medical and surgical emergencies and major trauma Flashcards
(223 cards)
1
Q
pre-hospital mx ACS
A
MONA:
morphine (IV 5-10mg with anti-emetics)
Oxygen (only if hypoxic)
Nitrates (sublingual IV, only if SBP>90mmHg)
Aspirin 300mg STAT (then 75mg OD thereafter)
2
Q
mx acute STEMI
A
<12h Sx onset and PPCI within 120 minutes = PPCI
Otherwise,fibrinolysis
3
Q
mx acute NSTEMI
A
Fondaparinux 2.5mg OD
DAPT = aspirin and ticagrelor
Coronary angiogram +/- stenting (speed of which depends on GRACE score)
4
Q
secondary prevention ACS
A
5As:
Aspirin 75mg OD
Another antiplatelet e.g., clopidogrel 75mg OD/ticagrelor 90mg BD
ACEi e.g., ramipril
Atorvastatin 80mg ON
Atenolol (aka beta-blockers, usually bisoprolol)
Echocardiogram to assess systolic function
Cardiac rehabilitation
5
Q
specific blood test if suspect MI
A
troponin
6
Q
scoring system for mx MI
A
GRACE
7
Q
moderate acute asthma
A
PEFR 50-75%
RR<25
HR<110
speech normal
8
Q
severe acute astham
A
PEFR 33-50%
RR>25
HR>/= 110
unable to complete full sentences
9
Q
life threatening acute asthma
A
PEFR<33%
Spo2<92%
silent chest and cyanosis
haemodynamically unstable
exaustion/altered GCS
ABG=normal co2
10
Q
ix acute asthma exacerbation
A
Routine bloods e.g., FBC, U&E, LFTs, CRP,
Viral throat swabs
ABG
CXR
11
Q
mx acute asthma exacerbation
A
O SHIT ME) -
Oxygen (>94%)
Salbutamol 2.5-5mg nebulised (oxygen driven)
Can trial IV if B2B nebs not helping
Hydrocortisone 100mg IV or PO pred 40-50mg
Ipratropium bromide 0.5mg nebulised QDS
Theophylline IV (senior staff/ICU decision)
Magnesium sulfate IV 2g (senior staff)
Escalate early – involve ICU if not improving
12
Q
hyperkalaemia classification
A
Mild 5.5–5.9, moderate 6.0–6.4, severe ≥ 6.5
13
Q
ECG features hyperkalaemia
A
Flattened P waves
Tall-tented T waves
Widened QRS
Sinusoidal pattern ventricular fibrillation
14
Q
ix in hyperkalaemia
A
U+E
ECG
15
Q
when to tx hyperkalaemia as an emergency
A
K+ ≥6.5 or ECG changes
16
Q
mx hyperkalaemia
A
FIRST = calcium gluconate: Stabilises the myocardium, protects from VF
COMBINED insulin/dextrose infusion
Nebulised salbutamol
Calcium resonium
?Loop diuretics
Consider dialysis if refractory hyperkalaemia despite medical management
Suspend drugs that increase K+ e.g., ramipril, spironolactone etc.
17
Q
A-E approach to tachycardia and bradycardia
A
O2 if <94%
IV access
monitor ECG, O2,
identify and tx reversible causes e.g. electrolyte abnormalities, hypovolaemia
18
Q
life threatening features adult tachycardia/bradycardia
A
shock
syncope
myocardial ischaemia
severe HF
19
Q
what to do if tachycardia with life threatening features
A
synchronised DC shock - up to 3 attempts
need sedation/anaesthesia if conscious
no success: amiodarone 300mg IV over 10-20mins
repeat shock
20
Q
mx tachycardia with no life threatening features, broad and irregular QRS
A
consider:
-AF with bundle branch block -> control rate with BB, consider digoxin or amiodarone if HF, anticoag if duration over 48h
-polymorphic VT (torsades de pointes)-> magnesium 2g over 10 min
21
Q
mx non life threatenin tachycardia with broad regular QRS
A
if VT or uncertain rhythm: amiodarone 300mg IV over 10-60min
if previous SVT with bundle branch block/aberant conduction: vagal manoevres, adenosine 6mg IV rapid bolus, then 12mg, then 18mg. verapamil or BB
if ineffective syncronised DC shock
22
Q
mx non life threatening tachycardia with narrow regular QRS
A
- vagal manoevres
- adenosine 6mg IV rapid bolus, if ineffective 12mg, 18mg. need to monitor ECG
- if ineffective verapamil or BB
- syncronised DC shock
23
Q
mx non life threatening tachcyardia with narrow irregular QRS
A
probable AF: rate control with BB, digoxin or amiodarone if HF, anticaog if duration over 48h
24
Q
mx adult bradycardia with life threatening signs
A
atropine 500mcg IV
response and no risk asystole then observe
no response: interim measures = atropine 500mcg IV repeat to max 3mg, isoprenaline 5mcg/min IV, adrenaline 2-10 mcg/min IV
OR transcutaneous pacing
transvenous pacing
25
mx bradycardia with no life threatening signs and no risk asystole
observe
26
features in bradycardia at risk of asysteole
recent asystole
mobitz II block
complete heart block with broad QRS
ventricular pause >3s
27
most common causes pancreatitis
alcohol, gallstones and ERCP
28
presentation pancreatitis
Acute severe abdominal pain, vomiting, nausea, fever, tachycardia, shock, peritonitis.
