MEDICINE
12/8/10
Venkatesh, B et al (2003) “Data Interpretation in Critical Care Medicine” Elsevier
Alex Pirides Notes
PY Mindmaps
FANZCA Part II Notes
Adrenal insufficiency -> increased ADH
Hyponatraemia
Hyperkalaemia
Hypotension
Hypoglycaemia
Also consider Spirinolactone therapy
Anaemia
Decreased production
Increased destruction
Bleeding
Haemodilution
Microcytic
Normocytic
Macrocytic
Anti-fungals (APE)
Azoles (Fluconazole)
Polyenes (Amphortericin B)
Echinocandins (Caspafungin, Andulafungin, Micafungin)
AHA/ACC Guidelines
Patient (active medical problems, intermediate risk, low risk)
Exercise capacity (</> 4 METS)
Surgery (high, intermediate or low)
Apheresis Indications (A CHIP O)
-
autoantibodies
circulating immune complexes
hyperviscosity syndromes
immunoglobulins
protein bound substances
other
Jeremy Fernando (2011)
Ankylosing Spondilitis
Seronegative Polyarthritis
MSD
AIRWAY – difficult, can’t extend their heads, limited mouth opening
CVS – AR, pericarditis, amyloid
RESP – restrictive lung disease
PAIN EYE – scleritis, iritis
RENAL - impairment
IMMUNOSUPPRESSION - DMARDS
REGIONAL – difficult
Approach to a Disease
Severity
Stability
Duration
Anaesthesia during Pregnancy
-
physiology – two patients, aorto-caval
pharmacology - teratogenesis
prevention of labour
perfusion of uterus
try and delay surgery
Apgars
Colour
Tone
Response to stimulation
P
Respiratory effort
Aspiration Prophylaxis
30mL of Na+ citrate
Ranitidine 50mg IV
Omeprazole 40mg IV
Metoclopramide 10mg IV
Bleeding Tonsil
Full stomach -> aspiration
Shock -> resuscitation
Paediatric patient
Rapid airway securing
Brain Death Testing
Jeremy Fernando (2011)
Preconditions - 8
Examination – responsiveness, brain stem reflexes, apnoea
Other processes
Cardiac Arrest Prognostication
Rhythm
CPR (time to and quality)
Time to ROSC
Cause of arrest – ability to treat cause
Therapeutic hypothermia
Coma -> need to wait until 72 hrs
Myoclonic jerks
Assessment @ 72 hours – pupils, corneal reflexes, motor response, SSEPs (N20 peak), isoelectric EEG, burst suppression, status myoclonus
-> reliability of prognostic markers @ 72 hrs are now questionable with the introduction of
therapeutic hypothermia
Cardiogenic Pulmonary Oedema
-
preload reduction: diuretics, opioids, decrease intake, spirinolactone
afterload reduction: ACE-I, GTN, IABP
increase contractility: milrinone, dobutamine, adrenaline, VAD
decreased myocardial work: beta-blockers, IABP, VAD
increased coronary perfusion and oxygenation: O2, Hb, Stents, CABG, IABP
Red = decreases mortality
Causes of Stevens Johnson Syndrome (MIDI)
Malignancy
Infectious
Drugs
Idiopathic
Classification of Renal Injury/Failure (RIFLE)
Risk
Injury
Failure
Loss
ESRF
Cerebral Palsy
Non-progressive CNS disorder – affecting posture and motor function
Antenatal, intra-partum and postnatal causes
Severity!
MSD
Airway – difficult
RESP – GORD, chest
Jeremy Fernando (2011)
CVS – co-morbidity, iv access
CNS – pain, agitation, spastic, seizures
Meds – many with many interactions
Latex allergy
Childhood Collapse
ACLS
DIC
Priorities
1.
2.
3.
4.
