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quick Acute + Pharma Flashcards

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1
Q

What is an ectopic pregnancy?

A
  • implantation of a fertilised ovum outside the uterus
  • Most common site is the fallopian tube. Can also implant into the ovary, cornul region( entrance to fallopian tube), cervix or abdomen
  • 97% are tubal, with most in ampulla
  • more dangerous if in isthmus
  • 3% in ovary, cervix or peritoneum
  • trophoblast invades the tubal wall, producing bleeding which may dislodge the embryo
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2
Q

Risk factors for an ectopic?

A
  • damage to tubes e.g. PID, surgery
  • endometriosis
  • IUCD
  • Progesterone only pill
  • IVF
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3
Q

Typical history for an ectopic?

A

Usually around 6-8 weeks gestation
* lower abdominal pain ( iliac fossa)
◦ due to tubal spasm
◦ typically the first symptom
◦ pain is usually constant and may be unilateral.
* vaginal bleeding
◦ usually less than a normal period
◦ may be dark brown in colour
* history of recent amenorrhoea
◦ typically 6-8 weeks from the start of last period
◦ if longer (e.g. 10 wks) this suggest another causes e.g. inevitable abortion
* peritoneal bleeding can cause shoulder tip pain and pain on defecation / urination
* dizziness, fainting or syncope may be seen- from blood loss
* symptoms of pregnancy such as breast tenderness may also be reported

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4
Q

Examination findings - ectopic pregnancy?

A
  • abdo tenderness
  • Cervical excitation - cervical motion tenderness: pain when moving the cervix during a bimanual examination
  • Adnexal mass: NICE advise NOT to examine for an adnexal mass due to an increased risk of rupturing the pregnancy.
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5
Q

Investigations for an ectopic pregnancy?

A
  • transvaginal ultrasound
    ◦ Gestational sac containing yolk sac or fetal pole may be seen in fallopian tube
    ◦ Sometimes a non specific mass may be seen in a tube - When a mass containing an empty gestational sac is seen, this may be referred to as the “blob sign”, “bagel sign” or “tubal ring sign
    ◦ A mass representing tubal ectopic pregnancy moves seperately to ovary - cropus luteum will move WITH the ovary
    ◦ Empty uterus
    ◦ Fluid in the uterus
    In the case of pregnancy of unknown location, serum bHCG levels >1,500 points toward a diagnosis of an ectopic pregnancy
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6
Q

3 options for treatment of ectopic pregnancies?

A

Expectant, medical, surgical

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7
Q

Expectant criteria for ectopic pregnancies/

A
  • follow up needs to be possible to ensure successful termination
  • ectopic needs to be unruptured
  • Adnexal mass <35mm
  • No visible heartbeat
  • No sigificant pain
  • HCG level <1500 IU/l
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8
Q

Medical criteria for ectopic pregnancy treatment?

A
  • Same as expectant management except:
    ◦ HCG level must be <5000 IU/L
    ◦ Confirmed absence of intrauterine pregnancy on ultrasound
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9
Q

Medical treatment for ectopic pregnancy treatment?

A

Management with Methotrexate
* Highly teratogenic( harmful to pregnancy)
* Given as an intramuscular injection into a buttock
* Halts the progress of pregnancy and results in spontaneous termination
* Women are advised not to get pregnant for 3 months following treatment - harmful effects on pregnancy can last this long
* Common side effects: vaginal bleeding, nausea and vomiting, abdo pain, stomatitis( inflammation of the mouth)

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10
Q

Surgical criteria for ectopic pregnancy treatment?

A
  • Anyone that doesn’t meet criteria for medical or surgical
    `
  • Laparoscopic salpingectomy
  • Laparoscopic salingotomy

Laparoscopic salpingectomy.: first line. General anaesthetic and key hole surgery with removal of the affected fallopian tube, along with the ectopic pregnancy inside

Laparoscopic salpingotomy- used in women at increased risk of infertility due to damage to the other tube. Aim to avoid removing fallopian tube - cut open

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11
Q

What is compartment syndrome?What are the main fractures it happens after?

