1
Q
What are the signs of acute severe asthma ?
A
- use of accessory muscles
- wheeze
2
Q
What are the features of acute severe asthma ?
A
- inability to complete sentences in one breath
- respiratory rate >25
- HR > 110
- PEFR 33-50% of expected
3
Q
Features of life threatening asthma attack ?
A
- altered conscious level
- exhaustion/poor respiratory effort
- silent chest
- PEFR
4
Q
Features of near fatal asthma attack ?
A
Raised PaCO2/ requiring mechanical ventilation with raised pressures
5
Q
What is the initial response in a severe acute asthma attack ?
A
O SHIT
- oxygen: 15L non rebreath mask
- salbutamol - 5mg nebs every 15/20 mins if PEFR
6
Q
What investigations do you send for in acute severe asthma ?.
A
- (IV access) bloods- FBC, U&Es, glucose ~CRP, Blood and sputum cultures if sepsis suspected
- ABG (sats
7
Q
What are the symptoms of an acute exacerbation of COPD ?
A
- increasing cough
- reduced exercise tolerance
8
Q
What are the signs of an acute exacerbation of COPD ?
A
- use of accessory muscle
- tachypnoea
- cyanosis
- wheeze
9
Q
What drug treatment would be administered in an acute exacerbation of COPD ?
A
- Oxygen (controlled, aim for sats 88-92%) - adjust O2 with Venturi mask, but in emergency 15L non rebreath first then titration down when reassess
- Salbutamol 5mg neb
- hydrocortisone 200mg IV/prednisolone 40mg PO
- ipratropium bromide neb
*antibiotics if evidence of infections (empirical- broad spec) e.g. Amoxicillin
10
Q
What investigation should you request in an acute exacerbation of COPD ?
A
- bloods- FBC, U&Es, glucose
- consider blood and sputum cultures if sepsis suspected
- ABG (decreased PaO2, raised PaCO2 and raised bicarbonate if chronic disease)
- CXR to exclude pneumothorax/infection
- ECG (may show cor pulmonale)
11
Q
If there is no response to nebuliser bronchodilators, oxygen and steroids what should be done next in an acute exacerbation of COPD ?
A
Non invasive, positive pressure ventilation
- if RR > 30, pH
12
Q
What are the features of a pneumothorax ?
A
- SOB, sudden onset
- pleuritic chest pain
- unilateral reduced chest expansion
- unilateral deceased breath sounds
- unilateral hyper resonance to percussion
- CXR confirmation
13
Q
What are the features of a tension pneumothorax ?
A
all same signs of pneumothorax (SOB, pleuritic pain, unilateral reduced expansion, decreased breath sounds, hyper resonance) AND:
- hypotension (must be present to make diagnosis of tension pneumothorax)
- tracheal deviation (away from affected side)
- distended neck veins
14
Q
What is the response to a tension pneumothorax ?
A
- ABCDE assessment:
- O2 15L/min via reservoir mask
- needle decompression - large bore needle in 2nd intercostal space mid clavicular line
- insertion of chest tube
- DO NOT DELAY MANAGEMENT TO GET CXR*
15
Q
What are the risk factors for PE ?
A
- malignancy
- post surgery
- immobility
- oral contraceptive pill
- pregnancy
- previous DVT or PE
- increasing age
- infection
- dehydration
- obesity
- smoking
16
Q
Symptoms of PE?
A
- sudden SOB
- pleuritic chest pain
- haemoptysis
- syncope
17
Q
What imaging technique should be used to confirm PE ?
A
CT pulmonary angiogram
18
Q
What drugs are administered in emergency treatment of massive PE ?
A
- O2 15/L per min via reservoir mask
- morphine (5-10mg IV)with antiemetic (if in pain or very distressed)
- fluid bolus to treat hypotension
- anticoagulant with LMWH e.g. Tinzaparin, enoxaparin
19
Q
Signs of PE ?
A
- hypotension, tachycardia (CV collapse)
- gallop rhythm
- raised JVP
- right ventricular heave
- pleural rub
- tachypnoea
- cyanosis
20
Q
Investigations for PE ?
