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ACCS Flashcards

1
Q

What type of hypersensitvity reaction is Anaphylaxis

A

Type 1

igE- histamine, mast cells, basophils

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2
Q

sx of anaphylaxis

A
  • skin flushing
  • hives/urticaria- pruritis
  • Swelling of throat/mouth- wheeze, SOB, dyspnoea
  • N+V, diarrhoea, abdo pain
  • confusion, headache, anxiety
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3
Q

signs of anaphylaxis

A
  • hypotension
  • wheeze
  • weak, rapid pulse
  • pallor
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4
Q

immediate management of anaphylaxis

A 
- 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
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5
Q

what is the refractory anaphylaxis algorithm

A

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

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6
Q

Immediate management of chest pain pt

A

MONA

  • IV opioids- Morphine
  • O2, sats
  • GTN- buccal or SL
  • Aspirin 300mg
  • hyperglycaemia- if >11mol/L- give insulin (5-10u actrapid)
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7
Q

Management of confirmed STEMI

A
  • 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
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8
Q

Management of NSTEMI

A

MONA plus

  • clopidogrel/ticagrelor/prasugrel
  • angio, PCI
  • fondaparinux
  • herparin if renally impaired/low body wt
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9
Q

tx bradycardia with pulse

A

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

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10
Q

tx tachycardia with pulse

A

Unstable

  1. 3x DC shock
  2. amiodarone 300mg IV over 10-20mins
  3. repeat shock
  4. 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

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11
Q

immediate management of pt without a pulse (cardiac arrest)

A
  • 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?

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12
Q

What are the shockable rhythms

A
  • Pulseless VT- wide QRS, regular

- Vent fib- wide QRS, irregular, chaotic, deflections vary in amplitude

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13
Q

Management of shockable rhythms

A
  • 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
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14
Q

what are the non-shockable rhythms

A
  • asytole

- pulseless electrical activity (PEA)

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15
Q

management of non-shockable rhythma

A

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
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16
Q

what are the reversible causes of cardiac arrest

A

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
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17
Q

sx of acute hypertensive crisis

A 
- haemorrhage generally
HEART- 
- aortic dissection- tearing chest / back pain
- MI
BRAIN
**- confusion (encephalothpathy)
- SAH
- changes in vision
**RESP- acute pulmonary oedema
**RENAL- haematuria, oliguria
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18
Q

tx acute hypertensive emergency

A

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 ))

19
Q

sx aortic dissection

A
  • sudden tearing in chest
  • radiation to back classically (often more subtle than this)
  • LoC
  • Neuro sx , vision problems
  • leg pain, issues walking
20
Q

signs in aortic dissection

A
  • tachycarda
  • hypotension
  • new aortic regurg murmur
  • endo organ hypotension (reduced UO, paraplegia, , lower limb ischaemia, abdo pain, GCS)
21
Q

immedaite management of Aortic dissection

A
  • hgi flow O2
  • IV access 2x wide bore
  • fluid resus- <110mmHg
  • **- IV labetalol/CCB
  • urgent vasc surg input
22
Q

management of DKA in paeds

A
  • *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
23
Q

management of DKA adults

A

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

24
Q

immediate management of acute asthma exacerbation

A

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
25
Q

immediate management of acute COPD exacerbation

A 
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
26
Q

immediate management of PE

A

Well’s

  • <=4- d-dimer
  • > 4- CTPA
  • ABCDE
  • 15L nonrebreath
  • analgesia
  • thrombolysis IV alteplase
  • urgent snr review
27
Q

immediate management of pneumothorax

A
  • 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
28
Q

immediate management of flash/acute pulm oedema

A 
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)
29
Q

immediate management of ARDS

A
  • CPAP 40-60% O2
  • fluids
  • LMWH
  • inotropes- dobutamine
  • vasodilators=- nitrates
  • blood transfusion- haemofilreation

?Sepsis 6

30
Q

management of cardiogenic shock

A
  • vasopressors- adrenaline
  • *- inotrope- dobutamine
  • IV opioids
  • aspirin 300mg
  • *- monitor for hyperglycaemia- give insulin if >11mol/L
31
Q

Management of sepsis

A

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
32
Q

how to manage low UO

A

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
33
Q

immediate management of an open #

A

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

34
Q

management of Compartment syndrome

A
  • high flow O2
  • consider fluid bolus to increase BP
  • remove decompression/splint/casts
  • fasciotomy- leave open for 24-48hour
  • post op UEs for rhabdomyolysis
35
Q

immediate management of head injury

A

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
36
Q

signs of basal skull #

A
  • panda eyes
  • bruising behind ears- battle sign
    • blood behind eardrum
    • CSF leak- nose/ear
37
Q

immediate management of basal skull #

A

DO NOT put NG tube in

- CT head within 1 hour

38
Q

Management of unconscious burns pt

A

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
39
Q

sx neuroleptic malignanct syndrome

A
  • delirium, confusion
  • lead-pip rigidity , cogwheeling
  • hyperthermia
40
Q

ix neuroleptic malignancy syndrome

A
  • raised CK, WCC, kalaemia, lactate

- metabolic acidosis

41
Q

tx neuroleptic malginant syndrome

A
  • stop cause
  • cooling
  • IV fluids
  • benzos
  • Dantrolene
  • bromocriptine/amantadine
42
Q

sx of serotonin syndrome

A

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
43
Q

management of serotonin syndrome

A
  • stop cause
  • IV fluids
  • O2
  • cooling
  • AntiHTN
  • benzo
  • cyroheptadine (5-ht2antagonist)

Finals (15 decks)

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