A

When pressure within fascial compartment is raised
Cuts off blood supply to that area = necrosis
Happens following fractures or following ischaemia reperfusion injury in vascular patients `
2 main fractures: supra condylar fractures and tibial shaft injuries

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12
Q

Acute compartment syndrome presentation?

A

5 P’s
* Pain, especially on movement ( even passive) - worsened by passive stretching of the muscles
* excessive use of breakthrough analgesia - raises suspicion for compartment syndrome
* Parasthesiae
* Pallor
* Arterial pulsation may still be felt as the necrosis occurs as a result of microvascular compromise
* Paralysis of the muscle group

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13
Q

Diagnosis of compartment syndrome?

A
  • Measurement of intracompartmental pressure measurements using needle manometry
  • Inject saline through a needle into the compartment
  • pressures in excess of 20mmHg are abnormal and >40 mmHg is diagnostic
  • Compartment syndrome typically DOES NOT show any pathology on an XRAY
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14
Q

Management of compartment syndrome?

A

Initial management: escalating to the orthopaedic reg
* Removing any external dressings or bandages
* Elevating leg to heart level
* Maintain good BP- avoid hypotension

Emergency fashiotomy ASAP

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15
Q

Chronic compartment syndrome features?

A
  • During exertion the pressure within the compartment rises, blood flow to the compartment is restricted and symptoms start. DUring rest, the pressure falls and symptoms resolve. NOT AN EMERGENCY
  • Symptoms usually specific to the location of affected compartment
  • Pain, numbness and paraesthesia. Made worse by activity and resolve with rest
  • Needle manometry to pressure pressure before nad during and after exertion
  • Fashiectomy
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16
Q

Signs of opiod overdose

A

CNS depression e.g. coma, resp depression, hypotension, miosis
GIVE NALOXONE

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17
Q

What is fourniers grangrene?

A

specifically necrotising infection of the perineum… most commonly affected site

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18
Q

2 types of necrotising fascitiitis?

A

TYPE 1: caused by mixed anaerobes and aerobes, often occurs post surgery in diabetics. More common.
TYPE 2: Caused by streptococcus pygogenes

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19
Q

Risk factors for necrotising fascitis?

A

Skin factors: e.g. recent trauma, burns or soft tissue infections
DM - most common preexisting medical condition, particularly if patient is treated with SGLT2 inhibitors
IV drug users
Immunosuppression

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20
Q

Features of necrotising fascitis?

A

Acute onset
* pain, swelling, erythema at affected site
* Often presents as rapidly worsening cellulitis with pain out of keeping wtih physical features
* Extremely tender over infected tissue with hypoaethesia to light touch
* Skin necrosis and gas gangrene are late sign
* Fever and tachycardia may be absent or occur late in teh presentation

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21
Q

What is gas gangrene

A
  • form of necrotising fasciitis caused by Clostridium species resulting in gas being produced by bacteria within the tissue
  • Clostridial organisms involved produce alpha and beta toxins that lead to extensive tissue damage, alongside producing large volumes of gas within the tissue
  • Present in an equally severe state BUT get tissue creptius on light palpation of affected area
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22
Q

Investigations for nec fascitis?

A
  • blood tests- high levels of WCC and CRP
  • Raised lactate metabolic acidsosi
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23
Q

Management of nec fascitis?

A
  • IV abx
  • Urgent surgical referral debridement
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24
Q

Testicular torsion - what is ti?

A

Twist of spermatic cord resulting in testicular ischaemic and necrosis
Most common in males between 10 an d30
Often triggered by activity

