Wednesday [01/09/2021] Flashcards
(101 cards)
1
Q
What is the ATMIST method used in A+E?
A
Improves communication between medical practitioners, for team handover and crew briefing. Aage, name, DoB Ttime of incident Mechanism of injury Injuries/exam findings Signs [GCS/BM/Temp/BP etc.] Treatment given [drugs etc.]
2
Q
What preparations should be made before a trauma call out?
A
2222 inform seniors PPE prep resus room
3
Q
What’s hands off handover
A
Hands off, eyes on, mouth shut -> everyone stops to listen to handover
4
Q
First thing to do in trauma call out?
A
cABCDE c -> control by pressure/tourniquet
5
Q
What’s often early sign of major haemorrhage?
A
Tachycardia - though doesn;t exlcude major haemorrhage if patient doesn’t have it as can be bradycardic - hypotension late sign
6
Q
What is blood on the floor and four more?
A
Places of major haemorrhage likely 1. On the floor 2. Chest 3. Abdomen and retroperitoneum 4. Long bones
7
Q
Define shock
A
life-threatening conditions of circulation failure so inadequate O2 supply to organs so cellular and tissue hypoxia; no as vitals all still within normal range other than tachycardia and O2 at good level
8
Q
Steps to do in major trauma
A
- Obtain IV access -> need 2 large bore cannula in trauma 2. Start normal saline, ECG 3. FAST scan [focussed assessment of sonography in trauma] -> part of primary survey -> do it in four places on the patient 4. Moniotr urine output beause it’s important to see if in shock or not 5. Log roll patient and see if any back/neck trauma 6. feel pulss etc. and start secondary s
9
Q
Which blood tests would you ask initially in trauma?
A
Lactate good prognostic factor Group and save/crossmatch are essential too: crossmatch is for more severe bleeding that needs immediate blood
10
Q
When does pneumothorax occur?
A
Intrapleural air accumulates progressively with haemodynamic compromise -> life threatening occurence
11
Q
Sx pneumothorax
A
Blushing of skin, chest pain/ache/tightness, coughing, fatigue, fast breathing, fast HR
12
Q
Tx for tension pneumothorax
A
Important for quick recognition and rapid decompression Needle thoracotomy [e.g. 14G IV cannula] can be inserted, typically in the 2nd ICS in the mid-clavicular line to gain valuable time, before a larger underwater drain can be inserted
13
Q
Tenderness LUQ of the abdomen, no guarding/rebound tenderness in trauma patient. Is this suggestive of peritonism?
A
Yes - blood might still be pooling -> could be broken ribs/splenic rupture Repeat the exam 3-4 hours later
14
Q
Appropriate Ix for patient with trauma chest trying to find damage inside the body?
A
Ideal answer would be serial bosy examinations, but now time wise would be WBCT - head, neck, chest, abdo, pelvis - done when patients stable as patients can die [doughnut of death]
15
Q
WBCT has shown a small splenic laceration which the surgeons are keen to manage conservatively. His pelvis appears to be intact and there is no significant visceral injury in his chest. 18) What needs to be considered now?
A
No splenectomy as important organ to stop infection Femoral nerve block ideal
16
Q
What to do before fixing a femoral fracture?
A
XR check it’s displaced and not completely misshapen
17
Q
Pain relief for before/after Tx femoral fracture
A
- Check distal pulse and distal neurology before and after doing the procedure - Give morphine - entonox not strong enough here because a femoral fracture is extremely painful - Also, femoral nerve block (in the inguinal triangle) - used in addition to morphine
18
Q
Why wouldn’t you give patients with low BP in shock fluids
A
Won’t work as not hypovolaemic -> lowered BP becuase of compression of the major veins [IVC/SVC in the mediastinum]
19
Q
What injury could lead to an open pneumothorax?
A
Stab injury: open chest wound
20
Q
How to bandage open pneuothorax/
A
Occlusive dressing with 3-way tape for tension pneuothorax -> if completely occlude wound will lead to tension
21
Q
What is a flail chest?
A
Multiple rib fractures in 2+ places Disruption of chest wall movements Instability with paradoxical motion Hypoxia due to pain [shallow breathing] and underlying lung contusion Flail chest is a life-threatening traumatic condition that occurs when a segment of the rib cage breaks and becomes detached from the rest of the chest wall. … It occurs when multiple adjacent ribs are broken in multiple places, separating a segment, so a part of the chest wall moves independently. Specifically - 2 or more ribs in 2 or more places
22
Q
Mx of flail chest
A
- Adequate ventilate ventilation - Analgesia - Humidified O2 - Carefully controlled fluid resuscitation - Short period of intubation and ventilation
23
Q
What is a major haemorrhage?