Early Oxygenation (open airway, 5 attempted breaths, early intubation)
Support circulation (assess pulse, CPR 15:2, fluid, antiarrhythmics)
Defibrillation (if indicated, 4 J/kg)
Treat cause
Chronic Alcohol Abuse
MSD
CNS – encephalopathy, dementia, korsakoff’s psychosis, SDH
CVS – HT, cardiomyopathy
RESP – aspiration and chest infections
GI – GORD, malnutrition,
LIVER - cirrhosis
HAEM – megaloblastic anaemia, coagulopathy, bleeding
PANCREATITIS - chronic
GENERAL - falls
Categories of EmLSCS
I – immediate delivery c/o threat to life of mother or baby (GA)
II – urgent: threat is not immediate (RA)
III – early: no threat but delivery needs to be early (RA)
IV – elective: when mother, surgical and anaesthetic available (RA)
Coagulopathy (high PT and APTT) and Low Fibrinogen
DIC
Primary fibrinolysis
Dilutional coagulopathy from massive transfusion
Post thrombolysis
Snake bite
CTG
Determine Risk
Contractions
Base line rate (120-160)
Variablity (5-15)
Accelerations
Decelerations (variable, late, profound with bradycardia, sinusoidal)
Jeremy Fernando (2011)
Overall impression
Downs Syndrome
Genetic disorder
MSD
AIRWAY – tracheal stenosis, difficult airways and BMV, large tongue, hypersalivation, TMJ
laxity
RESP – OSA, recurrent infections, tonisillar hypertrophy
CVS – ASD and VSD + others
GI – duodenal atresia, GORD, diarrhoea and constipation
CNS – global developmental delay, epilepsy, hypotonia, squint, deaf, cataracts
MUSK – atlanto-axial instability, cervical spondylitis
ENDO – DM, obesity, hypothyroidism
SKIN – difficult IV access
HAEM – immunodeficient, leukaemia, lymphomas
Eclampsia
-
terminate and prevent further seizures
support A, B and C
treat complications of seizures
interpartum resuscitation (if required)
ESLB organisms
Klebsiella
E coli
Enterobacter
ESCAPPM – Gram –ve Rods which rapidly produce beta-lactamase with
cephalosporins
Enterobacter species
Serratia species
Citrobacter freundii
Aeromonas species
Proteus vulgaris
Providencia species
Morganella morganii
Fluids
Bolus
Crystalloid - 10-20mL/kg
Colloid – 10mL/kg
RBC – 10mL/kg
Plt – 10mL/kg
FFP - 15mL/kg
Cryo – 5mL/kg
Jeremy Fernando (2011)
Maintenance
Neonate (10% dex) – 60, 90, 120, 150, 150mL/kg/day
Infant – (2.5% dextrose + ½ NS) - 100kcal/kg/day which requires 1mL of H2O -> 4, 2,
1mL/kg
HACEK organisms that cause Endocarditis
Haemophillus aphrophilus, parainfluenzae and paraphrophilus
Actinobacillus actinomycetemcomitans
Cardiobacterium hominis
Eikenella corrodens
Kingella kingae
Haemofiltration/Dialysis Indications (FAKE)
Fluid overload (pulmonary oedema)
Acid (renal failure)
K+
Extras – toxins, CK, sepsis, Na+, uraemia
Haemolytic Uraemic Syndrome vs Thrombocytopaenic Thrombotic Purpura
(FATRN)
Fever
Anaemia
Thrombocytopaenia
Renal – HUS
Neurological - TTP
Haemoptysis (TILDA)
Trachobronchial disorders
Iatrogenic
Localised parenchymal disease
Diffuse parenchymal disease
Anticoagulants, DIC, leukaemia, thrombocytopaenia (Haematology)
Heart Transplant
Transplant itself
Drugs
Co-morbidities
Physiological and Pharmacological alterations
Immunosuppression
Autonomic denervations
Talk to transplant co-ordinator
Jeremy Fernando (2011)
Hyperosmolar Hyperglycaemic Syndrome
- hyperosmolar (>320mmol/L)
- hyperglycaemia (>33mmol/L)
- dehydration (increased U:Cr ratio)
Hypotension > PEA Arrest Post Asthmatic Intubation
- causes:
(1)
(2)
(3)
(4)
(5)
(6)
(7)
(8)
sedation
DHI
pneumothorax with tension
arrhythmias
hypovolaemia (rare)
endobronchial intubation
myocardial depression from prolonged hypoxia
reversal of pleural pressures impairing venous return
->
->
->
->
->
->
->
->
->
disconnect from ventilator
slow RR and load with fluid
auscultate the chest
check ETCO2 and ECG
urgent CXR
treat cause
fluids + inotropes
heliox
ECMO
ICD
Shock chamber
Chamber to which anti-tachycardia pacing delivered
Means of detection of tachyarrhythmia (electrically or haemodynamically)