29
ix pancreatitis
Obs, routine bloods, LFTs inc Amylase (or lipase), Calcium, ABG if requiring O2, USS/CT depending on clinical picture.
30
what is the imrie-glascow score
for pancreatitis
Reflects severity of inflammation alongside assess involvement/failure of other organs
31
factors in the imrie-glascow score
P – Pa02 < 8 KPa
A – Age > 55
N – Neutrophils (WBC > 15)
C – Calcium < 2
R – uRea >16
E – Enzymes (LDH > 600 or AST/ALT >200)
A – Albumin < 32
S – Sugar (Glucose >10)
32
Interpretation of the imrie-glascow score
0-1 is mild, 2 is moderate and >3 is severe
33
atlanta classification pancreatitis
Mild: No organ failure or systemic complications
Moderate: Transient organ failure (<48 hrs) and /or local or systemic complications (sterile or infected) without organ failure
Severe: Persistent organ failure (>48 hours): single organ or multiple organ failure
34
mx pancreatitis
IV fluid resuscitation
Analgesia
Eat as able
Cholecystectomy ~ 6/52
CT if unwell 7-10 days after presentation
35
complications pancreatitis
NECROSIS IS BAD
Interstitial oedematous pancreatitis: Acute inflammation of pancreatic parenchyma and peripancreatic tissues, but without recognisable tissue necrosis
Necrotising pancreatitis: Pancreatic parenchymal necrosis or peripancreatic necrosis, or both
Acute peripancreatic fluid collection: Peripancreatic fluid with interstitial edematous pancreatitis but no necrosis (this term applies only within the first 4 weeks after onset of interstitial edematous pancreatitis and without features of a pseudocyst)
Pancreatic pseudocyst: Encapsulated collection of fluid with a well defined inflammatory wall usually outside pancreas with minimal or no necrosis (usually occurs > 4 weeks after onset of pancreatitis)
Acute necrotic collection: Fluid and necrosis associated with necrotising pancreatitis affecting pancreas or peripancreatic tissues, or both
Walled-off necrosis: Mature, encapsulated collection of pancreatic or peripancreatic necrosis with an inflammatory wall, or both (walled-off necrosis usually occurs >4 weeks after onset of necrotising pancreatitis)
36
cholelithiasis
Stones in gallbladder
37
features cholelithiasis
Asymptomatic (90%)
Biliary colic (10%)
38
mx cholelithiasis
USS to confirm gallstones, LFTs, add to (very long) elective list
39
cholecystitis
Inflammation of gallbladder
40
features cholecystitis
Pain – Murphy’s
Fever
N&V
41
mx cholecystitis
Confirm via USS - >4mm
10% may have obstructive jaundice picture
IVI + Abx – observe/operate
42
choledocholithiasis
Stone in CBD
43
presentation choledocholithiasis
Pain
Obstructive jaundice
44
mx choledocholithiasis
USS/MRCP
ERCP (usually pre-elective cholecystectomy)
45
cholangitis
Infection of the bile duct
46
presentation cholangitis
Pain
Fever/Septic
Obstructive jaundice
47
mx cholangitis
Septic screen and start IV Abx early. ERCP as above to treat the blockage.