A
More than 1500ml blood loss Absence of breath sounds Wall dullness shock simultaneous restoration of blood volume and decompression
24
Q
What should do if patient is stabbed and has cardiac tamponade initally?
A
Don’t remove the knife!
25
What's present in cardiac tamponade?
Beck's triad: - hypotension - jugular venous distention - muffled sounds
26
How many l of blood normal adult
5-6l
27
What are the 5 life threatening chest injuries?
1. Tension pneumothorax 2. Open pneumothorax 3. Massive hemothorax 4. Flail chest 5. Cardiac tamponade
28
What is tension pneuomothorax/
Air rupture lung enters pleural cavity without means of escape. As air pressure builds up, the affected lung is compressed and all the mediastinal tissues are displaced to the opposite ends of the chest
29
How to Dx tension pneuothorax?
Dx clinically before CXR obtained
30
Classical presentation of tension pneumothorax?
- Distended neck veins - Hypotension or evidence of hypoperfusion - Diminised or absent breath sounds on the affected side - and tracheal deviation tot he contralateral side - one or more of these elements may be absent in the presence of hypovolemia
31
Result of having unsealed opening chest wall in open pneuothorax?
Some patients with traumatic pneumothorax have an unsealed opening in the chest wall. When patients with an open pneumothorax inhale, the negative intrathoracic pressure generated by inspiration causes air to flow into the lungs through the trachea and simultaneously into the intrapleural space through the chest wall defect. There is little airflow through small chest wall defects and hence few adverse effects. However, when the opening in the chest wall is sufficiently large (when the defect is about two thirds the diameter of the trachea or larger), more air passes through the chest wall defect than through the trachea into the lung. Larger defects can eliminate ventilation on the affected side. Inability to ventilate the lungs causes respiratory distress and respiratory failure.
32
What is a massive hemothorax?
Blood loss \> 1,500 mL or 1/3rd of blood volume Blood loss \>200 mL/h (3 mL/kg/h) for 2-4 hours.
33
What's a massive hemothorax an indication for?
Indication for CT referral and thoracostomy
34
Mx of massive hemothorax
Fluids BLood Chest drain [5th ICS, site of skin incision]
35
Problems with flail chest
• Severe pain - multiple rib fractures • Paradoxical breathing • Lung contusion- alveoli filled with blood- no oxygenation • Poor ventilation and subsequent infection
36
Mx flail chest
• Pain relief - lots off it • Epidural - HDU • Chest physio • Look out for infection • May need IPPV • Cardiothoracic referral for fixation
37
How does tamponade cause hypotension
Heart does not stretch out fully between contractions -\> chambers don't fill properly -\> less CO -\> hypotension
38
How does Beck's Triad differ from tension pneuothorax/
Both 1. Hypotension 2. Jugular venous distention Becks = muffled heart sounds Tension = absent breath sounds
39
Mx for cardiac tamponade?
Pericardiocentesis -\> under US guidance and cardiac monitoring [don't know if still used now?]
40
Tx blood loss
• 2 large bore cannula • Blood cross match • Fluids - crystalloids • 10ml/kg - ATLS resuscitation - assess response • Upto 3 lots of fluids • Permissive hypotension - aim for BP of 90 systolic .Enough to maintain vital organ perfusion.
41
What is permissive hypotension?
Permissive hypotension - aim for BP of 90 systolic .Enough to maintain vital organ perfusion.
42
Define massive transfusion
Massive transfusion is defined, in adults, as replacement of \>1 blood volume in 24 hours or \>50% of blood volume in 4 hours (adult blood volume is approximately 70 mL/kg).
43
What to history/exam diabetic patient before surgery?
- Diagnosis when - Type of diabetes - Usual diabetes medication - HbA1c level [within 3 months] - CBG level - Inspect foot/pressure areas - Metabolic status [renal profile, lactate, ketones, electrolytes, bicarbonates documented] - ABG - Evidence of end organ damage [neuropathy, retinopathy, nephropathy, CVD] and co-morbidities
44
Starvation rules theatre
- Usually, 6 hours w/o food, 2 hours for fluids
45
What could happen if patient continues to take oral diabetic medication whilst fasting?
hypo
46
Which DM medication particular risk hypo surgery
- Sulfonylureas are associated with hypoglycaemia in the fasted state and therefore should always be omitted on the day of surgery until the patient is eating and drinking again. Capillary blood-glucose should be checked hourly. If hyperglycaemia occurs, an appropriate dose of subcutaneous rapid-acting insulin may be given. A second dose may be given 2 hours later, and a variable rate intravenous insulin infusion considered if hyperglycaemia persist
47
Which people is sliding scale used to manage DM?
