Y4 Medicine > Acute > Flashcards

Acute Flashcards

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1
Q

ABCDE - Airway

A

Is the airway patent?
* If they can talk to you = yes
* Sounds of obstruction = added sounds / silence / cyanosis
If not patent;
1. Jaw thrust (avoid healt tilt due to risk of C spine injury)
2. NPA - do not do this is suspecting basal skull fracture
3. OPA - only it patient is unconcious
4. If these fail = ET intubate + call anesthetist

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2
Q

ABCDE - Breathing

A

Observations:
* RR
* Sp02
* Assess for any obvious cyanosis

Examination;
* Feel - for tracheal deviation / chest wall movements
* Percuss chest
* Ausculate chest + denote breath sounds

Action;
1. 15L non-rebreathe 02 - almost all pts should get this
2. Aim to keep sats 94-98%
3. Request ABG + CXR
4. Needle decompression if tension pneumothorax is present

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3
Q

ABCDE - Circulation

A

Observations;
* Pulses - rate, rhythm, character
* CRT
* BP

Examination;
* Cardiac examination - look for JVP then auscultate the heart sounds + check for oedema.

Interventions;
1. Gain IV access
2. Bloods + blood cultures
3. 12 lead ECG
4. Measure Urine output
5. Give IV fluids if hypovolemic - 500ml bolus over 15 mins
6. If haemorrhaging - stop the bleed / TXA

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4
Q

ABCDE - Disability

A

Assesment;
* GCS / AVPU
* Pupillary size + reactivity
* Glucose
* Urine dipstick

Interventions;
* Consider oral glucose/detrose if needed, naloxone if indicated
* Head CT id indicated

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5
Q

ABCDE - Exposure

A
  • Temerature
  • Check skin for swelling (+ roll patient over)
  • Calf swelling
  • Bleeding
  • Signs of infection
  • Abdominal palpation
  • Fuller examination of relevant systems
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6
Q

Anaphylaxis

A

Common causes = foods, insect venom, latex, antibiotics, anaesthetic, contrast, NSAIDs, vancomycin

Sx; Sudden onset + rapid progression of;
* Airway problems - stridor, swelling of throat/tongue
* Breathing = respiratory wheeze + SOB/dyspnoea
* Circulation = Hypotension + Tachycardia
* Generalised pruritus
* Widespread erythematous / urticarial rash

Management;
1. IM Adrenaline - 0.5mg repeat every 5 minutes
2. IV fluids bolus 500ml
3. Chlorphenamine 10mg (adults) - IM or slow IV
4. Hydrocortisone 200mg

Monitor. & Beware for biphasic anaphylaxis (recurrence within 72hours)

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7
Q

Cardiac Tamponade

A

= Accumulation of blood (or fluid or gas) in the pericardial space.
Causes = Trauma / post surgery / CABG / Malignancy / post MI / Renal failure / Aortic dissection / Pericarditis

Features: **Beck’s triad **
1. Hypotension
2. Raised JVP
3. Muffled heart sounds

Additional = SOB / Tachycardia / Chest pain / Pulsus paradoxus / Abdo pain

Investigations;
1. ECG = electrical alternans (alternating amplitude/axis of the QRS complexes)
2. Echocardiogram

Management = Thoracotomy (definitive management) / Urgent needle pericardiocentesis can be done in peri-arrest to buy time

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8
Q

Main differences between Cardiac Tamponade + Constrictive pericarditis

A

Tamponade = Absent Y descent on JVP.
Constrictive pericarditis = X + Y are both present on JVP. Kussmaul’s breathing more common. Also won’t have pulsus paradoxus.

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9
Q

Tension pneumothroax Features

A

Pt typically presents wth sudden onset;
1. Dyspnoea
2. Tachypnoea / ARDS
3. Tachycardia
4. Hypotension

Signs on examination;
* Absent breath sounds + Hyper-resonance to percussion - on the affected side
* Tracheal deviation - *away from the affected side *
* Distended neck veins

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10
Q

Management of suspected tension pneumothorax

A

Clinical diagnosis - can get CXR to confirm it but do not wait for this it patient is deteriorating.