48
pre-hepatic jaundice causes
haemolytic anaemia
gilberts
criggler-najjar syndrome
49
hepatocellular causes of jaundice
alcoholic liver disease
viral hepatitis
iatrogenic-medication
hereditary haemochromatosis
AI hepatitis
primary biliary cirrhosis or primary sclerosing cholangitis
hepatocellular carcinoma
50
post-hepatic causes of jaundice
intra-luminal e.g. gallstones
mural: cholangiocarcinoma, strictures,
extra-mural causes: pancreatic cancer
51
ALP
Biliary obstruction/stasis or bone turnover
52
ALT and AST
type of hepatic damage
53
albumin and clotting derangement
Liver damage ↓ synthetic ability
54
pre-hepatic jaundice bilirubin
cause a unconjugated hyperbilirubinemia – typically from excessive turnover of red blood cells that overwhelms the liver. This cannot be conjugated and secreted in the bile (and ultimately the urine/stool) so gets stuck on blood transport proteins and then skin/tissues.
55
hepatic jaundice bilirubin
Mixed jaundice of conjungated/unconjugated as cirrhosis can cause element of biliary obstruction (look at ALT/AST to work out)
56
post-hepatic jaundice bilirubin
Conjugated hyperbilirubinaemia
57
AST/ALT ratio
indicates the type of liver damage, if it’s 2 its liver damage, if roughly 1 its viral hepatitis, if it’s 0.4 it’s paracetamol
58
complications cholecystectomy
Gallbladder perforation is one – usually due to very inflamed/calcified gallbladder that is spiral down complications - wash out and IV Co-amox.
Bile duct injury - comes from difficult anatomy and being unable to identify calot’s triangle. Life changing injury.
59
duodenal ulcers
Pain when hungry eased by eating
60
gastric ulcers
Pain worse with eating
61
RF gastric and peptic ulcer
H Pylori associated with 95% of duodenal ulcers and 75% of gastric ulcers as causes increased acid secretion (increasing risk of ulceration). Also need to consider meds (NSAIDs, SSRIs, steroids, bisphosphonates). Rarely will be Zollinger-Ellison syndrome (gastrin producing tumour)
62
ix ulcers
FBC, Stool antigen/urea-13, OGD
63
mx gastric/duodenal ulcers
PPI and eradication therapy-lansoprazole + amox (metro if pen a) + clari/metro
64
features perforated peptic ulcer
sudden horrendous epigastric pain, looking shocked and likely peritonitis.
65
mx perforated peptic ulcer
Emergency – access, bloods (including ABG), erect CXR if cannot CT straight away (air-perforation). Give IVIs to maintain organ perfusion and get to theatre if unstable and evidence of unseal perforation. Lap or open, generally will need a washout
66
causes oesophageal bleed
Varices:
Oesophagitis:
Cancer:
Mallory-Weiss tear:
67
features oesophageal varices
bleed
Large volume, will likely be shocked and unstable. Will likely need intervention acutely to prevent re-bleeds
68
features oesophagitis
Usually small volume blood streaking vomit, preceded by GORD like symptoms
69
features oesophageal cancer
Will have s/s of Ca alongside a variable bleed. Can be small volume as tumour grows or a massive terminal event.
70
features mallory-weiss tear
bleed Will follow excessive vomit, usually self terminates
71
gastric causes GI bleed
ulcer
cancer
72
duodenal causes GI bleed
ulcer
73
what is blatchford score for
upper GI bleed
0=no intervention and discharge
>6 = urgent intervention
74
blatchford score
BUN
Hb: Men: 120-130 (1), 119-100 (2), <100 (6)
Women: 100-120 (1), <100 (6)
BP: 100-109 (1), 90-99 (2), <90 (3)
Pulse >100 (1)
Melaena (1)
Syncope (2)
Hepatic disease (2)
HF (2)
75
mx upper GI bleed
Resuscitate, 2x large bore cannulas, assess clotting. Assist clot formation if platelets under 50, fibrinogen is under 1 or PT/APTT is 1.5x normal with platelets/FFP
Endoscopy: Within 24 hours if severe bleed
If non-variceal: Endoscope and give PPI, if re-bleeds consider IR or laparotomy
If variceal: terlipressin and prophylactic antibiotics should be given to patients at presentation (i.e. before endoscopy)
band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices
76
rockall score use
post-bleed re-bleed risk, as rises so does re-bleeding risk (and then mortality risk)
77
features splenic rupture
blunt trauma
epigastric/LUQ pain with peritonism that gradually spreads as the spleen bleeds
78
ix splenic rupture
CT
79
mx splenic rupture
TLDR: If unstable – diagnostic laparotomy to assess damage
Conservative management: Small subcapsular haematoma, Minimal intra-abdominal blood, No hilar disruption (grade 3 and below). Resection if hilar injury/major haemorrhage.
