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1

Causes of a metabolic acidosis?

Normal anion gap
- Renal tubular acidosis
- Dehydration
- Addisons

Raised anion gap
- Sepsis, hypoxia (Raised lactate)
- DKA (raised ketones)

2

Causes of a metabolic alkalosis?

Cushings
Conns
Diuretics
Vomiting/aspiration
hypokalaemia (H+ is sucked into cells, in exchange for K+ into ECF)

3

Max length of QT?

2 big squares

4

Max length of PR interval?

1 big square

5

Max length of QRS?

3 small squares

6

Indicators of pancreatitis severity?

PaO2< 7.9kPa
Neutrophils (WBC > 15)
Calcium < 2 mmol/L
Albumin < 32g/L (serum)
Sugar (blood glucose) > 10 mmol/L

7

What differentiates Ascending cholangitis and Cholecystitis?

Jaundice

8

Management of pancreatic pseudocysts?

If they are systemically well then conservative.

However, if not: The indications for active drainage would be signs of infection, mass effect on abdominal organs or a persisting pseudocyst beyond 12 weeks from it developing.

9

Common presentation of chronic pancreatitis?

Abdominal pain following meals, pancreatic enzymes, steatorrhoea, and diabetes.

10

Most common causative organism for ascending cholangitis?

E.Coli

11

What is the causes of a pulmonary effusion?

Transudate:
- HF
- Hypoalbuminaemia
- Liver cirrhosis

Exudate:
- Pneumonia
- Malignancy

12

A-E proforma?

A
- Patent? Are they talking, is there anything in there?

B (RESPS)
RR
Exertion
Sats
Percussion
Sounds (auscultation)

C (in a c, start at hands)
- Hands warm/well perfused
- Cap refill
- Radial pulse
- Carotid
- JVP
- Central cyanosis
- Heart sounds

D (GAPSS)
- Glucose/Don't forget glucose
- AVPU
- Pupils
- Pain
- Seizures

Expose, examine abdomen

13

4 Hs and Ts of reversible causes of cardiac arrest?

Hypovolaemia
Hypothermia
Hypoxia
Hyperkalaemia

Tamponade
Tension Pneumothorax
Toxins
Thrombus (PE)

14

General run-through of advanced life support?

DR ABC
- Dynamic assessment
- Response
- Shout for help
- Airway: Head tilt/chin lift, check there is nothing obstructing the airway
Breathing: Feel carotid and breath at same time, whilst maintaining head tilt/chin lift

Chest compressions
- 30:2 chest compressions to rescue breaths
- Stop compressions every 2 mins for 5 sec rhythm checks and rescue breaths (NOT ventilations)
- Switch compressor every 2 mins

Defib
- Other person attaches pads (>8cm from pacemaker, move jewellery, can do AP if needed)
- Connect pads to defib and set to monitor
- Check rhythm every 2 mins, if lines are wavy then it is shockable (VF/VT), if asystole of PEA non shockable.

Drugs/IV access
- Get access and take VBG, bloods and give fluids
- If shockable the after 3rd shock give IV adrenaline 10ml 1 in 10,000 (flush with 20ml N saline) and amiodarone (300mg), repeat adrenaline every 4 mins (every other rhythm check)
- If not shockable immediately give adrenaline

15

What are the shockable/non-shockable rhythms?

VF/VT
- wavy lines

PEA (normal) or Asystole are non shockable

16

Management of acute asthma exacerbation, and classification?

Classify it:
1. Do PEFR

PEFR <33% (33, 92 CHEST) - life threatening
33: PEFR <33% predicted
92: sats <92
Cyanosis
Hypotension
Exhaustion
Silent chest
Tachycardia

PEFR: <50%: severe

PEFR: <75%: Moderate

PEFR: >75% Mild

Treatment (O SHIT ME)
Give all together:
- Oxygen, 15L, non-rebreathe
- Salbutamol Nebs, 2.5mg, back to back initially
- Hydrocortisone 100mg IV
- Ipratropium 500mcg Neb

If needed with senior input:
- Theophylline (aminophylline infusion)
- Magnesium Sulphate 2g IV over 2 mins
- Escalate

17

Management of COPD exacerbation?

- O SHIT (as in asthma, but give o2 24-28% via venturi)
- Abx as per local guidelines
- Chest physio
- Consider BiPAP

18

PE management?

A-E if critically unwell

Confirm/exclude:
- Wells score
Investigate severity:
ECG changes (Sinus tachy or Rv strain) CXR (infarcts), echo (R strain)

Wells 4 or less, then D-Dimer
Wells 5 or more then LMWH (1.5mg/kg OD), CTPA when poss then therapeutic anticoag for 6 months (DOAC)

Thrombolysis if haemodynamic instability

19

ACS acute Management?

A-E

MONAC

- Morphine 10mg in 10ml slow IV (& 10mg metaclopramide IV)
- Oxygen (IF sats <98%)
- Nitrates: Sublingual GTN
- Aspirin 300mg loading dose (75mg OD after)
- Clopidogrel 300mg loading dose (then 75mg OD)

20

Acute management of Pulmonary oedema?