A
- U&Es, FBC, baseline clotting
- ECG - commonly normal
- CXR - often normal ~ decreased vascular markings, small pleural effusion, wedge shaped area of infarct
- ABG: hyperventilation and poor gas exchange -> low PaO2 and low PaCO2, pH often raised
- D dimer
- CT pul. Angiogram
21
Q
What is the definition of status epilepticus ?.
A
Seizures lasting > 30 mins or repeated seizures without regaining consciousness
22
Q
Features of status epilepticus ?
A
- tonic clonic seizure
- non convulsive status is more difficult
- EEG can help confirm diagnosis
23
Q
If Someone presents with seizures and they are pregnant what us the likely diagnosis ?.
A
Eclampsia
24
Q
What investigations should be carried out in status epilepticus ?
A
- bedside glucose
- bloods: lab glucose, U&Es, FBC, Ca, Mg, LFTs
- ABG
- ECG
- consider anticonvulsant levels, toxicology screen, LP, Blood culture and urine, carbon monoxide level
- EEG
- pulse oximetry, cardiac monitor
25
What drugs should be administered in status epilepticus ?
- O2 15L/min non rebreath mask
- Lorazepam (repeat after 5 mins if fits continue )
- Phenytoin - if fits continue
- Diazepam
- continued seizures may require anaesthetist sedation
26
What are the symptoms of acute sever asthma ?
- SOB (dyspnoea)
- cough (often worse at night)
- chest tightness
27
What bloods should you order in an acute MI ?
FBC, U&Es, calcium, magnesium, glucose,troponin
28
Definition of acute kidney injury ?.
- rise in serum creatinine greater than 26umol/L within 48 hrs
OR
-rise in serum creatinine 1.5 x baseline value within 1 week
OR
- urine output less than 0.5 ml/kg/hr for 6 consecutive hours
29
Risk factors for AKI ?
- > 75 yrs
- CKD
- HF
- PVD
- liver disease
- DM
- nephrotoxins e.g. NSAIDs, gentamicin, iodinated contrast
- hypovolaemia
- sepsis
30
Pre renal causes of AKI
- dehydration (vom, diarrhoea, burns, haemorrhage)
- hypotension
- sepsis
- HF
31
Renal causes of AKI ?
- prolonged hypo perfusion
- nephrotoxins
- glomerulonephritis
- vasculitis
- interstitial nephritis
32
Post renal causes of AKI
- obstruction e.g. Renal stones, bladder cancer, pelvic mass, enlarged prostate
33
Signs of AKI
- hypovolaemia - assess volume status (cap refill, pulse, bp, JVP, skin turgor, pul oedema, peripheral oedema, urine output)
- palpable bladder
- signs of vasculitis (weight loss, fever, rash, uveitis, haemoptysis, joint swelling
- renal Bruits (renal artery stenosis)
34
Investigations to be done in AKI
- FBC, U&Es, bicarbonate, LFTs, calcium, phosphate
- blood cultures if sepsis expected
- urine dipstick (presence of blood and protein suggests infection or vasculitis)
- CXR
- renal tract ultrasound (exclude renal tract obstruction)
35
Response in AKI
- IV access
- treat underlying cause (fluids for hypovolaemia, antibiotics for sepsis)
- treat complications (hyperkalaemia, pul oedema, acidosis, pericarditis)
- REVIEW DRUG CHART (dose adjustments and avoid nephrotoxins)
- renal replacement if indicate (e.g. Intractable hyperkalaemia, pH
36
How would you recognise hyperkalaemia ?
- serum potassium >5mmol/L
| - ECG changes - tall tented T waves, small P waves, wide QRS
37
Causes of hyperkalaemia ?
- oliguric AKI
- potassium sparing diuretics (amiodarone, Spironolactone)
- drugs e.g. ACEi
- rhabdomyolysis
- metabolic acidosis
- Addison's disease
- massive blood transfusion
38
What are the complications of hyperkalaemia
- cardiac arrhythmias
| - sudden death
39
When is immediate treatment required in kyperkalaemia ?
- potassium >6mmol/L with ECG changes
OR
- potassium > 6.5mmol/L regardless of ECG change
40
Immediate treatment of hyperkalaemia
1. Calcium gluconate - 10%, 10mls over 2 mins (protects the heart)
2. Insulin (short acting) and dextrose - insulin sats potassium into cells temporarily *monitor BM*
3. Salbutamol neb - shifts potassium in to cells temporarily
4. Calcium resonate - removes potassium from GI tract (co prescribe with lactulose)
5. Renal replacement therapy for intractable cases
41
Signs/symptoms of anaphylaxis ?