  1. High flow 02
  2. Immediate decompression (IV cannula into 2nd intercostal mid-clavicular line)
  3. Axillary chest drain
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11
Q

Triangle of safety for chest drain

A

5th intercostal space, mid-axillary line between latissimus dorsi + pec major.

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12
Q

Open pneumothorax

A

A.K.A traumatic pneumothorax (Occurs when there is a large open wound to the chest)
This is when the pleural cavity pressure = Atmospheric pressure.

Management;
* Cover with sterile dressing securing 3 sides to the chest wall, leaving one side free. (allowing air to escape but not enter)
* Insert chest drain
* Surgery

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13
Q

Massive Haemothorax

A

Accumulation of blood in the pleural space following trauma.

Sx;
* Hypovolemic shock - hypotension + tachycardia + prolonged CRT
* Dull percussion of the chest wall (unlike tension pneumothorac which is hyper-resonant)
* Reduced breath sounds on affected side
* Collapsed neck veins

Management = IV fluids + Large bore chest drain. + Surgical thoractomy if >1500ml of blood comes out

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14
Q

Fat embolism

A

Presence of fat globules in the lung parencyhma + peripheral circulation.
Cause = typically occurs after trauma - mainly associated with long bone or pelvic fractures.

Sx;
24-72 hours post injury with;
1. Respiratory distress - Dyspnoea + tachypnoea + Hypoxia
2. Neurological abnormalities - confusion + focal neurological signs + seizures
3. Petechial rash

May mimic DIC with coagulation abnormalities, may have renal changes and you may see soft fluffy exudates with macula oedema scotoma

CXR = snowstorm appearance

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15
Q

Management of severe burns

A
  1. IV fluids (parkland formula)
  2. Urinary catheter
  3. Analgesia
  4. Send to burn unit if complex burn involving perineum, hands or face.
  5. Surgical excision/skin grafting
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16
Q

Mrs smith

Causes of Atrial Fibrillation

A

Mitral regurgitation
Sepsis
Mital stenosis
Ischemic heart disease
Thyrotoxicosis
HTN

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17
Q

Atrial fibrillation ECG

A

Absent P waves.
Narrow complex tachycardia
Irregularly irregular rhythm

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18
Q

Peri-arrest tachycardia Management

A
  1. ABCDE - give 02, Obtain IV access, Monitor ECG, BP, sats + Identify and treat reversible causes.
  2. If any life threatening feeatures = Synchronised DC shock (up to 3 attempts). If unsuccessful - give IV Amiodarone 300mg over 10-20 mins, then repeat the shock.

Broad-complex tachycardia - no life threatening Fx;
1. If regular rhythm - assume VT and give loading dose Amiodarone 300mg IV, followed by a 24hr infusion
2. If irregular = seek expert help (could be AF with BBB or Tdp - which needs magnesium 2g)

Narrow-Complex tachycardia (<0.12ms) - no life threatening Fx;
1. Regular = vagal manouevre followed by IV Adenosine 6mg to start, then 12mg, then 18mg. - IF this does not work consider Atrial flutter and give rate control
2. Irregular rhythm = AF so try cardioversion with flecainide or amiodarone or Electrical cardioversion

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19
Q

Initial Management of ACS

A

Initial management = Aspirin 300mg, 02, Morphine + Nitrates (GTN x2), gain IV access, do bloods, do ECG.

Use GRACE score to calculate 6 month mortality risk.
* High risk = Urgent coronary angiogram + PCI
* Intermediate risk = Early coronary angiogram + PCI (<72hrs)
* Low risk = Medical management

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20
Q

BATMAN

Medical management of ACS (low risk)

A

Beta-blockers
Aspirin 300mg stat dose
Ticagrelor 180mg stat (or clopi)
Morphine
Anticoagulant (e.g fondaparinux)
Nitrates

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21
Q

Secondary prevention after ACS

A

Aspirin
Antiplatelet (ticareglor/clopi)
Atorvostatin 80mg
ACEi
Atenolol
Aldosterone antagonist - if HF present

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22
Q

Assesing the extent of burns

A

**Simple rule **= the palmar surface is around 1% of TBSA - this is good for measuring small burns but no good for ones >15% TBSA.