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25
Features of testicular torsion?
* Rapid onset unilateral testicular pain * Abdo pain - sometimes the only symptom * Nausea and vomiting
26
Examination findings for testicular torsion?
* Firm sweollen testicle * Elevated/retracted testicle * Absent cremasteric reflex * Abnromal testicular lie * Rotation * Elevation of the testis doesnt ease the pain: Prehns sign
27
What is the bell clapper deformity?
One of the causes of testicular torsion Where the fixation between the testicle and the tunica vaginalis is absent. The testicle hangs in a horizontal position (like a bell-clapper) instead of the typical more vertical position. It is also able to rotate within the tunica vaginalis, twisting at the spermatic cord. As it rotates, it twists the vessels and cuts off the blood supply.
28
Management of testicular torsion?
* Urgent surgical exploration * Orpidopexy - correcting the position of the testicles and fixing them in place * Orchidectomy - removing the testicle... if the surgery is delayed or there is necrosis Scrotal ultrasound - shows the whirlpool sign
29
TSS signs?
* fever: temperature >38.9 * Hypotension: systolic BP <90mmHg * Diffuse erythematous rash * DEsquamation of rash: especially of palms and soles * Involvement of 3 or more organ systems e.g. GI, mucous membrane erythema, renal failure, hepatitis, thrombocytopenia, CNS involvement
30
Management of TSS?
= removal of infection focus e.g. retained tampon IV fluids IV abx
31
Upper limits of normal diameter of bowel?
* 3cm small bowel * 6cm colon * 9cm caecum
32
Causes of small bowel obstruction?
* adhesions ( main causes= abdo/pelvis surgery, peritonitis, endometriosis) * hernias
33
Features of small bowel obstruction?
* diffuse, central abdominal pain * nausea and vomiting * typically bilious vomiting * 'constipation' with complete obstruction and lack of flatulence * abdominal distension may be apparent, particularly with lower levels of obstruction * 'tinkling' bowel sounds (more common in early bowel obstruction)
34
Investigations for SBO?
ABDO XRAY: * considered dilated if small bowel is >3cm diameter * coiled spring CT: more sensitive
35
Management for sbo?
Management: intial steps: * NBM * IV fluids * nasogastric tube with free drainage Some patients settle with conservative management but otherwise will require surgery
36
What is a closed loop obstruction?
* Closed-loop obstruction describes a situation where there are two points of obstruction along the bowel; meaning that there is a middle section sandwiched between two points of obstruction. This might happen with: * Adhesions that compress two areas of bowel * Hernias that isolate a section of bowel blocking either end * Volvulus where the twist isolates a section of intestine * A single point of obstruction in the large bowel, with an ileocaecal valve that is competent * A competent ileocaecal valve does not allow any movement back into the ileum from the caecum. When there is a large bowel obstruction and a competent ileocaecal valve, a section of bowel becomes isolated and the contents cannot flow in either direction.
37
Causes of large bowel obsturction?
* Malignancy * volvulus * diverticular disease
38
XRAY for LBO
* coffee bean * dilated loops of bowel in periphery * >6 cm
39
Symptoms of upper GI bleed
* Haematemesis: typically coffee-ground like in appearance due to the presence of partially digested blood. * Altered bowel habit: patients may describe dark tarry stools or fresh rectal bleeding. * Abdominal pain: typically epigastric in location, but can be diffuse. * Pre-syncope/syncope: due to hypovolaemia and secondary cerebral hypoperfusion. Clinical signs: * Tachycardia * Hypotension * Abdominal tenderness * Malaena: black, tarry stools caused by the presence of digested blood. * Haematochezia: the passage of fresh red blood per rectum, which can occur in the context of profuse upper gastrointestinal haemorrhage due to rapid transit of blood through the gastrointestin
40
Treatment for acute upper GI bleed?
Blood transfusion- haemoglobin levels, O negative if not adequate time to match Platelets FPP Prothrombin - if taking warfarin and actively bleeding Terlipressin- causes vasoconstrction of the splenic artery - reducing BP in portal system, reccomended for variceal bleeding Prophylactic ABX therapy for variceal bleeding: Ciprofloxacin 1g OD Endoscopy PPIs for VARICEAL Rectal exam for GI beeding