- The VRIII is the preferred method of managing the surgical patient’s serum glucose in the following circumstances: o people with Type 1 or 2 diabetes undergoing surgery with a fasting period with more than one missed meal o people with Type 1 diabetes undergoing surgery who have not received background insulin. o people with suboptimal diabetes management as defined as an HbA1c \>69mmol/mol (\>8.5%) o most people with diabetes requiring emergency surgery. o people with persistent hyperglycaemia (CBG \>12mmol/l) in the perioperative period in the context of acute decompensation - I guess he’s undergoing surgery with a fasting period of more than one missed meal -\> so I think he’s a sliding scale candidate
48
Where should DM patients be put on a surgical list?
- National guidelines advocate minimising preoperative fasting and to ensure this, people with diabetes should have surgery first on the list
49
When to restart taking DM after surgery?
- promote restoration of usual diet and restoration of normal diabetes medications but note doses may need to be adapted, check the patients surgical care document and discuss with the person with diabetes - If you miss a dose of an oral medication, take the dose as soon as possible after realizing you missed it. However, if it’s been more than a few hours since the missed dose and you’re getting close to the next dose, skip the dose and take the next dose at its regular time. Don’t double the dose - See above guidance on Sulphonylureas
50
What happens in a patient with T1DM omits insulin
possible DKA
51
Concentration should insulin be RX T1DM surgery
Once daily long acting, no dose adjustment prior to admission then 80% dose on surgery day, with BM to be checked constantly
52
Which IV fluids to run for sliding sclae patient, how to choose whihc fluids to run?
- Start IV infusion of potassium chloride with glucose and sodium chloride [based on serum electrolytes and measured frequently] - Also, variable rate of IV insulin in sodium chloride 0.9% should be given via syringe pump at an initial rate determined by bedside capillary blood-glucose measurement. Hourly blood-glucose measurement should be taken to ensure that the intravenous insulin infusion rate is correct for at least the first 12 hours; the insulin infusion rate should be adjusted according to local protocol to maintain blood-glucose concentrations within the usual target range (6–10 mmol/litre; up to 12 mmol/litre is acceptable)
53
Anything added to the IV fluids?
Dextrose 5%
54
How is the rate of insulin infusion adjusted?
- Based on the blood-glucose concentrations [target range 6-10mmol/l; up to 12mmol/l acceptable]
55
How to manage patient morning surgery DM going into a coma due to hypo?
- intravenous glucose 20 % should be given if blood-glucose drops below 6 mmol/litre, and blood-glucose checked every hour, to prevent a drop below 4 mmol/litre. If blood-glucose drops below 4 mmol/litre, intravenous glucose 20 % should be adjusted and blood-glucose checked every 15 minutes, until blood-glucose is above 6 mmol/litre (testing can then revert to hourly).
56
What would do if patient with hypo didn't have IV access?
1mg glucagon IM
57
How does emergency surgery differ from elective surgery when managing pts with DM?
- Patients with diabetes (type 1 and 2) requiring emergency surgery, should always have their blood-glucose, blood or urinary ketone concentration, serum electrolytes and serum bicarbonate checked before surgery. If ketones are high or bicarbonate is low, blood gases should also be checked. If ketoacidosis is present, recommendations for Diabetic ketoacidosis should be followed immediately, and surgery delayed if possible. If there is no acidosis, intravenous fluids and an insulin infusion should be started and managed as for major elective surgery (above).
58
Why might blood sugar be elevated in an unwell surgical patient?
- Surgery is a stressful event, and hyperglycaemia is common. Date demonstrates that a CBG \>10mmol/l is associated with harm. However, it is also recognised that excess insulin treatment is also associated with harm. Therefore, for pragmatic reasons, it is suggested that whilst CBGs up to 10mmol/l are preferred, treatment should occur once CBG\>12mmol/l. Causes include: o Hospital acquired DKA [commonly in T1DM] o Hyperosmolar hyperglycaemic state or HSS [commonly in T2DM] o Stress hyperglycaemia o Insufficient medication for example omission of insulin, disconnection/blockage of CSII o Sepsis/infection
59
What problems may hyperglycaemia cause in a surgical patient?