Wallace’s rule of 9s;
* Head & neck = 9%
* Anterior chet = 9%
* Each arm = 9%
* Anterior abdomen = 9%
* Posterior abdomen = 9%
* Each anterior part of the leg = 9%
* Each posterior part of the leg = 9%

Lund & Browder chart = a more reliable way of assesing the extent.

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23
Q

Depth of burns

A
  1. First degree = superfifical epidermal. Red, glistening skin + Painful. No blisters. will heal in 7 days.
  2. Second degree - Superficial dermal = Pale pink + painful, blistered and weeping/wet. 2-3 weeks to heal with minimal scarring.
  3. Second degree - deep dermal = Typically white, may have patches of non-blanching erythema. Reduced sensation. Painful to deep pressure. No CRT. 3-8 weeks to heal with scarring.
  4. Third degree - full thickness = White (waxy) or Brown (leathery) or black in colour. No blisters & no pain. Requires surgical repair and grafting
  5. Fourth degree = sub dermal = includes subcut fat, muscle and sometimes bone. Requires reconstruction and sometimes amputation.
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24
Q

Parkland formula

A

= Used for burns with >15% TBSA.

Total fluid require in 24hrs = 4ml X TBSA X Weight (kg)

50% given in first 8 hours, then 50% in next 16.
Crystalloid only (e.g hartmann’s)

After 24hrs start colloid fluids (Albumin/FFP) at 0.5ml X TBSA X Weight followed by a maintenance (dextrose-saline) at 1.5ml