If stable and grade 1-3 can closely observe and repeat CT in 1 week. Increasing tenderness has a low threshold to reimage +/- laparotomy. If contrast escapes during CT – use IR services to embolise vessel if available.
Critically: All patients who are treated conservatively should receive prophylactic vaccinations (against Strep Pneumoniae, Haemophilus Influenzae B (HIB) and Meningococcus) at discharge. If spleen comes out will need Pen-V for life as the spleen is so immunologically active in destroying Pneumococcus, Meningococcus, and H. Influenzae
80
grade 1 splenic injury
capsular tear <1cm parenchymal depth
subcapsular haematoma <10% SA
81
grade 2 splenic injury
capsular tear 1-3cm parenchymal depth
subcapsular haematoma 10-50% SA or intraparenchymal <5cm
82
grade 3 splenic injury
capsular tear >3cm parenchymal depth or trabecular vessels
subcapsular haematoma >50% SA or intraparenchymal >5cm
83
grade 4 splenic injury
laceration involving segmental or hilar vessels, devascualirsing >25% spleen
84
grade 5 splenic injur
completely shattered spleen or hilar vascular injury devascularising the entire spleen
85
presentation appendicitis
Young patient usually fit and well presents with single vomit, anorexia and generalised -> RIF pain.
Percussive and rebound tenderness -> peritonitis.
progression of generalised pain to McBurnies point,
86
ix appendicitis
80-90% will have neutrophil leucocytosis
Urine – rules out UTI/renal colic
USS: useful to rule out pelvic issues
87
mx appendicitis
Laparoscopic appendicectomy is gold-standard, if perforated will need copious washout. Conservative management with Abx works for most patients but a significant proportion will end up needing a lap appendix anway.
88
commonset causes small bowel bstruction
Adhesions (open > laproscopic)
Incarcerated hernia
Crohn’s
Malignancy
89
ix small bowel obstruction
CT
90
presentation small bowel obstruction
elderly with previous abdominal operations. They present, nauseous, vomiting +/- fecal, +/- distended, with episodic colicky peristaltic pain. Patient will have a period of BNO/no flatus being passed. Bowel sounds may appearing high pitched and ‘tinkling’ in early obstruction.
91
mx small bowel obstruction
NBM
Anti-sickness
IVI and hydrate
Decompress bowel with NG (gastrograffin)
If conservative management fails, surgery
Generally simple/partial obstructions are amenable to conservative management.
Closed loop obstructions tend to compromise arterial supply or venous return. Leading to bowel oedema and perforation/ischaemia/awfulness. Will likely require resection.
92
what is ileus
Deacceleration or arrest in intestinal motility – generally innocent
93
RF for ileus
Patient RFs: age, electrolytes, neurological disorders and anti-cholinergics
Surgical RFs: opioids, excessive handling of bowel, resection, contamination
94
ix ileus
Check electrolytes and inflammatory markers
95
mx ileus
innocent in the majority of patients, it can be a sign of other intra-abdominal pathology
Manage with NG, fluids, daily bloods, encouraging mobilisation and reducing opioids
96
direct inguinal hernias
Bowel enters the inguinal canal “directly” through a weakness in the posterior wall of the canal, termed Hesselbach’s triangle
They occur more commonly in older patients, often secondary to abdominal wall laxity or a significant increase in intra-abdominal pressure
97
indirect inguinal hernia
Bowel enters the inguinal canal via the deep inguinal ring
They arise from incomplete closure of the processus vaginalis, an outpouching of peritoneum allowing for embryonic testicular descent, therefore are usually deemed congenital in origin
98
presentation inguinal hernia
lump in the groin, which (for reducible hernia) will initially disappear with minimal pressure or when the patient lies down. There may be mild to moderate discomfort, which can worsen with activity or standing. Check the cough impulse and try to reduce it yourself on examination.
99
mx inguinal hernias
Hernia repairs can be performed via open repair (Lichtenstein technique most commonly used) or laparoscopic repair.
100
femoral hernias
Entrance of abdominal contents into the femoral canal – much smaller with solid boundaries
101
presentation femoral hernias
elderly woman who has lost weight/fat which allows hernia through.
lump medial to femoral pulse
102
epigastric hernias
Abdominal contents breaches upper fibres of linae alba – low risk
103
spigelian hernias
Small tender mass at the lower lateral edge of the rectus abdominus – high risk
104
presentation diverticular disease
Colicky, lower abdominal pain – relieved by defecation +/- altered bowel habit/flatulence/↕︎ bowel habit
105
presentation acute diverticulitis
Acute, tender, stabbing lower abdominal pain + s/s of systemic upset
106
classification diverticulitis
Complicated diverticulitis refers to abscess presence or free perforation
simple diverticulitis describes inflammation without these features.
