
| Haloperidol
390
Antiemetic for brain cause
Cyclizine
| Prochlorperazine
391
How do metoclopramide and haloperidol work as antiemetics
D2 antagonist
392
How does ondansetron work as an antiemetic
Serotonin antagonist
393
How does cyclizine work as an antiemetic
H1 antagonist
394
Name 4 supportive measures
```
IV fluids
Lidnocaine mouthwash
Antacid
Lansoprazole fast tab
Nutrition supplement drinks
```
395
What to do if someone cant reliably take oral antiemetics
Syringe driver or IV
