Yr 6 PACES knowledge COPY RJ Challenger > Acute station > Flashcards

Acute station Flashcards

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1
Q

Define acute AF? How would you approach the management?

A

Acute AF is AF that started <48 hours ago

1) Are they haemodynamically stable?

If no –> emergency cardioversion (2nd line = amiodarone)

If yes –> 1) Rate control = b-blocker or diltiazem

2) Rhythm control (ONLY if <48h) = DC cardioversion or amiodarone
3) Start LMWH if chronic
4) Treat underlying cause

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2
Q

Define paroxysmal AF? How would you manage it?

A

DEF: self limiting + lasts <7 days

Mx:

Acute: Medical

Anticoagulate + rate/rhythm control

Rate control: diltaziam or a beta blocker (Eg Bisoprolol)

Rhythm control: amiodarone

Treat underlying cause

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3
Q

Mx of Ventricular tachycardia

A

If haemodynamiacally unstable, ie pulseless? –> CPR Adverse signs (Chest pain, HF) –> sedate + synchronised cardioversion!

If haemodynamically stable (ie no signs, pulse present)

-Beta blockers (Bisoprolol)

  • Amiodarone, IV (Antiarrythmic)
  • Correct electrolyte abnormalities
  • TTE (Transthoracic echocardiogram)
  • Optimal heart failuire therapy, if indicated

Ix:

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4
Q

ECG changes in hypokalemia

A
  • Prominent U waves
  • PR prolongation
  • T wave inversion
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5
Q

TIA - best brain imaging?

A

Diffusion weighted MRI

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6
Q

TIA - management? 5 aspects

A
  1. Antiplatelet: aspirin + clopidogrel
  2. If cardiac emboli –> Warfarin!
  3. Risk factor control (anti-HTN, statin, glucose, smoking)
  4. Assess risk for next stroke = ABCD2 score
  5. Follow Up in clinic
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7
Q

What scoring system is used to determine risk of stroke in TIA patients?

A

ABCD2 Age >60 BP >140/90 Clinical Findx: unilateral weakness (2), speech disturbance w/o weakness (1) Duration Diabetes

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8
Q

Fluid resuscitation formula in burns? Which fluid?

A

Parkland formula:

4 x wt x % surface area

Give half in first 8 hours HARTMANN’S, warmed

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9
Q

How to determine % BSA involvement in burns?

A

1 arm: 9%

Head and neck : 9%

Front torso: 18%

Back torso: 18%

1 leg: 18%

Perineum: 1%

1 hand: 1%

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10
Q

Tx of burns (exc fluid resus)

A
  1. Analgesia
  2. Dressing; silver sulfadiazine + sterile film
  3. Cadaveric skin
  4. Split thickness skin grafts
  5. Tangential excision
  6. Escharotomy (to prevent compartment syndrome)

///////////////////////////////////

“Burns, a dress could split, tits exposed”

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11
Q

DKA management summary

A

(Assuming its confirmed with pH, blood glucose and ketones)

INSULIN: 0.1 U/kg/hr Actrapid infusion with 0.9% Saline

-Aim ketones reduction >0.5mM/hr

FLUIDS:

If SystolicBloodPressure < 90 = 0.9% Saline 1L stat (Over 15 minutes)

If SBP > 90 = 0.9% Saline 1L over 1hr –> add K+ (potassium) if <5.5 (20mM/L)

Consider LMWH

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12
Q

Definition of DKA

A

pH < 7.3

glucose > 11.1

ketones > 3.0 (or 2+ on dip)

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13
Q

Definition and Mx of HONK

A

Hyperglycemia (>35) w/o ketones

Fluids Potassium in 2nd bag of fluids

LMWH

?consider insulin

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14
Q

In upper GI bleed, how is a pt managed AFTER endoscopy?

A

Depends on cause:

  • Peptic ulcer
  • IV bolus omeprazole 80mg
  • then 8mg/hr for. 48 hours
  • Endoscopic therapy
  • Consider surgery
  • Bleeding varices
  • Vasoconstrictors (Octreotide/ terlipressin)
  • Endoscopic therapy

/////////////OG answer

NBM + stop NSAIDs IV omeprazole Daily bloods H. pylori testing + eradication

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15
Q

ABCDE approach: How would you assess the airway?