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25
Smoke inhalation injury
Features; * Face/neck burns * Singeing of eyebrows + nose hairs * Carbon deposits + inflammation in oropharyngx * Carbon particles in sputum * hoarse voice * Carboxyhb >10% * SOB, Stridor, dribbling etc Management = ET intubation if stridor. Flexible bronchoscopy can help assess damage. If CO poisoning = hyperbaric 02 salbutamol if bronchospasm. IV fluids
26
A **unilaterally dilated pupil which is sluggish to react to light** in pt with head injury may indicate what
3rd nerve compression (may be due to tentorial herniation) Can also cause a bilateral dilated pupil if its a bilateral 3rd nerve palsy
27
Causes of bilateral pupil constriction
Opiates Pontine lesions Metabolic encephalopathy
28
Red flags for head injury requiring urgent CT scan
* GCS <13 on initial assesment * GCS <15 2 hours post injury * Suspected open/depressed skull fracture * Sign of basal skull fracture - *panda eyes, CSF leak, battle sign* * Post-traumatic seziure * Focal neurological deficit * 1+ episode of vomitting Other red flags (requiring CT in 8 hours) = Age >65, Bleeding disorders, Anticoagulation, Dangerous mechanism of injury, 30+ Minutues of retrogade amnesia.
29
Anti-cholingeric overdose
Agents = Carbamazepine / Antihistamines / TCAs Sx; * Urinary retention, bowel retention * Hyperreflexia * Hyperthermia * Dry mouth * Warm skin, Anhydrosis etc O/E = Tachycardia, Tachypnoea, Mydriasis Management = IV bicarb if arrythmia, seizure or acidosis. (if they go into VT may require amiodarone)
30
TCA overdose
Common. Usually amitryptyline or Dosulepin. Features = Dry mouth, Mydriasis, Urinary retention, blurred vision, tachycardia. Severe overdose = Arrythmias, seizures, Acidosis. ECG may show QT prolongation and widening of QRS. Management = IV bicarbonate & treat the arrythmia (but treat anything which prolongs depolarisation e.g amiodarone or flecainide)
31
Cholingeric overdose
E.g nerve agents, Organosphosphates (pesticides) Features = opposite of anticholingerics so Miosis, Sweating, Diarrhoea, Musle weakness, tremor etc. Can cause Cardiac arrest. Management = Atropine for bradycardia.
32
Amphetamines/Cocaine overdose
Features = Tachycardia + Tachypnoea + Hypertension + Mydriasis. Think - activation so hyperthermia, diaphoresis, hyper-reflexia, inc bowels etc. Management = Benzodiazepines. *Note - cocaine can cause SEVERE vasoconstriction resulting in stroke, MI, aortic dissection, ischemic colitis, QRS widening and QT prolongation.
33
Benzo overdose
benzo's enhance GABA. Features = CNS depression, Mydriasis, Nystagmus, Diplopia + Bradycardia + hypotension + hypothermia + resp depression. Management = Supportive management - give Flumazenil if severe.
34
Paracetamol overdose
Causes acute liver failure. Features; * Jaundice + RUQ pain + Raised PT time * Hypoalbuminemia * Hepatic encephalopathy * Hepatorenal failure Management; 1. If ingested in past 1 hour or >12mg = Activated Charcoal 2. N-acetylcysteine - transfuse it slowly 3. Liver transplant if sevre
35
Aspirin / Salicylate overdose
= Leads to a mixed Respiratory Alkalosis (due to hyperventilation) + Metabolic acidosis Features = Hyperventilation + **Tinnitus ** (v early sign) + Sweating + Hyperthermia + N&V + Coma/Seizures Management = Charcoal if <1hour. IV bicarbonate to help with acidosis. 2. Haemodialysis if >700mg/L or acidosis fails to improve or pulmonary oedema or seizures.
36
Digoxin toxicity
Likely to occur from 1.5-3mcg Features = Generally unwell, N&V, Yellow-green vision, Arrythmias (bradycardia / AV block) + Gynaecomastia It is classically precipitated by **hypokalemia ** Other precipitants = hypernatremia/calcemia + hypothermia + hypothyroidism + renal failure + MI ECG shows = Down sloping ST segment (reverse tick/scooped out) & flattened or inverted T waves. Management = Digibind (specific antibodies), Correct arrythmias + monitor K+
37
Lithium toxicity
Toxicity normally occurs at 1.5mmol/L Precipitating factors = Dehydration / Renal failure / Drugs e.g diuretics, ACEi, NSAIDs Features = coarse tremor + Hyperreflexia + acute confusion + seizure Management = 0.9% NaCl or haemodialysis if severe
38
Carbon monoxide poisoning q
Typically presents with multiple members of the family/household. Sx = Headache, N&V, Confusion, Weakness. If severe may cause pink skin,mucosa and arrythmia. Management = High flow / Hyperbaric oxygen. Monitor carboxyHb levels.
39
Ethylene glycol poisoning
found in household products e.g anti-freeze. Gets metabolised into calcium oxalate and glycolate (acidosis). Sx = similar to alcohol (without the smell), if severe will cause a metabolic acidosis + raised anion gap. Urine microscopy = calcium oxolate crystals Management; 1. Fomepiazole - to stop metabolism 2. IV bicarbonate for acidosis 3. Calcium gluconate if hypocalcemic