107
RF for diverticulum
age, low dietary fibre intake, obesity, smoking, family history, and NSAID use.
108
mx diverticular disease
Patients with uncomplicated diverticular disease can often be managed as an outpatient* with simple analgesia and encouraging oral fluid intake. Outpatient colonoscopy should be arranged to exclude any masked malignancies.
109
mx diverticular bleed
conservatively as most cases will be self-limiting.
Those that fail to respond to conservative management may warrant embolisation or surgical resection. Indeed, if a second bleeding episode occurs there is a significant chance of further episodes (up to 50%)
110
mx acute diverticulitis
with antibiotics, intravenous fluids, and analgesia
111
mx perforated diverticulitis
Surgical intervention* is required in those with perforation with faecal peritonitis or overwhelming sepsis. This is a major procedure and usually involves a Hartmann’s procedure (a sigmoid colectomy with formation of an end colostomy. Fig. 3); an anastomosis with reversal of colostomy may be possible at a later date
112
AAA
Dilation of aorta >3cm – pulsatile mass o/e
113
mx AAA
3 – 4.5cm: yearly USS
4.5 – 5.4cm: 3m USS
>5.5cm/growing >1cm/yr/unstable – URGENT
114
presentation ruptured AAA
abdominal pain, back pain, syncope, or vomiting. On examination they will typically be haemodynamically compromised, with a pulsatile abdominal mass and tenderness.
115
mx ruptured AAA
Oxygen
Access
Urgent bloods including 6u crossmatched
Assess whether stable: If stable – CT angio to assess ?endovascular. If unstable get to vascular centre and laparotomy
116
cause renal/ureteric colic
calcium stones (oxalate > phosphate) but important rarer stones (e.g. struvite
117
narrowings in ureter
Pelviuteric junction
Pelvic brim
Vesicouteric junction
118
presentation ureteric/renal colic
Primary symptom is pain – colicky loin to groin +/- vomiting or tenderness in flank.
119
ix renal/ureteric colic
Check bloods and urine dip + CT KUB
120
mx renal/ureteric colci
Hydrate
PR Diclofenac +/- opiate +/- Abx
If obstructed/significant infection
Uteric stent
definitive: Extracorporeal Shock Wave Lithotripsy (ESWL, Percutaneous nephrolithotomy (PCNL, Flexible uretero-renoscopy (URS) and laser lithotripsy
121
common causes acute abdomen
ABDOMINAL: Appendicitis, Biliary tract, Diverticulitis, Ovarian, Malignancy, Intestinal (Obstruction), Nephritic, Acute pancreatitis, Liquor
AEIOUs: Acute (appendicitis/pancreatitis)/AAA, ectopic, IBD/intestinal, Obstruction/Ovarian, Uteric/Uterine, Stones
122
ix in acute abdomen
Urine, ABG, Routine Bloods, ECG and imaging
123
causes acute abdomen in R upper quadrant
cholecystitis
pyelonephritis
ureteric colic
hepatitis
pneumonia
124
causes acute abdomen in L upper quadrant
gasrtic ulcer
pyelonephritis
ureteric clic
pneumonia
125
causes acute abdomenin R lower quadrant
appendicits
ureteric colic
inguinal hernia
IBD
UTI
gynae/testicular torsion
126
causes acute abdomen in L lower quadrant
diverticulitis
ureteric colic
inguinal hernia
IBD
UTI
gynae/torsion
127
causes acute abdomenin epigastric region
peotic ulcer disease
cholecystitis
pancreatitis
MI
128
causes acute abdomen in peri-umbilical region
small and large bowel obstriction
appendicitis
AAA
129
radio opaque stones
Urate and xanthine
130
sepsis initial mx
Blood cultures
Urine output
Fluids
Abx
Lactate
Oxygen
131
RF sepsis
surgery, age, immunosuppression, diabetes, invasive lines, IVDU, open wounds
132
main classes of bacteria causing intra abdo sepsis
Gram –ve baccili e.g. e.coli,
Gram +ve cocci e.g. staph aureus
133
why is lactate measures in sepsis
Shows level of anaerobic respiration from hypoxic tissues
134
mx anaphylaxis
IM adrenaline 1:1000 500mcg (0.5mls)
IM/IV Chlorphenamine 10mg
IM/IV Hydrocortisone 200mg
135
common features analphylaxis
wheeze, urticarial rash, Tongue swelling, lip and mouth tingling, shortness of breath, fatigue, clammy, palpitations
Signs: tachypnoea, tachycardia, hypotension, drowsiness, wheeze, stridor
136
what causes hypotension in anaphylaxis
Histamine release causes mass vasodilation and capillary leak. This vasodilation reduces TPR and thus drops blood pressure. Capillary leak moves fluid from intra to extravascular space and thus drops total circulating volume.