A

Ensuring a patent airway

If speaking –> patency assumed.

Look –> for airway secretions, angioedema

Listen –> gurgling Breathe Sounds or stridor Feel –> for expired air -

Any evidence that airway is not patent –> HEAD TILT + CHIN LIFT (Jaw thrust if C-spine injury) -

Consider airway adjuncts eg Guedel or nasopharyngeal airway - If still not achieved –> check pulse + periarrest call!!!

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16
Q

ABCDE approach: How would you assess breathing?

A

Ensuring target saturations are met

OBS –> Sats, RR,

administer 15L 02 non-rebreather mask

Inspection –> accessory muscle breathing, nasal flaring Palpate –> Tracheal deviation, equal chest expansion Percussion –> dullness?

Auscultate –> equal air entry, wheeze, crackles

ABG + CXR

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17
Q

ABCDE approach: assessment of circulation?

A
  • Ensure patient is haemodynamically stable
  • Ie BP normal, pulse present, well perfused.
  • -(This is good phrasing because you’re not supposed to move on from C until it’s stabilised)*

Obs: CRT

pulse - rate and rhythm,

BP in both arms

Ask nurse to help w 12 lead ECG

  • 2 large bore IV cannulae

Bloods: FBC, U+Es, glucose, CRP, Xmatch, G+S, clotting, blood cultures, troponin

  • if hypotensive: 500mL 0.9% saline bolus, then reassess BP.
  • Call for help if still hypotensive
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18
Q

ABCDE approach: assessment of disability?

A
  • Pupils: equal + reactive to light?
  • GCS: if <8 (or AVPU = P), call for an anaesthetist
  • GLUCOSE
  • Gross neuro assessment: plantar reflexes, sensation, power, grip
  • Drug chart + possessions for evidence of OD
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19
Q

Causes of shock

A

“Could Someone Hurry On down?”

CARDIOGENIC:

  • MI
  • Arrhythmia

SEPTIC:

HYPOVOLAEMIC:

  • Haemorrhage
  • Endocrine: DKA, addisonian crisis
  • Excess loss: burns, diarrhoea
  • 3rd spacing: pancreatitis

OBSTRUCTIVE:

  • PE
  • Tension pneumothorax

DISTRIBUTIVE (ie 3rd spacing):

  • Sepsis
  • Anaphylaxis
  • Pancreatitis
  • Burns
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20
Q

Causes of hypovolemic shock:

A
  • Haemorrhage
  • Endocrine: DKA

//////////////////////////////

  • 3rd spacing: Pancreatitis
  • Excess loss: burns, diarrhoea
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21
Q

How to differentiate between cardiogenic vs hypovolemic shock?

A

Cardiogenic: high JVP

Hypovolemic: low JVP

//////////////////////////

Cardiogenic: JVP: high, peripheries: cold

Sepitc: JVP: low, peripheries: warm

Hypovolaemic: JVP: low, peripheries: cold

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22
Q

How to differentiate between septic shock vs hypovolemic shock

A

Septic: warm peripheries

Hypovolaemic shock: cold peripheries

///////////////////////

Cardiogenic: JVP: high, peripheries: cold

Sepitc: JVP: low, peripheries: warm

Hypovolaemic: JVP: low, peripheries: cold

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23
Q

Pathophysiology of anaphylaxis

A

Type 1 IgE mediated hypersensitivity reaction Mast cell degranulation –> histamine release –> inc vascular permeability + bronchoconstriction

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24
Q

Dose of adrenaline in anaphylaxis?

