14. KFP: Emergency Flashcards
What is a management for anaphylaxis?
IM adrenaline 1:1000 0.01mL/kg [or 10microg/kg] (Max 0.5mL) in the lateral thigh
* it should be repeated after 5 minutes if not improving
What are the clinical features of an anorectal abscess?
- Severe pain in the anal or rectal area, with fever or malaise
- Superficial: perianal erythema and a palpable, fluctuant mass
- Deep: tender, often fluctuant mass internally on digital rectal exam
What is the management of an anorectal abscess?
- Surgical drainage
- All skin incisions should be made as close to the anal verge as possible to minimise the length of a potential fistula while still providing adequate drainage of the abscess
- Give antibiotics to all patients after incision and drainage
- Mild infection: augmentin DF (875/125mg) BD for 5 days
- Severe infection: Gentamicin IV + metronidazole 500mg IV BD + Amoxicillin/Ampicillin 2g IV Q6hourly
What is the management for a patella fracture that is non-displaced or minimally displaced with an intact extensor mechanism (patient able to perform straight leg raise)?
- Immobilise in knee extension with a Zimmer knee splint for four to six weeks
- The patient is usually allowed to weight bear in the splint during this time
What is the initial management for a snakebite?
- Apply a pressure bandage over the bite site and whole affected limb, and completely immobilised limb and the patient
- Arrange urgent hospital transfer - hospital must have adequate anti venom and critical care facilities in which the anti venom can be safely administered and anaphylaxis can be treated
What are the clinical features of serotonin syndrome?
- Neuromuscular excitation - hyperreflexia, clonus, ocular clonus, myoclonus, shivering, tremor, hypertonia, rigidity
- Autonomic effects - hyperthermia, sweating, flushing, mydriasis (pupil dilation), tachycardia
- Central nervous system effects - agitation, anxiety, confusion, altered conscious state
Describe the hunter serotonin toxicity criteria
Clinical diagnosis of surat synergic toxidrome can be made if the patient has taken a service allergic drug and meets one of the following criteria
* Spontaneous clonus
* Inducible clonus plus either agitation or sweating
* Ocular clonus plus either agitation or sweating
* Tremor plus hyperreflexia
* Hypertonia plus Temperature more than 38°c plus either inducible clonus or ocular clonus
What are the clinical features of mild serotonin syndrome?
- Tremor
- Mild tachycardia
- Inducible clonus
- Lower limb hyperreflexia
What are the clinical features of moderate serotonin syndrome?
- Agitation
- Sustained clonus
- Tachycardia
- Hyperthermia less than 39°c
What are the clinical features of severe serotonin syndrome?
- Rapidly progressive hyperthermia
- Muscle rigidity with sustained clonus
- Seizures
What is the management for moderate serotonin syndrome?
- Cease the offending medication
- If distressed by symptoms: 5 to 20 mg PO; repeat after 30 minutes if required; usually no more than 120 mg is required in 24 hours
Management for severe serotonin syndrome?
- Urgent transfer to hospital
- Seek advice from a clinical toxicologist
- For rapidly progressive hyperthermia: rapid cooling techniques eg cold IV fluid
- For muscle rigidity was sustained clonus: sedate the patient
- For seizures: benzodiazepines
When should silver sulphadiazine (Flamazine) cream be used for wound management?
- Initial short term use only as it only provides antimicrobial activity for 8 hours
- May delay healing compared to other antiseptics
- Can impair reassessment of the wound
When is silver dressing (Acticoat) indicated in wound care?
Indicated if wounds are contaminated or deep
When is a silicone foam dressing (Mepilex) indicated?
- Moderately exudative wound
- Useful in the first 72 hours when superficial dermal burns often produce significant exudate
When is combine (cellulose blend within fabric) dressing used?
It is highly absorbent but not usually used as burns dressing
When is hydrocolloid dressing (Duoderm) indicated?
Useful for wounds with low exudate
When is silver based silicone foam dressing (Mepilex Ag) indicated?
Moderately to highly exudative burns that are contaminated or deep
Why is blister debridement indicated in the management of burns?
- The build up of fluid under the intact blister can put pressure on the underlying dermis, which in turn can reduce perfusion and potentially deepen burns
- Blister skin is dead and should be removed as it is a potential focus for infection
- Intact blisters are painful
What is recommended for different severities of pain when managing burns?
Mild (pain score 0-3):
* Paracetamol 1g Q6hourly PRN and Naproxen 250mg TDS PO PRN (+/- gut protection)
Moderate (pain score 4-7):
* Add tapentadol 100-250mg BD OR IR opioid 5-10mg Q2-4hourly
Severe (pain score 8-10):
* Add SR opioid & IR opioid
* Add pregabalin 75mg BD
* Consider admission for IV analgesia
What are examples of high risk ingested foreign bodies?
- Button batteries in the oesophagus
- Large objects (>6cm long or >2.5cm wide)
- Two magnets OR one magnet + metal object
- Sharp object in the oesophagus
- Toxic objects e.g. lead
What constitutes high risk community acquired needle stick injury?
- Source known to be infected with a bloodborne virus
- Community acquired needle stick injury from a deliberate assault
- Deep, large volume injection with hollow bore needle
- Personal history of injecting drug use
- Needle directly placed into vein or artery
- Device visibly contaminated with blood
In the work up for community acquired needle stick injury, what is the minimum investigation required?
Take blood for hepatitis b surface antibody and serum storage (for consideration of Hep C and HIV testing in high risk situations)
What is the management of community acquired needle stick injury?
- Assess for high risk factors
- Take blood for hepatitis B surface antibody and serum to store (BUT do not routinely test for Hep C or HIV)
- First aid: wash site with soap and water
- Dispose of needles safely
- Give tetanus booster if not updated (if >5 years since last booster)
- Consideration for HIV post-exposure prophylaxis if high risk and on discussion with Infectious Diseases
- Consider referral to Infectious Disease outpatient clinic to provide an opportunity for questions and to plan follow up investigations and immunizations, if required
What is the management for a seizure lasting more than 5 minutes or of unknown duration?
Commence active treatment:
* Continuous monitoring, oxygen
* Obtain venous access
* Check BSL
* Give benzodiazepine (If IV access is difficult, use IM/buccal midazolam)
When should active seizure management be started?
- After 5 minutes of continuous seizure activity
- When the patient has repeated seizures without full recovery of consciousness between attacks
What are the pharmacological options for management of acute seizures?
IV access available:
* 1st: Midazolam 10mg IV; over at least 2 minutes
* 2nd: Diazepam 10mg IV; over at least 2 minutes
* 3rd: Clonazepam 1mg IV; over at least 2 minutes
IV access NOT available:
* 1st: Midazolam 10mg IM (adult >40kg)
* 1st: Midazolam 5mg IM (adult <40kg)
* 2nd: 5-10mg buccal or intranasal
Where does epistaxis usually occur in children?
Little’s area (on the anterior septal wall)
What is the first line treatment for epistaxis?
Simple measures:
* Sitting up in comfortable position
* Tilt head forward slightly
* Apply continuous pressure on the anterior portion (cartilage) of the nose with thumb and forefinger for 10 minutes
* Breathe through the mouth and allow any blood to run into a kidney dish rather than swallowing
