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Give 5 ways of preventing a post op PE ?
- TEDS (thromboembolic deterrent stockings)
- Pneumatic calf compression
- LMW Heparin at prophylactic dose
- stop HRT, pill pre op
- ask about FH of thromboembolism and consider for inv for thrombophilia
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Give 5 symptoms of PE?
- breathlessness
- pleuritic chest pain
- haemoptysis
- syncope
- dizziness
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Give 8 signs of PE
- tachycardia
- tachypnoea
- pyrexia
- cyanosis
- raised JVP
- pleural effusion
- pleural rub
- hypotension
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what signs of a cause of PE would you look for?
- DVT - swollen leg
- scar from recent surgery
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what are the main RF for PE? in categories
- surgery: major abdo, pelvis, hip or knee replacement
- obstetrics: late pregnancy, post partum, C section, pill, HRT
- Lower limb problems: fractures, varicose veins (valves not working)
- Malignancy
- Prolonged bed rest, reduced mobility
- Previous PE
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What is the treatment for a PE?
- Anticoagulation:
- 1. LMW heparin (dalteparin SC)
- 2. start oral warfarin 10mg
- stop heparin when INR is >2
- continue warfarin for a minimum of 3 months, aiming for INR: 2-3
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what would you consider if pt develops emboli despite adequate anticoagulation?
vena caval filter
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which test may help EXCLUDE a PE?
D dimer test - do in pts with a low clinical probability of PE, to exclude it. NB it cannot prove there is a PE though
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What are the signs of a PE on CXR?
- often normal!
- decreased vascular markings
- small pleural effusion
- wedge shaped area of infarction
- atelectasis
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what are the 2 most sensitive and specific tests for diagnosing PE?
- VQ perfusion scan
- CT pulmonary angiography
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what are the signs on ECG of a PE?
- tachycardia
- RAD
- RBBB
- RV strain pattern in V1 to V3: dominant R wave, inverted T wave, ST depression
- rare: SI, QIII, TIII: deep S waves in I, pathological Q waves in III, inverted T waves in III
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With anaphylaxis do you get facial pallor or flushing?
flushing
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What are the cardiovascular effects of anaphylaxis?
- tachycardia
- arrhythmias
- hypotension
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what are the respiratory effects of anaphylaxis?
bronchoconstriction
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for an anaphylactic reaction, what must you immediately administer and hOW MUCH?
adrenaline, 1:1000
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What are the signs of anaphylaxis in terms of ABC and skin?
- airway: swelling, hoarseness, stridor
- breathing: O2 sats < 92, cyanosis, rapid breathing, wheeze, confusion, fatigue
- circulation: pale, clammy, low BP, faintness, drowsy/coma
- Rash, facial flushing
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Once adrenaline given, what other measures can be taken?
- lie patient FLAT, raise legs
- establish airway and 2 iv access
- high flow oxygen
- iv fluid challenge: 500mL crystalloids NOT COLLOIDS
- anti-histamine: chlorphenamine 10mg
- steroids: iv hydrocortisone 200mg
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What things do you need to monitor in anaphylaxis
- pulse oximetry
- ECG
- blood pressure
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A 72-year-old man who underwent AAA repair presents with a very low urine output postoperatively. His BP is stable. what is the diagnosis?
Acute tubular necrosis
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Name a major type of intrinsic renal failure and what causes it?
- Acute tubular necrosis
- ischaemia: due to hypoperfusion
- nephrotoxins: drugs (aminoglycosides, amphoterecin B, tetracyclines), radiological contrast agents, uric acid crystals, Hburia in rhabdomyolysis, myeloma
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A 54-year-old man has just had a hernia operation and is in the recovery room when he is found to be very restless despite a smooth recovery. There seems to be a swelling in his lower abdomen. whats the diagnosis?
urinary retention: clues restless post op
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A 68-year-old man underwent a total cystectomy. During the first postoperative night he was not producing a satisfactory urine output despite adequate hydration. You involved a senior colleague, and after adequate resuscitation the patient’s urine output slowly picked up. Now, the following day, he has started diuresing. diagnosis?
ATN: clue diuresis after adequate resuscitation
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What happens to the urea:creatinine ration in dehydration?
goes up, i.e. as there is a lower body water content, the urea concentration goes up
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With a patient undergoing hemicolectomy and needing prep bowel prep what are all the sources of fluid loss?
- 1. NBM: pre op starvation - dehydration
- 2. bowel prep fluid loss
- 3. daily fluid requirement
- 4. intraoperative blood and fluid loss
- 5. fluid loss from through evaporation of open laparotomy wound 1L in 1h
- 6. insensible losses: increased with fever
- 7. losses in drains via NG tube
- 8. post op vomiting and diarrhoea
- 9. haemorrhage: primary - at time of op, reactionary in first 48h due to bv rupture or unseal
- 10. post op paralytic ileus with accum of intraluminal fluid
- 11. septic shock with dilated vessels and leakage of fluid out into interstitial space
- 12. third space losses e.g. pancreatitis fluid accum in peritoneal cavity
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What is the stress response to surgery?
- neurohumoral response (Catecholamines, ADH, cortisol, aldosterone) in direct proportion to the magnitude of surgery
- leads to catabolic state with salt and water retention and potassium loss
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What are your daily requirements of Na, K and water?
- water: 3L
- Na: 150mmols
- K: 60mmols
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What are the signs if you give too much iv fluid to a patient? (3 categories)
- signs of R heart failure: tachycardia, increased JVP, PERIPHERAL oedema
- signs of L heart failure: tachycardia, breathless, wheeze (cardiac wheeze), PULMONARY oedema
- electrolyte imbalance: check U&Es
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What are the signs if you give too little fluid and which fluid compartments suffer accordingly? (2 categories)
- dehydration (depletion of ICF): thirst, dry mucous membranes, headache, listlessness, decreased skin turgor
- hypovolaemia (depletion of intravasc compartment): tachycardia, tachypnoea, clammy, anxiety, low BP, reduced UO, delayed cap refill, decreased pulse pressure
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What are the signs of acute loss of 15%
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What are the signs of acute loss of 15-30%
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What are the signs of acute loss of > 40%
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