- Diabetic coma - Dehydration and low blood pressure -\> poor organ perfusion and ischaemia - Kidney/nerve/eye damage - Risk of strokes/heart attacks
60
Rate to start patient insulin at?
- If neither DKA [check ketones, bicarbonate and venous pH], HSS [hypovolaemia, hyperglycaemia, osmolality over 320mOsm/kg] or on CSII, consider correction dose of subcutaneous rapid acting analogue insulin. Insulin correction doses for people with T2DM - give 0.1units/kg of subcut rapid acting analogue insulin recheck blood glucose one hour later to ensure it is falling - repeat the subcut insulin after 2h if the blood glucose is still above 12mmol/l - in this situation the insulin dose should take into account the response to the inital dose. COnsider odubling he dose if the rewsponse is inadequet, but not ethe risk of hypo with stacking indulin in fasted cases - repeat the BM after 60-90m, if it's not falling htne consider introudcing VRIII
61
Define HSS
hypovolaemia, hyperglycaemia, osmolality over 320mOsm/kg
62
Criteria to Dx DKA
- Hyperglycaemia \>11mol/l or known DM - Presence of ketones \>3mmol/l or significant ketonuria [\>2+ on dipstick] - Venous pH\<7.3 and/or bicarbonate \<15mmol/l
63
PP of DKA
Pathophysiology of DKA Insulin deficiency causes the body to metabolize triglycerides and amino acids instead of glucose for energy. Serum levels of glycerol and free fatty acids rise because of unrestrained lipolysis, as does alanine because of muscle catabolism. Glycerol and alanine provide substrate for hepatic gluconeogenesis, which is stimulated by the excess of glucagon that accompanies insulin deficiency. Glucagon also stimulates mitochondrial conversion of free fatty acids into ketones. Insulin normally blocks ketogenesis by inhibiting the transport of free fatty acid derivatives into the mitochondrial matrix, but ketogenesis proceeds in the absence of insulin. The major ketoacids produced, acetoacetic acid and beta-hydroxybutyric acid, are strong organic acids that create metabolic acidosis . Acetone derived from the metabolism of acetoacetic acid accumulates in serum and is slowly disposed of by respiration. Hyperglycemia due to insulin deficiency causes an osmotic diuresis that leads to marked urinary losses of water and electrolytes. Urinary excretion of ketones obligates additional losses of sodium and potassium. Serum sodium may fall due to natriuresis or rise due to excretion of large volumes of free water. Potassium is also lost in large quantities, sometimes \> 300 mEq/24 hours (\> 300 mmol/24 hours). Despite a significant total body deficit of potassium, initial serum potassium is typically normal or elevated because of the extracellular migration of potassium in response to acidosis. Potassium levels generally fall further during treatment as insulin therapy drives potassium into cells. If serum potassium is not monitored and replaced as needed, life-threatening hypokalemia may develop.
64
Risk of administering too much fluid
- Fluid overload -\> HBP, anxiety, trouble breathing
65
What electrolyte disturbances can be caused whilst treating DKA? How can you minimise this?
- Hypokalaemia: include potassium chloride in the fluids unless anuria is suspected; adjust according to plasma-potassium concentration (measure at 60 minutes, 2 hours, and 2 hourly thereafter; measure hourly if outside the normal range). - Also, hyponatraemia: infuse with sodium chloride 0.9%
66
WHy should you inform patients of the Sx and Sx of DKA?
"In several cases, blood glucose levels were only moderately elevated (eg \<14mmol/L)—representing an atypical presentation for DKA, which could delay diagnosis and treatment. Therefore, inform patients of the signs and symptoms of DKA (eg rapid weight loss, feeling sick or being sick, stomach pain, fast and deep breathing, sleepiness, a sweet smell to the breath, a sweet or metallic taste in the mouth, or a different odour to urine or sweat) and test for raised ketones in patients with these signs and symptoms."
67
What are the 3 main opiates that have major pscyhoactive effects?
Morphine, codeine and thebaine
68
Types of opioids [synthetics]
Fentanyl, heroin, hydromorphone, meperidine, methadone, oxymorphone
69
How much more potent is fentanyl than morphine?
Around 100 times stronger
70
How strong is alfentanyl?