41
What is the blatchford score?
* Calculated before endoscopy, identifying low risk patients who don't require intervention
42
What is the rockall score?
t risk of adverse outcome following acute upper gastrointestinal bleeding
43
Differentials for upper GI bleed?
Varices Oesphagitis Cancer Mallory Weiss Tear Gastric ulcer Gastric cancer Dieulafoy lesion Diffuse erosive gastritis Duodenal ulcer Aorto-enteric fisula
44
Duodenal ulcer features
Imrpoves after eating
45
Lower GI bleed cause?
* colitis * diverticular disease * cancer * haemorrhoids * angiodysplagia
46
Management of lower GI bleed
: PR, colonoscopy, colonscopic haemostasis surgery
47
What can't you give with methotrexate
Trimethoprim never try meth twice!
48
p450 inducers?
Rifampicin Phenytoin St johns Smoking Alcohol
49
Side effects of heparin
Thrombocytopenia
50
Contraindications to diclofenac?
Any form of CVD
51
Anticholinergic side effects
Dry mouth, dilated pupils, agitation, sinus achy Arrythmias, metabolic acidosis
52
Management of TCA overdose
IV bicarbonate
53
What might precipitate lithium toxicity?
-dehydration Renal failure Drugs - especially thiazides, ACEi, Angiotensin II receptor blockers, NSAIds and metronidazole
54
Tamoxifen side effects?
SERM Menstrual disturbance - can get vaginal bleeding and amenorrhoea Hot flushes! VTE Endometrial cancer
55
Statins contrainidcation
+ erythromycin/ clarithromycin = common interaction - Can get rhabdo and hepatotoxicity
56
Corticosteroids side effects?
- Endocrine - impaired glucose regulation, increased appetite/weight gain, hyperlipidaemia - Cushings - MSK - osteoporosis, proximal myopathy, AVN of femoral head - Immunosuppression - Neutrophilia - Psych - insomnia, mania, depression, psychosis - GI - peptic ulcer, acute pancreatitis - Acne, ophthalmology - glaucoma, cataracts Intracranial HTN
57
Thiazide diuretics side effects
Common adverse effects * dehydration * postural hypotension * hypokalaemia ○ due to increased delivery of sodium to the distal part of the distal convoluted tubule → increased sodium reabsorption in exchange for potassium and hydrogen ions * hyponatraemia * hypercalcaemia ○ the flip side of this is hypocalciuria, which may be useful in reducing the incidence of renal stones * gout * impaired glucose tolerance * impotence Rare adverse effects * thrombocytopaenia * agranulocytosis * photosensitivity rash pancreatitis
58
Digoxin toxicity Features
* generally unwell, lethargy, nausea & vomiting, anorexia, confusion, yellow-green vision * arrhythmias (e.g. AV block, bradycardia) gynaecomastia
59
Precipitating factors to digoxin toxicity?
* classically: hypokalaemia ○ digoxin normally binds to the ATPase pump on the same site as potassium. Hypokalaemia → digoxin more easily bind to the ATPase pump → increased inhibitory effects * increasing age * renal failure * myocardial ischaemia * hypomagnesaemia, hypercalcaemia, hypernatraemia, acidosis * hypoalbuminaemia * hypothermia * hypothyroidism * drugs: amiodarone, quinidine, verapamil, diltiazem, spironolactone (competes for secretion in distal convoluted tubule therefore reduce excretion), ciclosporin. Also drugs which cause hypokalaemia e.g. thiazides and loop diuretics
60
Management of digoxin toxicity?
* Digibind * correct arrhythmias monitor potassium
61
Cocaine side effects
Coronary artery spasm - MI HTN, QRS widening, QT prolongation, seizures, hypertonia, mydriasis, hyperreflexia, agitation, seizures, psychosis, hallucinations, ischaemic colitis
62
Treatment for cocaine overdose
Benzos
63
Opiod toxicity features
Rinorrhea, drowsy, pinpoint pupils, yawning
64
Ecstasy overdose features
Hyponatreamia Agitation, anxiety, confusion, ataxia, tachycardia, HTN, rhabdo
65
Treatment of ecstasy overdose
Supportive DantroleneL
66
LSD overdose features
Psychedelic Halllucinations Tachycardia HTN myiasis
67
Organophosphates insecticide poisoning features
Accumulation of acetylcholine Salivation Lacrimation Urinarion Diarrhoea Small pupils
68
Treatment of organphsophate insecticide poisoning
Atropine
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