137
CXR features in tension pneumothorax
Flattened R hemi-diaphragm, increased R intercostal spaces, total R sided collapse
Absent lung markings R side, mediastinal shift to L side, trachea deviated to L
138
mx tension pneumothorax
High flow O2 via 15L NRB, needle thoracostomy/chest drain insertion 2nd intercostal space mid-clavicular line
139
cautions following tension pneumothorax
Avoid flying for at least 1 month post pneumothorax. Do not fly until CXR proof that pneumothorax resolved. Never ever go scuba-diving
140
how to prevent tension pneumothorax recurring
Pleurodesis with sterile talc (either via chest drain or laparoscopic surgery), pleurectomy, or pleural abrasion (irritating pleura)
141
RF PE
Factors which cause hypercoagulability, venous blood stasis or vascular wall damage (Virchow's triad)
142
score determining PE prognosis
PESI
143
interpreting wells score for PE
Score >4 : PE likely CTPA
Score <4: PE unlikely D-Dimer first CTPA if positive.
144
mx PE
anticoag- apixaban, rivaroxaban or LMWH
145
mechanism of action rivaroxaban
Factor Xa inhibitor
146
preventing PE
immediate mobilisation post surgery, TED stockings, LMWH prophylaxis
147
mx acute HF
: Furosemide and O2
daily wt and fluid balance chart
148
mx chronic HF
ACEI +BB
Spironolactone
Specialist stuff (hydralazine, nitrates, ivabradine, sacubitril valsartan)
149
CXR features HF
Alveolar oedema, kerley B lines, cardiomegaly, upper lobe diversion, pleural effusions
150
diagnosis HF
Transthoracic echocardiogram
to measure Left ventricular ejection fraction
151
mx bleeding varices
Stabilise patient with IVI, RBC, correct clotting abnormalities (platelets/FFB/Vit K)
Terlipressin 1-2mg every 4-6h until bleeding controlled
Antibiotics: broad spectrum abx cover e.g. IV co-amoxiclav 1.2g TDS
Urgent endoscopy for variceal banding or gastric sclerotherapy
TIPS (trans-jugular intrahepatic porto-systemic shunt) if varices resistant or recurrent.
152
severe hypovolaemia
Tachycardia >100bpm, hypotension <100mmhg systolic, CRT >3s, pallor, reduced GCS, urine output <0.5ml/kg/hr
153
lab ix after vomiting blood
FBC, U&E, LFTs, Crossmatch, clotting screen
154
mechanism causing bleeding oesophageal varices
Cirrhosis leads to portal hypertension (high pressure in portal venous system). When this pressure exceeds 10mmHg blood flow is redirected to a lower pressure system. This develops a collateral circulation around the lower oesophagus. As portal pressure increases, pressure increases in varices. They are thin walled and fragile and can burst causing UGIB.
155
diagnosing bleeding oesophageal varices
Upper GI endoscopy (OGD)
156
Glasgow Blatchford Score
can identify pts at low risk
(If GBS =0, risks of endoscopy outweigh benefits.)
157
Rockall Score
Calculates risk of re-bleeding and death
(good to know)
158
ix in MI
ECG, troponin at 0 and 3 h
later: CXR, echo
159
complications of MI
Arrhythmias (brady or tachy), Left ventricular failure, cardiac arrest, pericarditis/dresslers syndrome
160
RF MI
Smoking, Diabetes, hypertension, hypercholesterolemia, obesity, sedentary lifestyle, male gender, age, family history
161
medications discharged on after MI
B-Blocker, ACEI, aspirin, clopidogrel/ticagrelor 1 yr, Statin
162
driving after MI
4 weeks without driving if no successful revascularisation
1 week without driving if successful revascularisation
163
hyperkalaemia categories
Mild (5.5-6.5)
Moderate (6.5-8.0)
Severe (>8.0
164
when to tx hyperkalaemia
Treat hyperkalaemia if moderate/severe or if ECG changes
165
ECG changes mild hyperkalaemia
peaked T wave
prolonged PR
166
ECG changes moderate hyperkalaemia
loss of P wave
prolonged QRS
ST elevation
ectopic beats and escape rhythms
167
ECG changes in severe hyperkalaemia
widening QRS
sine wave
VF
asystole
axis deviation
bundle branch block
fascicular blocks
168
tx hyperkalaemia
Calcium Gluconate (10ml of 10% over 10min)
IV Insulin (10units) in IV glucose (50mls of 50%)
Regular monitoring of BMs and hourly K+ via bloods/VBG.