- rash
- urticaria (hives)
- laryngeal oedema
- angioedema (swelling if deep layers of skin)
- severe bronchospasm
- hypotension and shock
- nausea, vomiting, diarrhoea
42
What type of hypersensitivity reaction is anaphylaxis ?
Type 1, IgE mediated hypersensity
43
Drugs administered in anaphylactic shock ?
- Adrenaline (0.5 mg IM) *repeat as necessary, reassess every 5 mins
- chlorphenamine 10mg IV
- hydrocortisone 200mg IV
- fluid bolus - Hartmanns 500ml stat (10-15 mins)
- may need ionotropes/vasopressors to maintain BP
- if audible wheeze treat for asthma
44
What simple manoeuvre can be done to help restore circulation in an anaphylactic shock ?
Raise legs
45
What blood tests should be sent for in an anaphylactic shock ?
FBC, U&Es, LFTs, calcium and glucose
46
How would you recognise a broad complex tachycardia ?
- ECG rate greater than 100 bmp
- QRS complex > o.12s (3 small squares)
- presence of pulse (if no pulse start advanced life support)
47
What bloods should be tested in broad complex tachycardias ?
FBC, U&Es , LFTs, calcium, magnesium, glucose
48
Response in broad complex tachycardia
- give oxygen
- IV access
- attach cardiac monitor
- monitor bp and O2 sats
- 12 lead ECG
- identify and treat underlying cause (e.g. Electrolyte disturbance esp. Hypo K and Mg)
49
How would you recognise brandy arrhythmias ?.
ECG rate less than 50 Bpm
50
How would you treat bradyarrhythmia with adverse features ?
Add atropine to standard treatment (O2, bloods, monitoring etc)
51
How would you treat a narrow complex tachycardia with adverse features ?
- synchronised DC shock
52
How would you treat a REGULAR narrow comes tachycardia without adverse features ?
- treat as Supraventricular tachycardia
- use vagal manoeuvres
- adenosine
53
How would you treat an IRREGULAR narrow complex tachycardia ?
- treat as for AF
- digoxin or beta blocker for rate control
- amiodarone for chemical cardio version and rate control
54
What might be adverse features in a broad or narrow complex tachycardia ?
- shock (systolic
55
How would you treat a broad complex tachycardia with adverse features ?
Synchronised DC shock
56
How would you treat a broad complex tachycardia without adverse features ?
Amiodarone
57
What a the causes of pulmonary oedema ?
- left ventricular failure
- fluid overload
- neurogenic
58
What are the signs of pulmonary oedema ?
- dyspnoea
- orthopnoea
- pink frothy sputum
- pale, sweaty, distressed
- raised JVP
- inspiratory crackles
- wheeze
- triple gallop rhythm
59
What findings would you see on a CXR in pulmonary oedema ?
- cardiomegaly
- fluffy bilateral shadowing with peripheral sparing (bat wing)
- kerley b lines
- pleural effusion
60
Drug treatment in emergency presentation of pulmonary oedema ?
- oxygen
- diamorphine (caution in COPD and liver failure)
- furosemide
- glyceryl tri nitrate
- salbutamol nebs if wheeze
61
How would you recognise sepsis ?
Two or more of the following:
- temp 38
- HR > 90bmp
- tachypnoea >20
- white cell count 12
62
What counts as severe sepsis ?
Sepsis (I.e. Due to infection) + organ disorder
63
What is septic shock ?
Sepsis plus hypotension despite adequate fluid resuscitation
64
What is the response to sepsis ?.
'Sepsis 6' - 6 things to be completed within an hour - use BUFALO:
B - blood cultures
U - urine output (catheter, monitor hourly)
F - fluid - treat hypotension
A - antibiotics- broad spec stat
L - lactate (and Hb) - measure
O - oxygen - 15L/min
65
What is the most common cause of airway obstruction in adults ?
Reduced consciousness level
66
What is see saw chest movement a sign of?
Complete airway obstruction
Core Conditions
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