ACCS Flashcards
What type of hypersensitvity reaction is Anaphylaxis
Type 1
igE- histamine, mast cells, basophils
sx of anaphylaxis
- skin flushing
- hives/urticaria- pruritis
- Swelling of throat/mouth- wheeze, SOB, dyspnoea
- N+V, diarrhoea, abdo pain
- confusion, headache, anxiety
signs of anaphylaxis
- hypotension
- wheeze
- weak, rapid pulse
- pallor
immediate management of anaphylaxis
- ABCDE A- establish airway B- high flow O2 C- pulse ox, ECG, BP , IV fluid bolus (500ml adults, 10ml/kg children) D- GCS monitoring
- if stridor- adrenaline 5mL of 1mg/mL nebs
- if persistent bronchospasm- neb salbutamol, ipratropium
- remove trigger eg stop infusion
- *- sitting position if conscious (for breathing)
- *- if pregnant- lie on L (venous return)
IM 1:1000 (1g in 1000ml) Adrenaline
- <6m 100-150mcg
- 6m-6y 150 mcg
- 6y-12y 300mcg
- > 12yo/post pubescent 500mcg
- -> repeat after 5 min no response
- cetrizine, ***chlorphenamine
- after 2 IM injections prepare the infusion and follow refractory anaphylaxis algorithm- see other FC
what is the refractory anaphylaxis algorithm
After 2 IM injections of adrenaline with no response:
- IV fluid bolus
- continue IMs every 5 mins until infusion up and running
INFUSION
- 1mg (1mL of 1mg/ml– 1g:1000ml) adrenaline in 100ml 0.9% NaCl
- start at 0.5-1mL/kg/hour in both adults and children
- give in dedicated line and not on same side as BP cuff
- consider vasopressin
- consider glucagon in betablocker pts (reverses)
- take sample of mast cell tryptase
- high flow O2, aim spO2 94-98%
- monitor HR, BP, sats, ECG
NB- hgih BP means adrenaline overdose
Immediate management of chest pain pt
MONA
- IV opioids- Morphine
- O2, sats
- GTN- buccal or SL
- Aspirin 300mg
- hyperglycaemia- if >11mol/L- give insulin (5-10u actrapid)
Management of confirmed STEMI
- MONA plus
- PCI within 12 hours of sx onset
- if PCI not available within 120mins of diagnosis- thrombolyse (alteplase)
- if pt is in shock/has CI to fibrinolysis- PCI
- if fibrinolysis fails- PCI
- if thrombolysis is successful- -revasc via angioplasty within 24 hours
Also give:
- clopi/ticagrelor/prasugrel
- ACEI
- betablocker
- heparin
Management of NSTEMI
MONA plus
- clopidogrel/ticagrelor/prasugrel
- angio, PCI
- fondaparinux
- herparin if renally impaired/low body wt
tx bradycardia with pulse
Unstable (HF, shock, MI)
- atropine 500mcg
- repeat to 3mg
- (or isoprenaline, adrenaline, transcutaneous pacing)
Stable, with hx of asystole, mobitz II/complete block, vent pause >3s
- atropine 500mcg
- up to 3mg
- (or isoprenaline, adrenaline, transcutaneous pacing)
If stable- observe
tx tachycardia with pulse
Unstable
- 3x DC shock
- amiodarone 300mg IV over 10-20mins
- repeat shock
- amiodarone 900mg over 24hours
Stable:
Broad, regular QRS
- VT- amiodarone 300mg IV, then 900mg over 24hours
- SVT with BBB- adenosine 6mg bolus, then 12mg, then 12mg again
Broad irregular- get help
- AF with BBB- BB/diltiazem, digoxin/amiodarone if in HF
- **- pre-excited AF- amiodarone
- polymorphic VT (torsades de pointes)- Mg 2g 10m
Narrow, regular
- vagal manouvres
- adenosine 6mg bolus, 12mg, 12mg
- if not resolved ?atrial flutter–> beta blocker
Narrow, irregular
- probably AF- BB/diltiazem, amiodarone/digoxin if in HF
immediate management of pt without a pulse (cardiac arrest)
- shake their shouder, shout at them
- trap squeeze
- shout for help
ABCDE
- head tilt/chin lift
- pulse palpation– no pulse- move to ALS
- listen, feel, look for breathing for 10s
- commence CPR 30:2
- attch defib pads (one on upper R side below collar bone, other on L side below axilla
- pause CPR to analyse rhythm
is it shockable or not?
