Acute 1 Flashcards
What suggests partial loss of airway and give some examples
- Added sounds
- Snore (loss of tone, usually soft palate)
- Gargle (fluid)
- Stridor (laryngeal obstruction)
What suggests complete block of airway?
- Silent airway
- Seesaw breathing in peri-arrest
What are some causes of loss of airway?
- LOC (most common, causes loss of tone)
- Foreign bodies (most common in kids)
- Blood or vomit
- Oedema (burns, infection, anaphylaxis)
- Tumour or abscess
What is the process of opening the airway?
1) Head tilt chin lift
2) Airway adjunct
3) Call anaesthetist
What are 2 airway adjuncts and when are they used?
- Nasopharyngeal (conscious patient, contraindicated in basal skull fracture)
- Oropharyngeal (patient must be unconscious)
What action should you take in relation to breathing in A-E assessment?
- 15L oxygen through non-rebreather to target sats
- ABG pre- and post-oxygen
- Reassess (are sats going up)
What action should you take in A-E in relation to circulation?
- 2 wide bore cannulae and 500ml fluid bolus (250ml in CCF)
- Relevant bloods
- ECG
- Urine output
Consideration in disability for A-E?
- Are they conscious
- AVPU
- GCS (if below 8 secure airway)
- Blood glucose (if below 4 give 100ml 20% dextrose)
What are the big 3 for anaphylaxis?
- Rapid onset and deterioration
- Life threatening ABC symptoms
- Skin and mucosal changes (absent in 20%)
What are some triggers of anaphylaxis?
- Venom (bee sting)
- Food (nuts and shellfish mainly)
- Latex (delayed onset and not as bad)
- Drugs
What drugs can cause anaphylaxis?
- Antibiotics, anaesthetics and contrast
- NSAIDs (mast cell independent bronchospasm)
- Vancomycin (non-allergic mast cell degranulation)
What is the ranking system for anaphylaxis?
Ring and Messmer
What are the 4 levels of the Ring and Messmer system?
1) Skin changes only
2) Slight hypotension or tachycardia
3) Severe hypotension or tachycardia
4) Cardiac arrest
What is the basic management for anaphylaxis?
1) Adrenaline (0.5ml 1 in 1000; (repeated every 5 mins)
2) 500ml fluid bolus
3) Chlorpheniramine (IM or slow IV)
4) Hydrocortisone (IM or slow IV)
What amounts of adrenaline are given to different ages in anaphylaxis?
- Adults: 0.5ml 1 in 1000 (500mcg)
- Kids 6-12: 0.3ml 1 in 1000 (300mcg)
- Kids under 6: 0.15ml 1 in 1000
What amounts of chlorpheniramine are give to different ages?
- Adults: 10mcg
- Kids 6-12: 5mcg
- Kids under 6: 2.5mcg
What amounts of hydrocortisone are given to different ages?
- Adults: 200mg
- Kids 6-12: 100mg
- Kid under 6: 50mg
What is the main investigation for anaphylaxis?
- Mast cell try-take when stable
- At 2 and 24 hours
Further notes son anaphylaxis?
- Can’t be diagnosed until seen specialist (suspected anaphylaxis before)
- Admit kid under 16
- Kids over 16 require 6-12 hours observation
What are biphasic and refractive anaphylactic reactions?
- Biphasic: second onset of symptoms within 72 hours despite no exposure to trigger
- Refractory: continuing anaphylaxis despite 2 doses IM adrenaline
What are the big 3 signs of sepsis?
- Vasodilation
- Oedema
- Coagulation (DIC: test for with fibrinogen level)
What are the 2 most common causes of sepsis?
1) Pneumonia (35%; strep pneumonia)
2) UTI (15%; E. coli; UTI most common in over 65s)
What is the management for sepsis?
The Sepsis 6
What are the 3 in for the sepsis 6?
- IV broad spectrum antibiotics
- 500ml IV fluids in 15 mins (30ml/kg/hour in septic shock)
- 15L oxygen
What are the 3 out for the sepsis 6?
- Bloods cultures
- Lactate (VBG)
- Urine output
What are some signs of sepsis?
- Evidence of original infection
- Oliguria
- Cyanosis
- New onset AF
- Non-blanching rash (meningococcal)
- Bounding pulse
- Quick cap refill
What QSOFA score suggests high mortality?
> 2
What are the red flags for sepsis?
- Confusion
- RR>35
- BP <90 or 20% lower than usual
- Lactate >2
- Coagulopathy
- HR>130
- Recent chemo
What is neutropenic sepsis?
- Sepsis with neutrophils <1
- Temperature >35 in neutropenia is always sepsis
- Requires immediate tazocin treatment
What 2 drugs are in tacozin?
Piperacillin and tazobactam
What its septic shock?
- Sepsis that is not responding to treatment
- BP <90
- Lactate >4
Where are the 2 general area the human body can bleed into?
- Where there’s lots of space (abdomen, pelvis, long bone; results in typical symptoms)
- Where’s there’s not much space (intracranial and pericardium; result in pressure symptoms)
What are the typical symptoms of acute haemorrhage?
- Pallor
- Cold
- Clammy
- Tachycardia
When might tachycardia be hidden in acute haemorrhage?
- Young people compensate well (the narrow off cliff)
- Old people on rate control drugs (e.g. beta-blockers)
What is the classification of acute haemorrhage?
1) Normal physiology (<15%)
2) Slight hypotension or tachycardia (15-30%)
3) Severe hypotension or tachycardia (30-40%)
4) Major haemorrhage (>40%)
When should you consider a concealed haemorrhage?
Young trauma patient who seems stable except fro tachycardia
What is the lethal triad of haemorrhage and why?
- Hypotension (keep warm)
- Acidosis (from tissue hypo perfusion resulting in lactic acidosis)
- Coagulopathy
How do the lethal triad affect haemorrhage?
They all impair platelet function
How do you prevent the lethal triad?
Damage control resuscitation
What are the 3 components of damage control resus?
- Permissive hypotension (MAP of 65 and systolic of 90)
- Haemostatic resus
- Early damage control surgery
What are the BP targets in permissive hypotension?
- MAP or 65
- Systolic of 90
How should haemostat resus be given?
- Don’t use crystalloids
- Give packed red cells, FFP and platelets in 2:1:1 ratio
What other medications can be considered in acute haemorrhage?
- TXA 1g bolus and then 1g over 8 hours
- Calcium chloride 10% 10ml over 10 mins if calcium is below 1.1
What is acute coagulopathy of bleeding?
- Presents in the same way as acute haemorrhage but is independent of it
- Due to protein C and systemic fibrinolysis
- Manage the same as acute haemorrhage