A

IM adrenaline 500micrograms

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25
How often can you repeat IM adrenaline in anaphylaxis?
every 5 mins
26
Define a pneumothorax
Accumulation of air in the pleural space
27
Classification of a pneumothorax
Open: defect in chest wall: communication btw PTX + exterior Closed: chest wall is intact. air from lung --\> pleural cavity Tension: one way valve --\> mediastinal compression
28
Causes of pneumothorax
SPONTANEOUS: primary (no underlying lung disease) or secondary (Marfan's, COPD, pulmonary fibrosis) TRAUMA: penetrating or blunt trauma w rib #s IATROGENIC: Central line insertion, CPAP, transbronchial biopsy
29
How on earth can PTX lead to surgical emphysema
Broken rib --\> damaged pleura --\> air from lung enters pleural space --\> air in pleural space enter subcut tissue
30
Ix for suspected pneumothorax
Basic obs ABG CXR USS (more sensitive than supine CXR!)
31
Mx of tension pneumothorax
No CXR! 10L oxygen through non-rebreather mask Large bore cannula in 2nd ICS, MCL (just above the rib!)
32
Mx of pneumothorax in pt with no underlying lung disease (or\<50yo)?
If the patient SOB or PTX\>2cm ---\> needle aspiration - if aspiration fails -\> chest drain If pt is not SOB + \<2cm --\>10L oxygen + observation
33
Mx of secondary pneumothorax
If pt is SOB or \>2cm: CHEST DRAIN If pt is asymptomatic: \<1cm: admit for 24hrs + 10L oxygen 1-2 cm: needle aspiration (+ chest drain if this fails)
34
Causes of surgical emphysema
Rib fracture Iatrogenic: CPAP, any chest surgery, thoracotomy Infection
35
safe triangle for intercostal drain
- Lat border of pec major - Ant border of lat doors - 5th ICS (level of nipple)
36
Asthma attack: Mx?
Basic obs Breathing: ABG + O2 via non-rebreathe mask - 5mg salbutamol nebs (order CXR) Circulation: FBC, U+Es, CRP, blood cultures. +/- fluid resus - Oral pred 50mg/IV hydrocort 100mg
37
Nebs in acute asthma - how frequently?
Salbutamol: 15 mins Iptropium: 4-6 hourly
38
Monitoring in acute asthma
- Sats\>92% - PEFR every 15-30 mins - ABG if the initial PCO2 is normal or high
39
Acute COPD exacerbation: you have already given SABA and SAMA nebs + steroids. What can you do next if they're not responding?
Repeat nebs ?IV aminophylline ?BIPAP
40
ECG changes in hyperkalemia
Tented T waves Small p waves widened QRS
41
Causes of hyperkalemia
- AKI - Drugs: ACEIs, spironolactone, ARBs, Heparin!! - Rhabdomyolysis - Addison's - Metabolic acidosis (Haemolysed sample)
42
stages of AKI
stage 1: Creatinine 0.5-1x normal (oliguria for 6 hours) stage 2: creatinine 1-2x normal (oliguria for 12 hours) stage 3: creatinine \>2x normal (olig for 24 hours/anuria)
43
Investigations for pneumonia
Sputum MC+S, cytology Urine: cold agglutinins FBC (wcc), U+Es (Na, urea), CRP (trend), LFTs (mycoplasma, legionella), Blood cultures ABG CXR, ECG
44
Management of pneumonia
O2, fluids, analgesia, antibiotics F/u: CXR @ 6 weeks if \>65 --\> pneumovax Smoking cessation
45
Complications of pneumonia
1. Septic shock 2. Parapneumonic effusion --\> empyema 3. Respiratory failure 4. Abscess
46
Def of Hospital acquired pneumonia
\>48 hrs after hospital admission
47
Commonest causative organisms of hospital acq pneumonia
Pseudomonas MRSA
48
Anatomical classification of pneumonia? which one is more common?
Bronchopneumonia (patchy, in diff lobes) vs lobar pneumonia Bronchopneumonia = atypical
49
Commonest causative organisms of community acq pneumonia
Strep pneumonia Mycoplasma Viral
50
Mx of hospital acquired pneumonia
Co-amoxiclav or taz+vanc
51
Commonest causative organisms of atypical pneumonia
Mycoplasma, Legionella, Chlamydia
52
CURB 65
Confusion Urea\>7 RR\>30 BP\<90 \>65yo
53
Define SIRS
Inflammatory response with \>=2 of: HR: \>90 Temp: \>38 or \<36 RR: \>20 or PaCO2\<3.6 WCC: \>12 or \<4
54
