Acute Care Flashcards
Adrenaline Dose in anaphylaxis
0.5ml of 1:1000 IM
Adrenaline Dose in Cardiac Arrest
1mg or 10 ml of 1:10,000 IV
1ml of 1:1000 IV
What is the Fluid replacement formulae?
30ml/kg/hr
What is the formulae for K+ Na+ Cl- replacement?
K+ Na+ Cl-
1mmol/kg/hr
When is IV magnesium given?
If Mg levels <0.4 or signs of tetany.
When is Oral Mg used?
If >0.4
What is a side effect of oral Mg?
Diarrhoea
What is a usual infusion of IV Mg
40mmol over 24 hours
Causes of Hypomagnesia
PPI Diarrhoea Chronic alcoholism Diuretics TPN Hypokalaemia Hypercalcaemia
How does Hypomagnesia present
Parasthesia, Tetany, Seizures, Arrythmia, reduced PTH
When is IV Calcium Gluconate used?
If K+ over 6.5 or ECG changes
What is the initial fluid resus volume?
500ml 0.9% saline
If someone is in an acute confusional state what is used?
Oral or IM haloperidol
NEVER BDZ as will worsen confusion
In an ABG what is the normal anion gap?
8 to 14 if not using K+
10-18 if using K+
What causes an elevated anion gap?
Excess exogenous or organic acid.
Causes of a Metabolic Acidosis with a raised Anion Gap
Methanol Uraemia DKA Paraldehyde Isoniazide Lactic Acidosis Ethyelen Glycol Salicylate Poisoning - Aspirin
What fractures are associated most with Compartment syndrome?
Supracondylar
Tibial Shaft
If a patient presents with a paracetamol overdose when they took all of them at once within an hour of arrival and A + E. What is the initial management?
Activated Charcoal
What are indications for Acetylcysteine use in a paracetamol overdose?
Patient staggered the dose over longer than an hour, or doubt over duration
Levels >100mg/l at 4 hours or 15mg/l at 24 hours
How is Acetylcysteine infused?
Over 1 hour
What are the indications for a liver transplant in a paracetamol overdose?
PTT > 100 seconds
Creatinine > 300
Grade III or IV encephalopathy
What is the preferred fluid used in burn resuscitation?
Hartmans (crystalloid) > Coloid
What is the formulae for Resuscitation fluid in burns and how is this applied?
4ml x % burn x kg
50% in first 8 hours
50% in last 16 hours
What is the maintenance fluid in burns?
0.5ml x % burn x kg
Signs of DKA
Blood Glucose >11 Ketone >3 pH <7.3 Bicarbonate <15 Raised Anion Gap \+/- pseudohyponatraemia
An STEMI presents in A + E what is given?
Aspirin + Ticagrelor + 5000 units of Heparin
Patient OD - Increased HR, Warm, Dilated Pupils, Dry
AntiCholinergic Medication
Patient OD - Pinpoint Pupils, Increased Bowel Sounds, Sweaty
Cholinergic - Mushrooms, Pilocarpine
Patient OD - Bradychardia, Reduced RR, Cold, Pinpoint pupils, Absent bowel sounds, Dry
Opiod
Patient OD - Tachychardia, Increased RR, Dilated Pupils, Hot , Inceased Bowel sounds, Sweaty
Sympathomimetics - Cocaine Ecstasy etc
How do you differentiate Opiod from BDZ overdose?
BDZ pupils aren’t affected.
If you have a patient who has OD who’s bloods show and Acidotic Picture and ECG shows Tachychardia or Arrhythmias what is the most important management?
IV Sodium Bicarbonate - Increase contractility and reduce arrhythmia risk by reducing acidosis.
Magnesium Sulphate if prolonged QRS
If and overdosed patient presents with seizures what is the treatment?
BDZ can still be used. Phenytoin should be avoided
What is the management plan of someone presenting with a Sympathomimetic OD?
BDZ - Sedation Ketamine - Sedation if needed quickly Check CK - Rhabdo is common U+Es - Rhabdo and dehydration ECG - Vasospasm is common finding
If a patient in DKA had a BP <90 what is their fluid resus?
500ml NaCl in 5 mins
If a patient in DKA has a BP >90 what is their fluid resuscitation?
1L NaCl over 1 hour
A patient who has received Naloxone is looking to be discharged. What are the guidelines on their discharge?
Patent Airway without naloxone for 6 hours
Management of Hypovolaemic Hyponatraemia
Normal Isotonic Saline
Hypovolaemic Hyponatramia - Isotonic Saline Increase Na
Likely Diagnosis is correct
Hypovolaemic Hyponatraemia - Isotonic Saline causes a decrease in Na+
SIADH is likely cause
Management of Euvolemic Hyponatraemia
Fluid Restriction - 500m - 1000ml a day
Vaptans used
Management of Hypervolaemic Hyponatraemia
Fluid Restriction -> 500ml-1000ml
Vaptans
Loop Diuretics
What can be used with care in Acute Hyponatraemia?
