Acute care Flashcards by Ina Ko

differentials for collapse

hypoglycaemia

cardiac: postural hypotension,
arrhythmias, outflow obstruction [HOCM, severe AS, massive PE], vasovagal syncope

seizure

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Lucy attends A&E finding it hard to breath. her lips are swollen and she has a diffuse rash. Her friend says she had just eaten a snack and then suddenly couldn’t breathe.

How would you manage lucy?

ANAPHYLAXIS

IM adrenaline 0.5ml 1mg/1ml 1:1000
10mg chlorphenamine (anti-histamine)
100mg hydrocortisone

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what are the boundaries of the triangle of safety for chest drain?

the lateral border of pectoralis major anterior; the mid-axillary line posterior and the level of nipple inferior

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management of anaphylaxis

A-E, stop drug, senior help, anaesthetics if concerned airway
Adrenaline 1:1000 IM
1. anterolateral thigh
2. 5 minutes apart, different thigh
3. after 2 consider refractory + start more Tx
additional meds
1. cetirizine 10mg adult
2. hydrocortisone 200mg
monitoring - pulse oximetry, ECG, blood pressure

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what is refractory anaphylaxis and how is it management?

no response to 2 x adrenaline

Peripheral low dose adrenaline IV infusion
- 1 mg (1mL of 1mg/mL 1:1000) adrenaline in 100mLof 0.9% saline
- Start at 0.5-1 mL/kg/hour rate
- Should only be started by critical care/anaesthetics
- Continue IM adrenaline every 5 minutes while this infusion is being set up to address ongoing ABC issues

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how do you estimate surface area burned?

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A-E assessment for burns

A-E assessment

A - assess for inhalation injury, consider pre-emptive intubation if high risk, C-spine protection
B - 100% O2, ABG, check carboxyhaemoglobin levels
- Inhalation burns - high flow O2 15L and urgent anaesthetic review regarding intubation
C - 2 large bore IV, routine bloods, G&S, clotting, CK, aggressive fluid therapy, urinary catheter + UO monitoring
D - GCS, temperature (risk of hypothermia)
E - estimate percental burns, tetanus booster
- Chemical burns - immediate irrigation of affected area

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what is parkland’s formula

for fluid resus in burns
volume of crystalloid fluid to be given in first 24 hours
- Adults - 4mL (Hartmann’s) x weight (kg) x % TBSA burned
- Children - 3mL (Hartmann’s) x weight (kg) x % TBSA burned
- Give 50% calculated in 8 hours post burn and 50% in remaining 16 hours

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shockable rhythms?

ventricular fibrillation

pulseless ventricular tachycardia

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what are the non-shockable rhythm?

PEA

asystole

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what are the reversible causes of arrest?

H
- Hypoxia
- Hypothermia
- Hyper/hypo-kalaemia
- Hypovolaemia
T
- Tension pneumothorax
- Tamponade
- Thrombosis
- Toxins

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management of non-shockable rhythm

PEA and asystole

Start CPR - 30:2
Adrenaline 1mg IM
- Continue giving every other cycle of CPR e.g. 1, 3, 5 (every 3-5 minutes)
Atropine 3mg IV if rate < 60bpm

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management of shockable rhythms

Ventricular tachycardia or fibrillation, SVT

Defibrillation shock (150 J)
CPR - 2 minute cycle, 30:2
Reassess rhythm
Repeat steps 1-3 provided rhythm remains shockable

Drugs

1mg IV/IO adrenaline after 3rd shock, then every 3-5 minutes
300mg IV amiodarone bolus if shockable rhythm persisting after 3rd shock
- Consider 150mg IV/IO amiodarone after 5 shocks

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ECG features of hypothermia

bradycardia
“J” wave formation on ECG
- Cardiac irritability starts around 33 degrees

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what is hypothermia?

temp < 35

mild 32-25, moderate 30-28, severe < 28

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what are the components of the qSOFA score?

> 2 indicates higher risk of mortality, used outside ICU
- Respiratory rate > 22/min
- Altered mentation (GCS < 15)
- Systolic BP < 100 mmHg

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what are the sepsis 6?

to be achieved within the 1st hour

Take: blood culture, lactate, urine output
Give: O2, IV antibiotics, fluid challenge

immediate management of high risk sepsis patient?

Initial
- immediate senior review
- Bloods - VBG, cultures, FBC, CRP, U&Es, creatinine, clotting screen
- Broad spectrum antibiotics
- Oxygen
Fluid resuscitation
- If lactate > 4 mmol/L or SBP < 90mmHg
  - IV fluid bolus of 500ml in 15 minutes, if fluid overloaded give 250ml
  - ICU r/v, consider central venous access, inotropes or vasopressors
- If lactate 2-4 mmol/L
  - IV fluid bolus of 500ml in 15 minutes, if fluid overloaded give 250ml
- Consider fluid bolus if lactate < 2 mmol/L
- No response to initial bolus → repeat
- No response after 2 boluses → consultant to review
Monitoring
- Maximum interval of every 30 minutes
- GCS/AVPU
- Vital signs
- Urine output - catheterise if required
Failure to response in 1 hour of initial antibiotics or fluid resuscitation → senior review
- Signs of failed response - SBP < 90 mmHg, ↓ GCS, RR > 25 or new need for mechanical ventilation, lactate fails to ↓ 20% in first hour

types of shock summaries

acute management of pulmonary embolism - haemodynamically unstable

Haemodynamically unstable

Resuscitation - O2 + mechanical ventilation + IV fluids (crystalloid if SBP < 90)
Thrombolysis - tissue plasminogen activator if imminent/in arrest
Surgical - embolectomy (if thrombolysis is CI)