40
Lead poisoning
Features = lethargy, abdo pain, vomitting, constipation, encephalopathy. **Foot drop ** + peripheral neuropathy. Blue discolourtion of gums. Bloods show a microcytic anemia + high lead concs. Management; * Chelation depends on seveirty. Can use sodium calcium edate or DMSA.
41
Acute asthma attac manaement
1. Oxygen 2. Nebulised salbutamol 5mg. 3. Steroids - Oral pred/IV hydrocortisone 4. Nebulised ipratropium bromide 5.IV aminophylline infusion 6.IV magnesium if severe/life threatening (relaxes smooth muscle) *Monitor K+ due to salbutamol.
42
DKA management
FIG-PICK Fluids - 0.9% NaCl Insulin infusion - 0.1unit/kg/hr Glucose - once glucose <14mmol/L begin 10% dextrose infusion Potassium - careful monitoring of K+, consider adding to fluids. Infection - treat any underlying sepsis Chart - monitor fluid balance + cardiac monitoring Ketones - monitor
43
What levels define resolution of DKA
Ph >7.3 Ketones <0.6 Bicarb >15
44
Treatment of thyroid storm
IV Propanolol Fluids Carbimazole or Propyluracil/iodine solution IV dexamethasone (blocks coversion of T4 to T3)
45
Hypothermia
Severe hypothermia = <32 degrees Features; * Shivering / Cold pale skin * Slurred speech * Tachypnoea, Tachycardia & HTN which then becomes Resp depression, bradycarda + hypotension (in severe hypothermia) * Confusion NOTE - babies with hypothermia often look fine. They will be limp, quiet and refusing to feed. Invx = Rectal thermometer. ECG shows ST elevation and J waves / Osborn waves Hb and Haematocrit may be raised. Low platelets / WBCs due to splenic sequestration. Management = remove wet clothing, warm with blankets. Secure airway. Warm IV fluids + Warm air (dont rewarm too fast as will lead to peripheral vasodilation and shock)
46
CPAP
Continuous positive airway pressure. Essentially delivers expiratory support which is analogous to PEEP with the aim of keeping the airways open and reducing alveolar collapse to increase Functional Residual capacity. Useful in HF, T1RF, Pulmonary oedema, OSA. May cause a low BP
47
BiPAP
Bi-level intermittent positive airway pressure. Looks the same as CPAP however the ventilator delivers 2 different airway pressure (inspiratory & expiratory) - the inspiratory one is higher to help the patients inspiratory effort IPAP increases C02 removal EPAP increases oxygenation. Useful in COPD + T2RF Contraindicated in structural abnormalities, trauma to face, open pneumothorax, haemodynamic instability + bowel obstruction.
48
Indications for invasive ventilation
Severe resp failure Apnoea GCS <8 Severe haemodynamic instability Pa02 <11 High PaC02 with pH <7.2 Exhaustion, severe shock or severe LVHF
49
Indications for Dialysis
AEIOU Acidosis (pH <7.2) Electrolyte derrangement - resistant to tx Intoxication Oedema (pulmonary) Uremia (>40 and rising) & *Related symptoms e.g pericarditis/encephalopathy* Also Creatinine >400 and rising
50
Beta Ionotropes
E.g Adrenaline, Dopamine, Dobutamine, Dopezamine, These act on the contractility of the heart to increase SV therefore increasing CO. *note - Adrenaline is best option when CO & BP are low, if just CO is low then use dobutamine.
51
Alpha vasopressors
E.g Noradrenaline / Phenylepinephrine These are peripheral vasoconstrictors - they aim to Inc BP and improve blood flow to organs. NOTE - if used n excess they can cause reduced splanchnic + renal flow and reduced CO due to inc afterload. *NOTE - Both these and ionotropes need to be given through a central line.
52
Fasting rules for surgery
No food 6 hours before Clear fluids up to 2 hours before
53
Which drugs are used to induce hypnosis
IV; * Propafol * Sodium thiopentone * Ketamine * Etomidate Inhaled; * Sevoflurane * Desflurane * Isoflurane * NO
54
Differnece between IV and inhaled hypnotics
IV tend to have a rapid onset and duration of action so they are better at inducing hypnosis. *(They can easily cross the BBB and then get distributed to tisse muscle and fat. This lowers the plasma conc and then pt regains consciousness so wears off as opposed to being metabolised) * Inhaled ones take longer to induce so are better as maintenance. They are all halogenated hydrocarbons (apart from NO). They work by diffusing into blood via lungs. Depth of anaestheisia is proportionate to alveolar partial pressure.
55
Which inhaled hypnotic agent has the highest MAC
NO MAC = 105% meaning it requires a high concentration to prevent movement following surgical stimulus. The max conc we can give is 70% so is given in conjunction with others.
56
Propofol
MOA = GABA receptor agonist. Widely used on its own as it causes prolonged apnoea (i.e for day surgery - both induction + maintenance) Characteristics; * Rapid onset * Pain on IV injection * Has antiemetic properties. Systemic effects = causes vasodilation (low BP) more so than other agents. Therefore reduces cerebral flow and ICP.
