A&E, Anaesthetics, Ortho and Rheumatology Flashcards
Acute Asthma Attack
O SHIT ME
Give oxygen 15L high flow through a non-rebreather mask, salbutamol and ipratropium should be given via nebuliser, 100mg IV hydrocortisone also given.
Theophylline (aminophylline) and magnesium sulphate should only be initiated by an anaesthetist - they may suggest NIV or intubation will be more effective.
Remember: moderate 50-70%, severe 33-49% and life threatening is <33% PEFR (with a silent chest, signs of tiring and reduced respiratory effort)
COPD exacerbation
iSOAP
- give ipratropium bromide and salbutamol through a nebuliser
- give oxygen: if patient is extremely unwell then can give 15L oxygen, however, if patient is conscious and not hypoxic then give 24% oxygen through a Venturi mask. Titrate oxygen concentrations up to 88-92% if a chronic CO2 retainer
- Antibiotics: only give if there is purulent sputum, yellow/green in colour, otherwise hold back on the antibiotics
- Prednisolone: give to patients to control exacerbation
Always check the CURB65 score and examination for underlying pneumonia (likely h.influenzae) and treat accordingly.
STEMI
ST elevation in territories across:
- inferior: II, III, aVF (RCA)
- Anterior: V1-4 (LAD)
- Lateral: V5-6, I and aVL (left circumflex)
Initial management: MONA+T/C (morphine, oxygen if required, nitrates, aspirin and ticagrelor or clopidogrel - if already on anticoagulation)
If patient presents with chest pain <12hrs and <120 mins to PCI then give PCI
If patient presents with chest pain <12hrs and >120mins to PCI then give thrombolysis - check ECG at 60-90mins and if abnormalities still present then do PCI immediately.
NSTEMI and unstable angina
Initial management: MONA+T/C
Doesn’t show ST elevation in leads but may show ST depression and T wave inversion.
Calculate GRACE score, if >3% then consider PCI in 48-72hrs. If <3% then just continue with MONA+T and monitor.
CTCA is really useful for assessing the degree of occlusion and for future surgery planning e.g. PCI or CABG
Ruptured AAA
This is a surgical emergency, patients present with abdominal pain and hypotension, may have collapse.
- requires immediate emergency vascular surgery (open) to clamp aorta and resect problem part and insert a graft. This has poor outcomes due to the timescale and severity of presentation.
- initial management is bloods for crossmatch, IV fluids, blood transfusion and compression of the abdomen.
(ABCDE approach)
Haemorrhage
dial 2222 and activate the major haemorrhage protocol, take bloods for G&S and crossmatch and request 4 units of blood.
If the patient is on warfarin with major bleeding: IV vitamin K and PCC
If patient is on warfarin with INR >8 and minor bleeding: IV vitamin K
If INR >8 with no bleeding: give oral vitamin K
If INR 5-8 with minor bleeding: give IV vitamin K
If INR 5-8 with no bleeding: withhold 1-2 doses and adjust regular dosing schedule
(Restart warfarin when bleeding has stopped and INR <5)
Overdose :
- Paracetamol
- Opiate
- Benzodiazepine
- Tricyclics
- Salicylates
- Warfarin
- ## Heparin
P = N-acetylcysteine (abdominal pain, liver pathology is a late sign) O = naloxone (pinpoint pupils, respiratory depression) B = usually supportive, only give flumenazil if severe due to increased risk of seizures (dilated pupils, respiratory depression, bradycardia) T = IV sodium bicarbonate (confusion, convulsions, coma, dilated pupils, tachycardia, hypotension, increased tone) S = IV sodium bicarbonate (abdominal pain, tinnitus, sweating, hyperventilation, N+V) W = vitamin K (INR or bleeding) H = Protamine Sulphate (APTT)
Head injury
CT head within 1 hour if: GCS <13 at the time or <14 2hrs later, signs of basal skull fracture (racoon eyes, battle’s sign, CSF leak from nose or ear), seizure, focal neuropathy, vomiting >3 times since
CT head within 8hrs if: LOC or amnesia and any of: >65yrs, on anticoagulation medications, dangerous mechanism of injury or >30mins of retrograde amnesia.
CT cervical spine in 1hr if GCS <13 or has been intubated
DKA
Ketones and glucose will be high, can be a first presentation of T1DM, often young.
- Fluid resuscitation is KEY: aim for 1L in the first hour, followed by 1L every 2hrs (+ K if <4.5 = 40mmol or if 4.5-5.5 = 20mmol)
- Insulin can be given after the first hour (0.1mg/kg/hr)
- Give 10% glucose 125ml/hr when capillary glucose <14
Children and adolescents are at increased risk of cerebral oedema from rapid fluid resuscitation and should have 1-1 nursing to detect any decline.
Hypoglycaemia
Low glucose either due to insulin overdosing or poor oral intake.
- if patient can swallow then give glucose tablets
- if patient cannot reliably swallow but is conscious then give glucogel
- if patient in unconscious then give IV glucose infusion (150ml of 10% glucose)
Anaphylaxis
- 5mg of IM Adrenaline STAT + 200mg hydrocortisone IV and 10mg chloramphenamine IV
- give IM adrenaline every 5mins up to 3x
- also give 15L O2 and salbutamol if there is wheeze
- IV fluids 500ml STAT
Cardiac Arrest (VT/VF)
2222 and state cardiac arrest.