Pacemaker code
Inhaled Foreign Body
Aims:
Keep spontaneously breathing
Anaesthetic depth to tolerate rigid bronchoscope
Shared airway
Intrapartum Resuscitation
Left lateral
O2
IVF
Stop oxytocics
Treat hypotension
GTN
Jeremy Fernando (2011)
Amnioinfusion
Cord prolapse -> knee elbow position, displace presenting part, keep cord warm and wet
Immunoglobulin Indications (HIV DNC)
Haematological
Infectious
Vasculitidies
Dermatological
Neuromuscular
Controversial
Liver Disease
CNS – encephalopathy
CVS – hypertension, hyperdynamic, CHF
RESP – infection, hepatic-pulmonary syndrome
HAEM – anaemia, splenomegaly, coagulopathy
GI – portal hypertension
METABOLIC – electrolytes
Liver Failure (DAVE)
Drugs – paracetamol, halothane, idiosyncratic
Alcohol
Viral (A->G, CMV, HSV, EBV)
Extras – fatty infiltration in pregnancy, HELLP, Wilsons, Reye’s
Massive Obstetric Haemorrhage
Causes:
Tone
Trauma
Tissue
Thrombin
Management:
Treat cause
Stop bleeding surgically and transfuse products early
Rub down
Bimannual compression
Syntocinon 5 IU -> infusion (10u/hr)
Ergometrine 0.5mg IM
Carboprost 0.25mg IM Q 15min (max 2g)
Misoprotol 1g PO/PR/SL
Embolisation
Iliac balloon inflation
C/S hysterectomy
Jeremy Fernando (2011)
Massive Transfusion Complications (HI ESTI V)
Haemostatic failure
Impaired oxygen transport
Electrolytes and Metabolic disturbance
Serological Incompatibility
Transmission of infection
Impaired Reticuloendothelial Function
Vasoactive Reactions
Myocarditis Causes (HIGAAP)
Hypersensitivity
Infectious
Giant cell myocarditis
Autoimmune
Active viral
Post viral (lymphocytic)
Neonatal Apnoea Differential
Patient
-
prematurity
history off
unwell (sepsis)
small gestational size
lung pathology
anaemia
hypoglycaemia
hypothermia
Anaesthetic
-
opioids
GA
sedatives
hypnotics
clonidine
Non-structural causes of Coma (MESOT)
Metabolic
Endocrine
Seizures, sepsis
Organ Failure – renal, hepatic
Toxins
Not absorbed by charcoal (MAC)
Metals
Alcohol
Corrosives
Jeremy Fernando (2011)
Opioid conversion
Morphine 30mg PO =
Morphine 10mg IV =
Fentanyl 100mcg IV =
Tramadol 100mg IV =
Codeine 300mg PO =
Oxycodone 12mg PO =
Pethidine 100mg IV =
Methadone 1-5mg PO
Morphine/day PO
Morphine:Methadone
<90
90-300
>300
4:1
8:1
12:1
Orthodeoxia + Platypnoea
Orthodeoxia = hypoxia when standing (resolves on assuming the supine position)
Platypnoea = SOB when standing (resolves on assuming the supine position)
DIFFERENTIAL
- intracardiac shunts: intra-atrial
- pulmonary vascular shunts: anatomical or parenchymal
Paediatric Neuro Assessment (TICLS)
Tone
Interactiveness
Consolability
Look/gaze
Speech/cry
Pain Assessment
HISTORY
Pain history – site, severity, onset, character, course, radiation, aggravating & relieving
factors, other symptoms, rest and dynamic pain.
Nociceptive or Neuropathic
Organic or Functional
Opioid tolerant patient
Chronic pain patient
Treatments
Effect on daily life
Expectations
Jeremy Fernando (2011)
EXAMINATION
- organic pathology
- neuropathic pain (allodynia, hyperalgesia, CRYPS)
INVESTIGATIONS
- to rule in/out above
MANAGEMENT
-
analgesia (multi-modal)
adjuncts (ketamine, clonidine, lignocaine, anti-convulsants, anti-depressants, blocks)
MDT
lifestyle factors
Parkinsons Disease
CVS instability
Drug interactions
Risk of respiratory failure
Reflux
Pacemaker Patient
Preop
Patient – indication, co-morbidity
Pacemaker – assess and set to non-sensing mode
Intraop
Notify surgeon
Bipolar
Pads + drugs
Post-op
Interrogate
Reset
PET
= hypertension (>140/90) after 20 weeks gestation and resolves within 3 months + one or
more organ dysfunction
Management:
1. Management of hypertension (methyldopa, labetalol, nifedipine, betablockers, hydrallazine,
GTN, SNP)
2. Prevention of eclampsia (MgSO4)
3. Planned delivery of baby and placenta
Jeremy Fernando (2011)
Placenta Praevia
Can baby be delivered vaginally?
Anterior or posterior?
Previous C/S?
Bleeding?