57
Sodium thiopentone
MOA = ultrashort acting CNS depressant. Characteristics; * Extremely rapid onset so good for rapid sequence induction * Little analgesic effect * Metabolites build up quickly so it is NOT suitable for maintenance. * Causes a strange garlicky taste, Nausea + Laryngospasm.
58
Ketamine
MOA = NMDA receptor antagonist Characteristics; * Used for induction * Has best anaglesic properties!!! * Good for those with haemodynamic instability as does not produce much myocardial depression. * Can cause nightmares **(dissociated anaesthesia)**
59
Etomidate
Enhances the effect of **Y-aminobutyric acid ** (inhibitory neurotransmitter) Characteristics; * Favourable cardiac safety profile so best for patients with CVD * No analgesic effect * Cannot be used as maintenance as may result in **adrenal supression** * Commonly causes post-op vomitting
60
General side effects of Inhaled hypnotics
* Dose related depression of CV system = low BP + vasodilation * N&V worse than with IV * They are hepatotoxic * Can cause arrythmias NO also causes short term marrow supression + causes hypoxia (overcome using high conc oxygen) Also diffuses into the middle ear.
61
Depolarising muscle relaxants
Suxamethonium MOA = mimics Ach & binds to the nicotinic receptor inducing depolarisation (causes a short period of fasiculations followed by **40-60s of paralysis**) It is then broken down by **pseudocholinesterase** - returning normal function within **6 mins**. It has Rapid onset - so ideal with rapid sequence intubation. SE; * Malignant hyperthermia * Bradycardia - due to vagal stimulation after repeated doses, this is avoided by giving atropine before hand. NOTE - **deficiency in psuedocholinesterase** causes prolonged effect of suxamethonium!!! Contraindications = Open angle glaucoma / penetrating eye injuries as it can increase intraocular pressure.
62
Non-depolarising Muscle relaxants
E.g Atracurium or Rocuronium Moa = Block the Ach receptors. Take longer to work than suxamethonium (90s - 3mins) but have a longer duration of action (40mins). They are usually used after suxamethonium when needed or in non-urgent cases. They do not cause fasicultations or K+ effluxes. Atracurium = can cause a histamine release (Tachycardia + Hypotension + flushing) Vecuronium = effects are prolonged in organ dysfunction.
63
Reversal agents for Atracurium/Vecuronium
Neostigmine = Anticholinesterase inhibitor. Give atropine alongside to avoid SE. Sugammadex = only used in emergencies (i.e if you have already given atracurium but then can't intubate)
64
Propafol infusion syndrome
A rare syndrome associated with long propafol use (i.e >48hrs). More commin in children or vrey ill pts or with Steroid / Catecholamine use. Features; * Cardiac failure (due to refractory bradycardia) * Rhabdomyolysis * Metabolic acidosis * Hyperkalemia Mx = stop the propafol
65
Malignant hyperthermia
Rare inherited disorder (Autosomal dominant) of skeletal muscle metabolism which is triggered by **Inhaled hypnotics or Suxamethonium ** Features; * Hyperthermia - *progressive risk in body temp* * Tachycardia / Tachypnoea * Increased end titdal CO2 level (if intubated) * Muscle rigidity + CK rise Essentially will result in serious hypoxia + hypercapnia + hyperkalemia Mx = stop agents. Hyperventilate pt with 100% oxygen. Maintain muscle relaxation (non-depolarisng). Start active cooling and give **Dantrolene **
66
When would cocaine be used for Local anaesthetic
In ENT surgery due to its vasoconstrictive effects Used topically
67
Local anaesthetic overdose
* Tinnitus * Metallic taste in mouth * Tingling of mouth * CNS overactivity - motor twitching, seizure, irritability * as it progressies this becomes cortical depression causing AV block, Hypotension, Coma etc Mx = raise legs to encourage venous return. IV fluids + IV atropine. IV intralipid emulsion can bind the LA out of the cells
68
What can be used alongside lidocaine to limit the systemic absorption
Adrenaline - particularly when higher dose is needed
69
Contraindications to Epidural/Spinal
Hypovolemia / poor cardiac function Respiratory depression Local skin infection Coagulopathy Raised ICP
70
Adjustment of anti-diabetic agents for surgery
**T1DM or those on insulin; ** * If good glycemic control - can just be adjusted on the day * Long acting insulin should remain * reduce insulin dose by 20% the day before surgery * Variable rate/sliding scale insulin can be used esp if fasting or missing 1+ meals. * T2DM with poor glycemic control / risk of renal injury **T2DM;** * DPP-IV inhibitors (e.g Gliptins) & GLP-1 analgoues (liraglutide) can be taken as normal * SGLT-2 inhibitors must be omitted on day of surgery
71
What tool can be used to assess ease of intubation prior to surgery