What are the shockable rhythms
- Pulseless VT- wide QRS, regular
- Vent fib- wide QRS, irregular, chaotic, deflections vary in amplitude
Management of shockable rhythms
- resume CPR immediately once trace is read
- charge defib, 150J
- when shocking- remove any O2 delivery devices/masks
- everyone stand clear
- 1 shock
- resume CPR for 2 mins
- if still shockable, give 2nd shock
- continue CPR for 2 mins
- if still shcokable, give 3rd shock
After 3rd shock, give:
- adrenaline 1mg IV (10ml of 1:10,000)
- Amiodarone 300mg IV
- continue shocks and CPR, giving the same dose of adrenaline and amiodarone after 5th, 7th, 9th, 11th shocks
- if non-shockable rhythms appear, swithc to that algorithm
- if organised electrcal activity is seen, commence post resus care
what are the non-shockable rhythms
- asytole
- pulseless electrical activity (PEA)
management of non-shockable rhythma
1st rhythm check:
- if asystole/PEA, ***resume CPR
- if returns to spontaneous circulation (pulse) or switches to shockable rhythm, switch to appropriate algorithm/care
- after 2 mins of CPR, give IV adrenaline 1mg (10ml of 1:10,000)
- resume CPR for 2 mins
- 2nd rhythm check
- resume CPR if still asystole/PEA for 2 mins
- 3rd rhythm check
- give IV adrenaline 1mg
- continue givign adrenaline after alternative rhythm checks (5th,7th,9th)
- if shockable rhythms is identified, switch to other algorithm, but continue giving adrenaline after alternative rhythm checks
what are the reversible causes of cardiac arrest
6 Hs, 5Ts- someone should be investigating/ruling out and treating these whilst ALS is occurring
- Hypovolaemia
- *- Hypoxia
- Hydrogen (acidosis)- tx cause/bicarb
- Hypo/hyperkalaemia
- *- Hypoglycaemia
- Hypothermia
- *- Toxins
- *- Tamponade - paricardiocentesis
- Tension PTX- needle compression, chets tube
- Thrombosis (MI, PE)
- Trauma
sx of acute hypertensive crisis
- haemorrhage generally HEART- - aortic dissection- tearing chest / back pain - MI BRAIN **- confusion (encephalothpathy) - SAH - changes in vision **RESP- acute pulmonary oedema **RENAL- haematuria, oliguria
tx acute hypertensive emergency
IV labtetalol
(( or
- IV nitroglycerin
- IV Na nitroprusside (CI in ICP)
- Nicardipine IV
- Aortic dissection- IV labetolol
- ACG- IV nitroglycerin
Pregnant:
- Methyldopa
- Nifedipine
- Hydalazine
- Labetalol
- Mg
Cocaine induced- diazepam 1st line ))
sx aortic dissection
- sudden tearing in chest
- radiation to back classically (often more subtle than this)
- LoC
- Neuro sx , vision problems
- leg pain, issues walking
signs in aortic dissection
- tachycarda
- hypotension
- new aortic regurg murmur
- endo organ hypotension (reduced UO, paraplegia, , lower limb ischaemia, abdo pain, GCS)
immedaite management of Aortic dissection
- hgi flow O2
- IV access 2x wide bore
- fluid resus- <110mmHg
- **- IV labetalol/CCB
- urgent vasc surg input
management of DKA in paeds
- *shock- bolus
- 20ml/kg over 15 min
- *- if still shocked give 10ml/kg
- *- if still shocked, give inotropes
Deficit (48hour)
- % dehydration x kg x 10
Maintenance (24hour)