Shockable rhythms vs non-shockable rhythms
non-shockable: PEA, asystole shockable: VF, pulseless VT
55
Mx of asystole
cannot shock! CPR 2 mins + IV adrenaline 1mg - repeat adrenaline at every other cycle
56
management of pulseless VT
CPR 1 shock CPR 2 mins IV adrenaline 1mg + amiodarone 300mg after 3rd shock Repeat adrenaline at every 3rd cycle
57
Crucial Ix in patient with an unprovoked DVT
CT abdo pelvis - look for malignancy!!!
58
Features of benzodiazepine OD? Mx?
Respiratory depression Reduced GCS Mx = flumazenil
59
beta blocker OD - fx? mx?
Fx: bradycardia + hypotension Mx: Atropine
60
Carbon monoxide poisoning - fx?
Fx: dizziness, nausea, headache PaO2 is low but sats are high Metabolic acidosis
61
Digoxin OD - 3 fx? mx?
Arrhythmia Yellow green halos Reduced GCS Mx: anti-digoxin antibodies
62
Mx of Heparin OD?
Protamine
63
Lithium OD - fx?mx?
Fx: coarse tremor, confusion, N+V, POLYURIA Mx: Saline
64
Mx of organophosphate poisoning?
Atropine
65
Fx of amitriptyline (TCA) overdose?
Anticholinergic: hyperthermia, palpitations Metabolic acidosis PROLONGED QT - CARDIAC MONTOR
66
Mx of amitriptyline overdose
IV sodium BICARBONATE (they have met acidosis)
67
Mx of warfarin overdose
IV vitamin K Prothrombin complex
68
AKI - Initial Mx
ABC - O2 + large bore cannula + CATHETER + fluid monitoring Routine bloods, ABG, Urine dip, ECG/cardiac monitor!!! CXR, US kidneys CHECK DRUG CHART (NSAIDs, ACEis, vanc, gent, contrast) - correct instability w fluid bolus
69
Life threatening complications of AKI
Hyperkalemia Pulmonary oedema Acidosis
70
Clearing the C-spine - what is it? how?
ensuring pt doesn't have a C-spine fracture 1) ensure pt is in stiff neck collar 2) CLnical assessment: - Neuro deficit - Spinal tenderness - Altered GCS - Intoxication - Distracting injury (eg long bone #) 3) if any of th above: do X ray 4) if X-ray is abnormal, do CT
71
Mx of Anaphylaxis?
- Ensure **Airway** is clear - High Flow **Oxygen** - Request anaesthetic input if intubation needed. - Establish **Venous** access - IM **Adrenaline**, 500 mcg - Repeat every 5 minutes if no improvement - IV **Chlorphenamine**, 10mg - IV **Hydrocortisone**, 200mg - IV Haartman's solution, 1000ml - Escalate: - Senior medical reg on call - If no improvement: referral to **critical care outreach team** ///////////// *"Oysters Attack Chloe's Heart"* "AOV **ACHE**"
72
Mx of upper GI bleed?
- "I would start by stabilising the patient and treating life-threatening pathologies using an **A to E approach**" - Call switchboard **2222** and state "**Major Haemorrhage**", name of hospital and location - Admit to HDU - Brief history for co-morbidities A: - B: - C: -_Establish I**V** access with 2 large bore cannula_ (14-16g) _-**Monitor** pulse and blood pressure half hourly_ - **I**x: _FBC_, Us&Es, LFTs, Coagulation. _Group and save_ and cross match 2 units. - If shocked: **CVP** line - Consider blood **_transfusion_** - When _stable_: **urgent _Endoscopy_** - **_Escalate_** to senior Medical registrar on call - Most important differentials: - Peptic ulcer disease: PPI + endoscopic therapy - Varices: vasocontrictors + endoscopic therapy ////////////////////////////////////////////////////////////// "HDU, Venous access, Monitor BP, Ix, Central line, Transfusion, Endoscopy, Escalate" "**HV MIC TEE**" Call switchboard 2222 and state "Major Haemorrhage", name of hospital and location. Also call 5555 for Porter. Blood Bank will automatically thaw 4 units of FFP. Further units issued once clotting screen received in lab and discussion with medical staff.
73
Chest pain: Whats important to rule out?
Pulmonary embolism (PE) (D-dimer, CXR) Acute Coronary Syndrome (ACS) (Troponin T, ECG) Pneumothorax (CXR, Resp Ex) Aortic dissection (/How to rule out?) /////////////////// "PAPA"
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