Spend 10 seconds assessing patient - feel for pulse and assess breathing. If nothing then begin CPR at 30:2.
- Give up to 3 shocks by synchronised cardioversion defibrillator, one every 2 mins
- after give adrenaline (1mg) and 300mg amiodarone IV
- Adrenaline 1mg IV should be repeated every 3-5mins
Remember, don’t give adrenaline via PVC due to risk of limb ischaemia - CALL THE ANAESTHETISTS
Cardiac Arrest (Asystole/PEA)
2222 and state cardiac arrest
Spend 10 seconds assessing the patient - checking for pulse and RR. If nothing then begin CPR at 30:2. Attach defibrillator pads and allow for rhythm assessment. If PEA or asystole then is a NON-SHOCKABLE rhythm.
- Give adrenaline and amiodarone (adrenaline every 3-5mins)
- Continue CPR constantly, only stopping when signs of life - allow defibrillator to assess rhythm
SVT
- trial Valsalva manoeuvres intially - avoid dual carotid massage and avoid in elderly patients with potential carotid artery disease
- Adenosine IV - give 6mg initially then 12mg then 12mg (spaced apart)
AF (acute onset)
if <48hrs or haemodynamically unstable then consider DC cardioversion
If >48hrs and stable then consider delayed cardioversion and give anticoagulation for at least 3W - with either DOAC or LMWH and warfarin
Atrial flutter
If <48hrs or haemodynamically unstable then consider DC cardioversion
If >48hrs then delayed cardioversion with at least 3 weeks of anticoagulation
DO NOT GIVE ADENOSINE - this blocks the AV node and allows conduction at 1:1 causing incredibly fast HR of around 300bpm.
Stroke
Calculate ROSIER score and do CT head urgently.
- if CT head does not show bleed then give Aspirin 300mg
- Do not attempt to lower BP unless is malignant as this can further reduce perfusion
If ischaemia <4.5hrs = thrombolysis
If ischaemic <4.5hrs and in proximal anterior circulation occlusion with evidence of salvageable brain tissue = thrombolysis and thrombectomy in <6hrs
If >4.5hrs or a ‘wake up’ stroke = thrombectomy in 24hrs
If haemorrhagic = refer to neurosurgery, may require burr hole surgery or craniotomy or conservative management - this is at surgeons discretion and takes into account patient’s pre-morbid state.
Pulmonary embolism
ECG: sinus tachycardia is most common but S1Q3T3 is more specific ECG finding
Provoked: apixaban for 3M and treat the underlying cause
Unprovoked: apixaban for 3-6M
Active cancer: warfarin for 6M
APS: if PE then lifelong warfarin
Massive: thrombolysis within 48hrs and continuous heparin infusion.
CTPA is gold-standard: in pregnancy carries a risk of maternal breast cancer, remember it requires contrast so not suitable in severe CKD or contrast allergy.
V/Q scan is alternative: increased risk of childhood cancers in pregnant women.
Simple Pneumothorax
Primary: no underlying lung conditions and:
- <2cm with no SOB = discharge with worsening advice
- > 2cm or SOB = aspirate and if fail then test drain inserted
Secondary: underlying lung condition (COPD)
- <1 cm = give oxygen and admit for 24hrs
- 1-2cm = aspiration attempted, if fail then chest-drain inserted
- >2cm or SOB = chest drain inserted, no aspiration attempted
(admit all for 24hrs of observations)
Tension pneumothorax
Deviation of the trachea away from the affected lung.
- emergency decompression by large bore cannula inserted into 2nd intercostal space, mid-clavicular line
- do not wait for investigation result
- insert chest drain after initial decompression
Hyperglycaemic hyperosmolar state (HHS)
GIVE LOTS OF FLUID
- give around 9L of fluid to these patients
- if glucose is still remaining high then consider 0.05mg/kg/hr of insulin but only if not lowering with fluids alone.
- give prophylactic dose of LMWH due to increased risk of VTE
- stop metformin due to risk of lactic acidosis in patients with dehydration - continue insulin and oral glycaemics however. Also consider stopping ACEi, ARBs, NSAIDs and diuretics.
Seizure
Patients have status epilepticus if seizure activity is sustained for >5mins
- give 4mg IV lorazepam or 10mg IM diazepam (give at 10mins, 20mins)
- If seizure activity not stopped by 30mins then give phenytoin
- If seizure activity still ongoing then consider GA and ventilatory support
Carbon monoxide poisoning
high flow O2 and supportive treatment
- may require hyperbaric oxygen
Remember it can give a falsely high O2 saturation reading, presents with headache, N+V
Sepsis
Do the following within 1hr:
- Take bloods and blood cultures
- Take lactate and ABG
- Take urine output
- Give IV fluids (500ml saline)
- Give IV antibiotics (according to local guidelines)
- Give Oxygen (15L through non-rebreather)