Supportive measures

Oxygen
Ventilation
Fluid resuscitation
Analgesia

management of PE - haemodynamically stable

Haemodynamically stable

Anticoagulation
- Direct oral anticoagulants - apixban or rivaroxaban, OP setting
- Warfarin + LMWH heparin cover
  - LMWH heparin for at least 5 days and until 48 hours of therapeutic INR (> 2)
- Dabigatran or edoxaban with 5 days LMWH heparin prior → alternative to DOAC and warfarin
Duration of treatment
- Provoked i.e. identifiable RF - 3 months
- Unprovoked - 6 months
- Ongoing cause e.g. thrombophilia - life-long treatment

Supportive measures

Oxygen
Ventilation
Fluid resuscitation
Analgesia

management of upper GI bleed - NICE general principles

A-E assessment + resuscitation
- C - 2 cannula, bloods (FBC, U&E, LFT, glucose, clotting)
- Crossmatch 4-6 units
- Rapid IV crystalloid, give RBC if grade III/IV shock
- Correct clotting abnormalities
Transfusion + managing bleeding risk
- RBC - in context of clinical picture, definitely if Hb < 70
- Platelet if active bleeding and platelets < 50
- FFP if active bleeding and PT or APTT > 1.5 c of normal
- Cryoprecipitate if fibrinogen level < 1.5 g/L despite FFP transfusion
- Prothrombin complex concentrated if on warfarin
Endoscopy
- Severe acute upper GI bleed → immediate after resuscitation
- All others within 24 hours (if > 1 Blatchford)

when to give blood products?

RBC - in context of clinical picture, definitely if Hb < 70
Platelet if active bleeding and platelets < 50
FFP if active bleeding and PT or APTT > 1.5 c of normal
Cryoprecipitate if fibrinogen level < 1.5 g/L despite FFP transfusion

management of variceal bleed

A-E resuscitation
Blood transfusion
Vitamin K, FFP and platelet transfusions as needed
At presentation
- All varices:
  - Terlipressin (IV, 5 days)
  - Antibiotics (IV, as per local guidelines, quinolones)
- Gastric varices:
  - 1st line - endoscopic injection
  - 2nd line - TIPS
- Oesophageal varices:
  - 1st line- band ligation
  - 2nd line - Sengstaken-Blakemore tube + TIPSS
Urgent OGD once stable for it, ideally within 24 hours
- Variceal band ligation = treatment of choice
Management - prevention
- Non-selective beta-blockers e.g. PO propranolol (40mg, BD, PO)
- Variceal band ligation
- TIPSS

indications for CT head adult (immediate)

* Initial A&E GCS \< 13 * GCS \< 15 at 2 hours after the injury * Suspected open or depressed skull fracture * Any sign of basal skull # - haemotympanum, "panda" eyes, CSF leak from ear or nose, Battle's sign * Focal neurological deficit * Post-traumatic seizure * More than 1 episode of vomiting

indications for head CT within 8 hours (adult)

* 65 + * Hx of bleeding or clotting disorder * On anti-coagulants * Dangerous mechanism of injury * \> 30 minutes retrograde amnesia of events immediately prior to head injury

indications for CT c spine

* GCS \< 13, intubated * plain x-ray inadequate/abnormal, * definitive diagnosis required urgently * head being scanned * suspicion of cervical injury + \> 65/dangerous mechanism/focal neuro deficit/paraesthesia

management of status epilepticus

* A-E * 5 minutes - 4mg lorazepam IV or 10mg IM/buccal midazolam * 15 minutes - repeat benzo * 20/30 minutes - IV phenytoin, IV levetiracetam, IV fosphenytoin * 30/40 - GA with RSI using Propofol + continuous EEG monitoring

aspirin/salicyclate OD management

* \< 125 mg/kg OD aSx → 6hr observe, d/c with safety net * Larger dose or uncertain quantity: * **Oral activated charcoal** - consider if \< 1 hour * **Gastric lavage** - \> 500mg/kg (life-threatening) within 1 hr of ingestion * **IV sodium bicarbonate** - for urinary alkalinisation * **Emergency haemodialysis** - indicated if: * Salicylate levels _\>_ 900 mg/L * Salicylate levels \> 700 mg/L with metabolic acidosis * Coma due to overdose * Supportive care * Fluids. hypokalaemia, hyperthermia (dantrolene)

indication for NAC in paracetamol OD

* Immediate prescription * staggered OD or doubt over time of ingestion * Consider if those likely to have glutathione depletion so high risk of toxicity - AN, HIV, malnutrition * If estimated OD is \> 150mg/kg and cannot act on blood results within 8 hours of ingestion * If 4 hour paracetamol level over treatment line on nomogram

NAC regime

1 bag over 1 hour 1 bag over 4 hours 1 bag over 16 hours

what criteria mean NAC treatment should continue?

* ALT more than doubled admission measurement * ALT over 2 x the upper normal limit * INR \> 1.3 (in absence of other cause e.g. warfarin)

criteria for consideration of liver transplant after paracetamol OD

Criteria for liver transplant: * Arterial pH \< 7.3 24 hours after ingestion * PT \> 100 seconds _and_ creatinine \> 300 umol/L _and_ grade III/IV encephalopathy

antidote for benzodiazepine

flumazenil

management of beta-blocker OD

IV atropine IV glucagon

management of cyanide OD

dicobalt edentate oxygen

management of ethylene glycol poisoning

fomepizole

management of iron ID

* desferrioxamine IV (systemic toxicity management) * cardiac monitoring * whole bowel irrigation if \> 60mg/kg ingested * surgical/endoscopic removal of tablets if lethal ingestion or WBI not feasible

management of organophosphate poisoning

* atropine * pralidoxime

management of TCA OD

sodium bicarbonate