169
what can cause hyperkalaemia
medications: Spironolactone, lisinopril
AKI
170
reversible causes cardiac arrest
4H: hypoxia, hypovolaemia, hypo/hyperkalaemia, hypothermia
4T: thrombosis, tension pneumothorax, tamponade, toxins
171
shockable rhythms
VF/Pulseless VT
172
non shockable rhythms
Not shockable: PEA/Asystole
173
Which drugs are administered during a cardiac arrest?
Adrenaline 1mg IV/IO every 3-5mins,
Amiodarone 300mg IV/IO after 3 shocks
174
DKA definition
Hyperglycaemia ( >11.0mmol/L or known DM)
Acidosis (pH <7.3)
Ketonaemia ( >3.0mmol/L)
175
aims of DKA tx
Fall in ketones 0.5mmol/L/hr and glucose 3mmol/L/hr
Continue Insulin until ketones <0.3mmol/L, pH >7.3 and pt eating and drinking
176
mx DKA
IV 0.9% NaCl approx1L/hr
50units insulin in 50mls NaCl 0.9% at a rate of 0.1unit/kg/hr
Hourly VBG (glucose, HCO3- and K+) Add K+ to IVI as required
Add 10% glucose IV once BM <14mmol/l to run alongside NaCl
177
sx DKA
Drowsiness, vomiting, abdo pain, polyuria, polydipsia, lethargy, ketotic breath, deep breathing
178
non epileptic causes of zeizures
electrolyte abnormalities, alcohol withdrawal, benzodiazepine withdrawal, , hypoxia, hyponatremia, hypocalcaemia, hypoglycemia, uremia, encephalitis etc.
179
mx eplileptic seizures
Secure airway
High flow O2 and suction if required
IV lorazepam 4mg slow bolus if cannulated (buccal midazolam 5mg or rectal diazepam if not)
Repeat after 10 mins if seizure continues.
If seizures continue or recur in 30mins = Status Epilepticus
Phenytoin infusion 1-2g slow IVI (monitor BP and ECG)
ICU for RSI if lasting >60mins
180
initial approach
Control catastrophic haemorrhage
Airway and cspine
Breathin gwith ventilation
Circulation with haemorrhage control
Disability-neuro
Exposure/environment/everything else
181
MOI in major trauma
blunt force: RTC, assualt, fall
penetrating: shot, stab
sports
blast
182
how to handover
Age
Time
Mechanism
Injuries
Signs and obs
Treatment
183
mx catastrophic haemorrhage
direct pressire
indirect pressure: exclude proximal artery
torniquet: 2-3 inches above bleeding, 2nd one moreproximal if needed
haemostatic agents - ceetox
184
mx airway
jaw thrust
need to secure in 45m
rapid sequence indiction
c-spine
oxygen
listen and look
185
indications for intubation
cant mantain airway
cant oxygenate
cant mantain normocapnoea
decreasing consciousness
significant facial injury
seizures
burns: hypoxaemia, hypercanoea, deep facial, full thickness neck
relative: haemorrhage, shock, agitated, multiple painful injuries, transfer
186
canadian c spine high RF
>65
MOI: fall >1.5m, axial load
paraesthesia
187
canadian spine low RF
minor rear end motorcollison
comfortable sittinhg
ambulatory
no midleine tenderness
delayed onset neck pain
188
when ti imobilise c spine
canadian c spine
any high RF
if low RF and cant rotate head 45 degrees L and R
189
life threatening thoracic injuries
airway obstruction
tension pneumothorax
open pneumothorax
massive haemorrhage
flail chest
cardiac tamponade
190
features tension pneumothorax
blunt or penetrating injury
tracheal deviation late sign
increased HR, decreased BP, hypoxia, agitated
191
massive haemothorax
>15oo ml blood or >200ml/hr
192
presentation massove haemothroax
decreased air sounds
hyporesonant
193
mx open pneumothorax
3 sided seal dressing or will turn to tension pneumothorax
194
what is flail chest
fractured 2 or more ribs in 2 or more places
moves paradoxically during respiration
195
features cardiac tamponade
becks triad: decreased bp, decrased heart sounds, distended neck veins
196
mx cardiac tamponade
thoracotomy
197
signs of bleeding