A-E:
To include:
- ECG, CXR, Echo, Catheterise (strict fluid balance), serial weights, BNP, ABG

POD MAN
Position upwards
Oxygen high flow
Diuretics (furosemide IV, 40mg initially)

Morphine (5-10mg, 2mg/min, 5 if elderly or frail)
Anti-emetic (metoclopramide 10mg IV)
Nitrates if severe (>110 BP then infusion >90 then 2 puffs spray)

21

Acute management of arrhythmia?

A-E if critically ill
- No pulse: ALS
- Adverse signs (Sys <90, Syncope, chest pain or ischaemia on ECG, HF)
-- Tachy: DC cardioversion
-- Brady: Atropine & pacing

If no adverse signs (call cardio reg?)

- 3 lead telemetery,
- Treat reversible causes (e.g. electrolyte disturbance)

Narrow complex tachy:
- Paroxysmal SVT:
1. vagal maneuvers
2. Adenosine (not in asthma) - use verapamil
3. B Blocker

- AF: Rate/rhythm control

Broad complex tachy:
VT - amiodarone, torsades - Mag sulf

Brady:
- treat cause (sinus/sick sinus/Heart block type 2)

22

Upper GI bleed acute management?

Usual A-E to include:
- Look for chronic/decompensated liver disease
- Melaena (PR)
- Bloods: G&S/Crossmatch, FBC. U&Es (urea), LFTs, Clotting, glucose
- Catheterise
- IV fluid resuscitation aiming for SBP 100
- If massive blood loss do local major haemorrhage protocol, FFP, platelets and blood.
- If Hb <7 or 8 then transfuse blood

Investigations once stable:
- CXR, AXR, OGD once stable

If varcieal bleed (signs of chronic liver disease)
- Terlipressin
- Prophylactic IV abx
- Endoscopic intervention

If non-variceal
- Straight to endoscopy
- After endoscopy IV PPI

23

Causes of Upper GI bleed?

Variceal bleed

Ruptured peptic ulcer

Oesophagitis

Mallory weiss tear

24

Acute management of DKA?

1. A-E

2. Confirm DKA with VBG, Urine Ketones and Glucose
- Acidosis pH <7.3
- Glucose >11 or known diabetic
- Ketones ++ urine

3. Fluids
1L over 1 hr - No KCl
1L over 2 hr
1L over 2 hr
1L over 4 hr
1L over 4 hr
1L over 6 hr
1L over 6 hr

After first litre add KCl dependent on VBG results

4. IV insulin at 0.1 units per kg per hour in 50ml of N saline, when you get Glucose below 14 start to also give 10% glucose at 125ml/hr and reduce saline rate in the insulin infusion.

Investigate to find cause
- Hx
- Examination
- Notes
- Bloods, culture, MSU CXR

Consider ITU if GCS<12, ketones > 6, SBP <90, Sats <92.

Check VBGs 2 hrly

Continue Long acting insulin throughout, if new presentation start long acting insulin

25

HHS acute management?`

Conform diagnosis
- >30 glucose, no ketones
- >320 serum osmolarity
- Hypovolaemia

Management
1. rehydrate with normal saline (same as DKA):
1L over 1 hr - No KCl
1L over 2 hr
1L over 2 hr
1L over 4 hr
1L over 4 hr
1L over 6 hr
1L over 6 hr

2. VTE prophylaxis

3. IV insulin at 0.05 units/kg/hour

Look for cause and hold metformin for 2 days (metabolic acidosis)

26

Acute mangement of hyperglycaemia (No DKA/HHS)?

Rehydrate if necessary

STAT dose of actrapid:
In T1DM aim for <12 glucose, one unit decreases by 3
In T2DM give 0.1unit/kg, aim for <14 glucose.

Identify and correct cause (are they taking their insulin correctly?)

Reasses in 1 hr

27

Acute management of Hypoglycaemia?

Unconscious
- 150ml 10% glucose/ 75ml 20%
- Glucagon 1mg IM if no IV access
- check glucose 10min later, give long acting carbs when conscious

Conscious, no swallow
- 2 tubes of glucose gel around teeth
- Check glucose 10min later

Can swallow
- 150ml fruit juice, 5 glucose tabs
- Long acting carbs

Correct cause and consider reducing insulin dose (do not omit.

28

Stroke acute management? inc hx and ex

Hx
- exact time of onset
- Progression of symptoms
- r/fs

Ex
- Full neuro exam
- Pulse, HS, bruising/bleeding, carotid bruits

Management

1. CT head within 1 hr

2. If intracranial bleed excluded:
- Alteplase if within 4.5 hrs & not contraindicated.
- If contraindicated aspirin 300mg PO OD for 2 weeks or Clopi 300mg stat followed by 2 weeks 75mg

Consider endovascular clot retrieval & transfer to stroke ward.

29

TIA acute management? inc hx and ex

Hx
- exact time of onset
- Progression of symptoms
- r/fs

Ex
- Full neuro exam
- Pulse, HS, bruising/bleeding, carotid bruits

1. Aspirin 300mg PO OD for 2 weeks or Clopi 300mg stat followed by 2 weeks 75mg
- If already on anti-platelet then continue
- If in AF start anticoagulation

Specialist r/v within 24 hrs

30

How long can't you drive after stroke?

4 weeks