Pulmonary Embolism
DIC
ACLS protocol
Priorities:
1. Prevent further embolism
2. Anti-coagulation
3. Reperfusion of PA
Poisoning
Resuscitate
Quantify drugs/exposure, severity and timing
Decrease drug absorption
Increased elimination
Antidotes
Manage complications
Paediatric Patient
-
Consent
Equipment
Drugs
Temperature
Glucose control
Fluid management
Premature baby
-
<37/40
physiological immaturity
apnoea
systems approach
standard paediatric issues
Pyloric Stenosis
1.
2.
3.
4.
Vomit – loose H2O, Cl, H+ and Na+
Aldosterone – reabsorption of Na+ + H2O, loss of K+ and H+
Hypokalaemia -> H+ in urine
Give Cl- and it all reverses
Jeremy Fernando (2011)
Positive QRS in V1
-
Right ventricular hypertrophy
Posterior infarction
WPW type A
RBBB
Duchenne’s muscular dystrophy
incorrect lead placement
Prolonged APTT and Bleeding Time
vWD
Aspirin + Heparin
Post cardiopulmonary bypass (heparin + platelet dysfunction)
Post haemodialysis (heparin + uraemia)
REMINISCE PAPA DAD – to prevent Antibiotic Resistance
Restrict access to specific agents if an outbreak of antibiotic resistance takes place
Early ID consult
Multiple drug classes
Infection control procedures
Narrow spectrum antibiotics
Isolation of those with MDR organisms
Surveillance to ID those infected/colonized with MDR organisms
Cease antibiotics after 24-48 hours after achieving appropriate response
Embrace local guidelines
Prophylaxis discouraged unless indicated
Appropriate drug, dose, duration, timing
Preventative measures (VAP and headup)
Avoid unnecessary use of antibiotics
Descale (empiric -> narrow spectrum once cultures known)
Antiseptic techniques for all invasive procedures
Disinfection of commonly used equipment
Renal Failure
Pre-renal – hypovolaemia, rhabdomyolysis, abdominal compartment syndrome, clamping
Intra-renal – drugs, HT, DM, GN, advanced age
Post-renal = obstruction – stone, BPH, ureter clipped
Risk factors for VTE
Major (SLOMMM)
Surgery
Lower limb problem
Obstetric
Jeremy Fernando (2011)
Malignancy
Mobility (im)
Miscellaneous
Minor (COM)
Cardiovascular
Oestrogens
Miscellaneous
Septic Child
ACLS
Early antibiotics – cefotaxime 50mg/kg IV (child), gentamicin and ampicillin (neonates)
Serious Skin Disorders (PTSD-D)
Primary blistering disorders
Toxic infective erythemas
SJS -> TENS
Disseminated infections
Drug reactions (exfoliative)
Surviving Sepsis Campaign – 2008 (IIMOSH)
Initial resuscitation
Infective issues
Mechanical ventilation
Other supportive care
Special drugs
Haemodynamic support
Severe Hypophosphataemia, Hypokalaemia, Hypomagnesaemia -> Refeeding
syndrome
Stents
Angio – 4 weeks
BMS – 6 weeks
DES – 12 months
Discuss with cardiology
Ideally keep clopidogrel going
Definitely keep aspirin going
Can use bridging therapy but not proven
Deal with bleeding risk
TCA OD
- anticholinergic effects
Jeremy Fernando (2011)
- inhibition of catecholamine reuptake (initial increase in sympathetic tone -> prolonged
decrease)
- profound alpha-adrenergic blockade
- myocardial toxicity
Management:
Supportive – ABCDE
Specific – avoid acidosis: NaHCO3, hyperventilation
Thrombocytopaenia (SHIPPP MI DAD)
Sepsis
Hypersplenism
Immune thrombocytopaenia (ITP, TTP, HITS)
Post-resuscitation dilution
Platelet consumption or destruction
Primary marrow disorders
Massive transfusion
Intravascular devices (IABP, PAC, ECMO)
Drug induced (antibiotics, frusemide, thiazides, H2 antagonists)
Antiphospholipid syndrome
DIC
Tocolytic Agents
Ca2+ channel blockers (nifedipine 10-20mg tds)
Salbutamol 15mcg/kg IV
GTN 50-100mcg IV
Volatiles MAC 0.5
TRALI
Definition = ALI within 6 hours of transfusion of plasma containing products
Mechanism: donor anti-WCC antibodies + recipient WCC antigens OR biologically activated
mediates reacting with lung
Management:
Stop transfusion
Supportive care – A, B, C, D, E
Lung protective ventilation
Inform blood bank
Weakness
CNS
Brain stem
Spinal
Nerves
Jeremy Fernando (2011)
Muscles
Other: electrolytes, sepsis, critical illness polyneuropathy
Jeremy Fernando (2011)