- 1st 10kg 100ml.kg/mday
- 2nd 10kg 50ml/kg/day
- plus 20ml/kg/day for rest
- up to 80kg
hourly rate= (deficit/48hr)+maintenance per hour
- give glucose 5% once <14mmol/L
- K- ensure every 500ml bag contains 20mmol (40mmol/L)
Insulin
- *- 50u actrapid in 50ml 0.9% saline (1U/ml)
- infusion- 0.05 or 0.1u/kg/hour
- continue normal long acting
- stop short acting and insulin pump
management of DKA adults
Shocked- 500ml NaCl 15mins
**Not Shocked- 500ml-1L NaCl 0.9% over an hour, then 250ml/hour until euvolaemic
Insulin
- 50u actrapid in 50ml 0.9% saline (1U/ml)
- infusion 0.1u/kg/hour
- *- fall in glucose should not exceed 5mm/hour
K
- start once K is normal
- *- KCl 20mmol/hour
- dont give if anuric
Glucose
- 5% dextrose once levels <14
immediate management of acute asthma exacerbation
ABCDE
OSHITME
- Oxygen
- Salbutamol 2.5-5mg in O2, repeat every 15-30min
- Hydrocortisone 100mg IV (or pred oral 40mg)
- ipratropium 0.5mg 4-6 hourly nebbed
- Theophylline/aminophylline 1g in 1L saline at 0.5ml/kg.hr
- MgSO4 2g IV over 20min
- Epinephrine
- fluid bolus 250-500mls
immediate management of acute COPD exacerbation
A- intubate? B - O2, CPAP or BiPAP - SABA 2.5mg-5mg - Anticholinergic (SAMA)- ipratropium 0.25-0.5 nebs
- abx if purluent- amox/ doxy, clarithro IV or Oral
immediate management of PE
Well’s
- <=4- d-dimer
- > 4- CTPA
- ABCDE
- 15L nonrebreath
- analgesia
- thrombolysis IV alteplase
- urgent snr review
immediate management of pneumothorax
- high flow O2
- any signs of resp distress /tension PTX- 2nd ICS mid-clav immediate decompression, then drain in 5th ICS mid-axillary
- admit if secondary (resp conditions
immediate management of flash/acute pulm oedema
A- secure airway (guedel/NP, head tilt, jaw thrust) if unconscious B - sit pt up - O2 hig flow CPAP C - take bloods - ECG
tx of pulm oedema: - IV furosemide 20-40mg slowly -vasodilators (nitroglycerin IV/GTN/buccal isosorbide dinitrate) - LMWH If in shock: - IV dobutamine - dopamine/adrenaline (vasopressor)
immediate management of ARDS
- CPAP 40-60% O2
- fluids
- LMWH
- inotropes- dobutamine
- vasodilators=- nitrates
- blood transfusion- haemofilreation
?Sepsis 6
management of cardiogenic shock
- vasopressors- adrenaline
- *- inotrope- dobutamine
- IV opioids
- aspirin 300mg
- *- monitor for hyperglycaemia- give insulin if >11mol/L
Management of sepsis
ABCDE
BUFALO 6
- bloods- cultures, X match, clotting, FBC, UE, LFT, VBG
- UO
- Fluids 250-500ml bolus, 200ml if hx cardiac, mnitor for fluid overload signs, up to 2L
- Abx IV
- Lactate (VBG)
- O2- 15L nonrethreathe
how to manage low UO
Low UO= <0.5kg/hour
Anuria= <100mls in 24hours
ABCDE assessment
Pre-renal-
- high flow O2
- bloods
- BP
- 250-500ml NaCl, aiming for >100mmHg systolic
- if anuric, think obstruction- check catheter, bladder washout using 50mls saline, abdo USS
- check drug chart fro renal damagign drugs
?AKI - chest auscultation - JVP (raised) - ankle oedema tx-- furosemide
immediate management of an open #
ABCDE
- spinal control
- analgesia
- inspect- gross deformity
- NV- pulses distal to break, sensation over dermatimes