Mallampati score.
72
Adjustments to warfarin before surgery
Must be stopped** 5 days before elective surgery**. Check INR day before surgery + give **P****hytomenadione if INR >1.5. ** However - if pt has mechanical heart valves (i.e with AF) seek specialist input. You can give LMWH instead of warfarin. Resume on evening of surgery. In emergencies - if the surgery can wait 6-8hrs give phytomeniadone and then to surgery. If it cannot wait, make sure to give Prothrombin complex concentrate.
73
DOAC adjustment for surgery
Stop 24hrs before (low risk) or 48hrs before (high risk) and recommence 6-12hrs post surgery.
74
ASA classification of surgical risk
I - normal health patient, non-smoking + no/minimal alcohol II - patient with mild diseases only with no functional limitation III - patient with severe systemic disease with functional limitation e.g COPD, poorly controlled DM, BMI >40 IV - A patient with severe systemic disease which is a constant threat to life (e.g Stroke, MI etc - ESRD only if not on dialysis) V - moribound pt who is not expected to survive without the operation VI - brain dead patient whose organs are being removed for donor.
75
Causes of post-op pyrexia by time
1. Acute (within hours) = normal physiological response. 2. Early (<5 days) = Blood transfusion reaction / Wound cellulitis / UTI / Systemic inflammation 3. Late = VTE / Pneumonia / Wound inflammation / Anastamotic leak / Atelectasis Rememer by 'wind, water, wound, walking' Wind, day 1-2 = pneumonia, aspiration, PE Water, day 3-5 = UTI Wound, day 5-7 = abscess/wound inf Walking, day 5+ = DVT, PE
76
WHO analgesic ladder
1. Non-opioid meds e.g Paracetamol/NSAIDs 2. Weak opioids e.g Codeine or Tramadol 3. Strong opiods e.g Morphine, oxycodone, fentanyl, buprenorphine.
77
Tramadol
Centrally acting opiod agonist (mu, kappa + deltoid receptors ) and SNRI Can be used for nociceptive + neuropathic pain. Has less respiratory depression than morphine but does cause withdrawal.
78
Morphine
Opioid agonist. Very effective. Good for palliation, cancer pain, MI etc. Has lots of available route - PO, IV, IM, SC. SE = N&V, Respiratory depression, Constipation Contraindications = Head injury, raised ICP, acute abdomen, Phaeochromocytoma! *Requires a 2nd checker
79
Fentanyl
It is a synthetic opioid & acts mainly at Mu receptors. It is stronger than morphine but has less adverse effects.
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What are the different types of nausea
1. CTZ -* D2 and 5-HT3 receptors in the CTZ located in the medulla. these are triggered by certain chemicals e.g chemotherapy. It is located outside the BBB so more susceptible to circulating substances. * 2. Motion/morning sickness - Signals sent from vestibulocochlear nerve to pons. contains H1 + muscarinic receptors. 3. Cerebrum mediated sickness - emotional factors, severe pain, repulsive smells etc. 4. Stomach mediated - enterochromaffin cells release serotonin in response to cytotoxic agents. Serotonin stimulates 5-HT3 receptors and stimulation of vagal nerve
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H1 receptor antagonists
Promethazine Cyclizine Best for motion sickness / morning sickness. Also helpful in allergic reactions. SEs = drowsiness due to anticholingeric effects.
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Ondansetron
5-HT3 receptor antagonists. These work in the CTZ and the GI tract Good for chemo + post-op N&V. SEs = headache + GI upset
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Metoclopramide
MOA = D2 receptor antagonist + promotes gastric emptying by increasing gut motility. SEs = Fatigue, GI upset & Extra-pyramidal SE (Akathisia, tardive dyskinesia, acute dystonia, galactorrhoea) AVOID in bowel obstruction!
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Domperidone
Also a D2 receptor antagonist. However does not cross the BBB so doesnt cause extra pyramidal side effects
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Hyoscine
Anti-muscarinic These block receptors in the Vomitting center & also work in the vestibular nuclei. Good for prophylaxis + motion sickness SEs = dry mouth, urinary retention, drowsiness.
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How much maintenance fluid is required
25-30ml/kg/day NICE recommend 0.18% NaCl in 4% dextrose on day 1.
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What are the reversible causes of cardiac arrest
Hypoxia Hypothermia Hyper/hypokalemia Hypovolemia Toxins Tension pneumothorax Tamponade Thrombosis
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Which types of surgery are likely to require pre-ordering 4-6 units of blood
Total gastrectomy Oophorectomy oesophagectomy elective AAA repair cystectomy hepatectomy
Y4 Medicine
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