Around 10 times stronger than morphine [so 10 times less stronger than morphine]
71
Why do opiates cause constipation?
They slow down the bowel motility -\> moisture taken out from the stool -\> gets stuck int eh bowel
72
What advice exists for SGLT2 inhibitors that has been updated?
Test for raised ketones in patients with ketoacidosis symptoms, even if plasma glucose levels are near-normal Advice for healthcare professionals: When treating patients who are taking a sodium-glucose co-transporter 2 (SGLT2) inhibitor (canagliflozin, dapagliflozin, or empagliflozin): • inform them of the signs and symptoms of diabetic ketoacidosis (DKA) – see below – and advise them to seek immediate medical advice if they develop any of these • discuss the risk factors for DKA with patients (see below) • discontinue treatment with the SGLT2 inhibitor immediately if DKA is suspected or diagnosed • do not restart treatment with any SGLT2 inhibitor in patients who experienced DKA during use, unless another cause for DKA was identified and resolved • interrupt treatment with the SGLT2 inhibitor in patients who are hospitalised for major surgery or acute serious illnesses; treatment may be restarted once the patient’s condition has stabilised • report suspected side effects to SGLT2 inhibitors or any other medicines on a Yellow Card
73
RFs for DKA in SGLT2 inihibitors
The mechanism by which SGLT2 inhibitors might lead to DKA has not been established. However, the following factors may predispose patients taking an SGLT2 inhibitor to DKA: • a low beta cell function reserve (eg, patients with type 2 diabetes who have low C-peptide levels, latent autoimmune diabetes in adults [LADA], or a history of pancreatitis) • conditions leading to restricted food intake or severe dehydration • sudden reduction in insulin • increased insulin requirements due to acute illness • surgery • alcohol abuse Discuss these risk factors with patients and use SGLT2 inhibitors with caution in patients who have them.
74
Why isn't 50% glucose infusions used anymore?
They are hyperosmolar and increase the risk of extravasation injury -\> so only 10-20% glucose solutions preferred now
75
When is IM glucagon used?
IM glucagon only Rx for insulin OD, although it is also used in the Tx of hypoglycaemia by sulfonurea therapy.
76
What is normal blood glucose w/o DM?
3.5-7
77
Concerning BM measurement in surgery
Diabetes Uk say "make 4 the floor"
78
What is atropine?
Antimuscarinic. Tx of intra-operative bradycardia/excessive bradycardia assocaited with beta blocker use
79
Midazolam
Can be used for induction of anaesthesia or for status epilepticus
80
Suxamethonium
Mimicks acetylcholine at NMJ and neuromuscular blockage during surgery/intubation
81
Propofol
Drug that killed MJ: - induction of anaesthesia - decreased LOC and retrograde memory
82
Rocuronium
Non-depolarising neuromuscular blocker widely used to promote muscle relaxartion to help faciliate surgery and tracheal intubatino
83
Phenylephrine Hcl
Used for acute hypotension
84
What is PEEP?
General anaesthesia causes atelectasis, which can lead to impaired respiratory function. Positive end-expiratory pressure (PEEP) is a mechanical manoeuvre that increases functional residual capacity (FRC) and prevents collapse of the airways, thereby reducing atelectasis. It is not known whether intraoperative PEEP alters the risks of postoperative mortality and pulmonary complications.
85
Diabetes in pregnancy known as what?
Gestational diabetes
86
Age over should you get eye screening diabetes?
12
87
How common T1DM
Around 8% DM patients have type 1
88
Clinical features of hypoglycaemia
pic
89
CXR shows?
CXR of tension pneumothorax
90
CLinical findings massive hemothorax
picture
91
CXR
CXR of massive hemothorax
92
Trauma triad of death
pic
93
After fluid bolus given
pic
94
Which fluid Rx to resus patient? How should this be started?
pic
95
She tells you she is 8 stone, what rate to infuse her?
5 units per hour
96
How often will you measure her BM and ketones?
- Monitor blood-ketone and blood-glucose concentrations hourly and adjust the insulin infusion rate accordingly. Blood-ketone concentration should fall by at least 0.5 mmol/litre/hour and blood-glucose concentration should fall by at least 3 mmol/litre/hour.
97
Go through algorithm for Tx and Mx of hypoglycaemia in adults with DM in hospital
98
Identify the vocal cords
pic
99
Anatomy of ENT
pic
100
How to manage adult with hypoglycaemia who are conscious and able to swallow?
pic
101
Mx of DKA