- align the limb
- recheck NV
- remove gross conntaminants, photograph and cover with saline soaked, sterile dressing
- splint #
- IV co-amox 1.2g within one hour (clinda 600mg if pen allergic)
- Bloods- clotting , G&S
- plain XR
Check tetanus status
- if all 5 vaccines had within 10 years- nothing needed
- if all 5 >10yrs- booster vaccine needed +- Ig if high risk wound
- if not complete vacc programme- give vaccine and give Ig if tetanus prone/high risk wound
- Prone= injuries in soily/rusty environment, wounds with foreign bodies, compund #, wounds/burns with sepsis, bites/scratches
- high risk= a prone wound with heavy contamination- soil, manure/ extensive devitalised tissue/ wounds requiring surgical intervention delayed by >6hours
- immediate referral to orthopods
DONT
- mini debridement in A&E
- digital exploration of wound
bare in mind compartment syndrome with pain not easing
management of Compartment syndrome
- high flow O2
- consider fluid bolus to increase BP
- remove decompression/splint/casts
- fasciotomy- leave open for 24-48hour
- post op UEs for rhabdomyolysis
immediate management of head injury
A-E with c spine immobilisation
check pupils
CT head- CFS NOT BAD **Coma (GCS <13) **Seizure Fx skull signs- boggy feeling **Neuro deficit- focal, new Old >65 and amnesia and LoC Two episodes of vomiting Blood anticoag- not incl aspirin, incl clopi Amnesia >30mins and retrograde (remembering before the event)- really ask specifics about before the incident Dangerous mechanism- high fall, RTC
signs of basal skull #
- panda eyes
- bruising behind ears- battle sign
- blood behind eardrum
- CSF leak- nose/ear
immediate management of basal skull #
DO NOT put NG tube in
- CT head within 1 hour
Management of unconscious burns pt
ABCDE
Burn eval
- mechanism
- depth- superficial epidermal (1st, CRT fast, red), dermal (2nd, blistering or no blanching/sluggish), full thickness (3rd, no pain, waxy)
- % coverage (arm 9%, leg 18%%, head 9%, chest 9% abdo 9%, back 18%, genitals 1%, palm 1%)
- NV status extremities- monitor for compartment
- do not remove things stuck to skin
- elevate, NSAID, opiate
- layer clingfilm
- 20-30min cool water
- chemical- 1% silver sulfadiazine/0.5% silver nitrate, 10% mafenide acetate
- electrical- same as above, ECG
- sunburn- aloevera, aspirin 2 every 2 hours, topical steroid 2-3days
sx neuroleptic malignanct syndrome
- delirium, confusion
- lead-pip rigidity , cogwheeling
- hyperthermia
ix neuroleptic malignancy syndrome
- raised CK, WCC, kalaemia, lactate
- metabolic acidosis
tx neuroleptic malginant syndrome
- stop cause
- cooling
- IV fluids
- benzos
- Dantrolene
- bromocriptine/amantadine
sx of serotonin syndrome
HARMED
- Hyperthermia
- *- Autonomic- tachy, HTN,
- Rigidity
- Myoclonus
- Eyes- ocular clonus- slow continuous horizontal movements
- Delirium, agitation
- tremor
- hypereflexia
- quicker onset than neuroleptic maliganant
- CK normal
management of serotonin syndrome
- stop cause
- IV fluids
- O2
- cooling
- AntiHTN
- benzo
- cyroheptadine (5-ht2antagonist)