decreased consciius, pale, sweaty, agitation, anxious
increased hr, increased rr, increased crt, narrow pulse pressure
198
bleeding compartments
thorax
abdo
pelvis
long bones
199
mx bleeding
permissive hypotension as too much fluid moves clot and makes worse
tranexamic acid
200
measuring neuro diability
AVPU
pupil size and response
GCS:motor best predictor
201
cushings triad
decreased HR and increased bp due to increased icp
irregular breathing
202
mx disability
prevent secondary brain injury
secure airway if gcs less than 8
control ventilation
normal icp, glucose and oxygen
203
what to look for in everything else
lumbs
keep warm
pain relief
204
what is major trauma
injury severity score (retrospective) >15
205
what is silver trauma
>65s
most commonly fal from standing
206
why does silver trauma happen
osteoporosis
polypharmacy
blood thinners
decresaed muscle mass, balance, stiff joints
207
radiology in trauma
now use CT
208
mechanism anaphylaxis
type 1 hypersnesitivity rxn which causes mast cell degranulation and histamine release
209
mx anaphylaxis
remove stimulus
A-E: focus on airway and 2 large bore cannulae
IM 1:1000 adrenaline to thigh (0.1mg <6m, 0.15mg 6m-6y, 0.3mg 6-12y, 0.5mg adults)
210
observation post anaphylaxis
24-48 hrs as biphasic rxn - more common in children
211
ix once stable after anaphylaxis
serum mast cell tryptase
also another within 6h
212
options for getting blood
group and save: get NONE - learn type and save
cross match: takes 45m
type specific: 20m, rarely used
O negative: can get from A&E and theatres and give to anyone
major haemorrhage protocol: 2222 and say MHP=4 uits RBC, 1 platelets, 3FFP brought by porter
213
what do you get in the major haemorrhage protocol
4 units RBC
1 platelts
3 FFP
and a porter to bring it all
214
Raised pCO2 and normal pH on ABG mx
Compensated
Therefore no panic
Sats 88-92%
Repeat ABG IF O2 demand increases
215
Raised PCO2 AND low PH mx
Acute T2RF
Urgent senior rev
Sats 88-92%
NIV (BiPAP)
216
T2RF causes
Copd
Obstructive sleep apnoea
Motor neurone disease
Guillean barre
Myasthenia gravis
Scoliosis
Resp fatigue
Opiates
Sedatives
217
Naloxone dose
IV or IM if no access
Can bolus 400mcg but usually give in smaller increments (50) unless peri arrest
218
Approach to reduced urine output
Is it actually low: norm=0.5ml/kg/hr, is it being measured accurately
Why: pre-renal (fluid status, med rev, sepsis), renal (urine dip), post renal (retention-bladder scan)
Ix; U&E, VBG hly input output chart
Trial IV fluid or encourage to drink if compliant
219
First mx low urine output
CHECK CATHETER
flush
Check isn't clamped
220
Mx hyperkalaemia
ALL AT THE SAME TIME
Cannula and repeat U&E
ask nurse to do ECG
Prescribe and ask nurses to givr calcium gluconate (1st priority) and insulin dextrose (50ml 50% Dextrose fluid with 10 units insulin in)
Senior input
Tx cause (AKI)
Other options for reducing K: salbutamol neb, sodium zirconium cyclosilicate/calcium resonium
Monitor response - need cardiac monitoring (if not on CCU/resus put on the defib Monitor), VBG within an hr
Monitor blood glucose
221
Less than what level is it unlikely to have ECG changes in hyperkalaemia
6
222
F1 role in major haemorrhage
FLUID BOLUS - ask nurse
2222 - major haemorrhage protocol +/- cardiac arrest
Bleep med reg
Try and limit bleeding - press artery, not much can do if GI
GET MORE ACCESS - large bore cannulas
223
Falls rev
Stable or caused by acute event (PE, bleed, stroke)
? CT head : anticoag, neurology, HI sx NICE CRITERIA
Other injuries: c spine, hips, joints
Why: Trip, BP, ECG
prevent: physio, mobility, supervision