Hypertonic 3% saline
Too rapid Hyponatraemia correction can lead to
Central Pontine Myelinolysis ‘locked in syndrome’
Too rapid correction of Hypernatraemia
Cerebral Oedema
ABG in Salicylate Poisoning
Initial Respiratory Alkalosis due to stimulation of CNS
Later Metabolic acidosis with +ve anion gap
Example of a Salicylate
Aspirin
Signs of Salicylate Poisoning
Hyperventilations
Tinnitus
Management of Salicylate Poisoning
Urinary Alkalinisation
IV Sodium Bicarbonate
Haemodialysis
Indications for Haemodialysis is Salicylate Poisoning.
Serum level >700
Pulmonary Oedema
Seizures
What is first line for the management of Neuropathic pain?
Amitriptyline
Pregablin
Duloxetine
Gabapentin
What is second line in neuropathic pain?
Try another 1st line drug monotherapy.
What is capsaicin useful for?
Small areas of localised neuropathic pain.
ECG signs of hypothermia
J waves
Prolonged PR QT and QRS
What is the adrenaline dose used in anaphylaxis in a child under 6 months?
100 - 150mcg
0.1 - 0.15ml 1 in 1000
What is the adrenaline dose used in 6 months to 6 years in anaphylaxis?
150mcg
0.15ml 1 in 1000
What is the adrenaline dose in a 6 - 12 year old in anaphylaxis?
300mcg
0.3ml 1 in 1000
When can someone be discharged from hospital after two hours post anaphylaxis?
No symptoms remain
required a single IM
Auto-injector and trained to use it
When is someone discharged after 6 hours post anaphylaxis?
2 IM doses needed
Previous biphasic reaction
When is someone discharged after 12 hours post anaphylactic episode?
Over 2 IM doses needed
Severe asthma
Late at night
Live in a remote area with poor access.
Paediatric BLS
Look for breathing -> 5 rescue breaths -> Pulse -> 15:2 CPR
What should be administered in hyponatraemia causing seizures or coma?
3% saline IV
Major Haemorrhage Protocol
SEND OFF TWO PINK TOPPED FOR GROUP AND SAVE 2L of warm IV crystalloid Tranexamic Acid 2 units of O negative blood Fully crossmatched blood
Glucose dose in Hypoglycaemia requiring an IV due to reduced consciousness
100ml 20% glucose IV STAT
Naloxone in Respiratory arrest
400mcg bolus
Naloxone in over sedation
Titrate to affect
In paediatric BLS where do you feel for a pulse?
Brachial or Femoral
If thrombolysis has been administered how long should CPR be carried on for?
60-90 minutes
Indication for IV sodium bicarbonate in an overdose.
pH - <7.1
QRS >160ms
Arrhythmias
Hypotension
In a Beta blocker OD what medication should be use and why?
Glucagon as dobutamine won’t work as its receptors and blocked
In an acute hypoglycaemic patient with reduced consciousness and no IV access what is used?
Glucagon IM
In children or young people what is the fuild resus formula?
20ml/kg over an hour
Whats the maximum in
Headache , N+V Vertigo Confusion weakness and cherry red flushed skin
Carbon Monoxide poisoning
How do you diagnose CO poisoning?
ECG and ABG
Carboxyhaemaglobin level
Describe what different levels of carboxyhaemaglobin tell you.
<3% = Non smoker <10% = smoker 10-30% = symptomatic CO poisoning >30% = Severe CO toxicity
What is the management of CO poisoning?
High flow oxygen via non rebreather mask.
if someone with a salicylate OD presents within an hour of ingesting what can be given?
activated charcoal
What is used in the treatment of Popper related hypoxia?
Methylene Blue
Why should a slower infusion rate be considered in a younger patient with a DKA?
They are at an increased risk of cerebral oedema
Presents similar to alcohol + metabolic acidosis with anion gap and osmotic gap
Tachychardia + Hypertension
AKI
Ethylene Glycerol Poisoning - Anti Freeze
Fomepizole is first line over ethanol now
Oxygen saturation targets in an acutely unwell patient
94 -98%
COPD - pCO2 normal = 94-98
- hypercapniac - 88-92% on a 28% venturi mask 4l min
How is tranexamic acid administered in a major haemorrhage
IV bolus the slow infusion
INR cut off for a chest drain insertion.
> 1.3
Most reliable line for administering long term medication i.e chemotherapy
Hickmans line
Haemorrhagic shock - class 1
<750 ml loss <100bpm Normal BP >30ml/hr urine Normal consciousness
Haemorrhagic shock - Class II
750-1000ml >100bpm Normal BP 20-30ml urine Anxious
Haemorrhagic Shock class III
1500-2000ml >120bpm BP is reduced 5-15ml urine Confused
Haemorrhagic shock class IV
> 2000ml
Blood pressure dropped
<5ml urine
Lethargic
Management of a N Acetylcysteine anaphylaxis
Stop -> nebulised salbutamol -> restart infusion at a slower dose
Non IgE mediated anaphylactoid reaction - not true anaphylaxis
Urticaria and hives.
Managment of an acute haemolytic reaction during a transfusion.
STOP the transfusion
Aggressive fluid resuscitation
Inform lab - send two pinks tops to lab for crossmatch and direct Coombs test
What is the first line management in magnesium sulphate induced respiratory depression.
Calcium Gluconate
COPD acute exacerbation - oxygen therapy
15l Non rebreather mask - all receive even in known CO2 retainers
- 28% venturi mask at 4L after
BLS - resus chest compression guidelines
Neonate - 3:1. 1 or 2 thumbs
Paediatric - 15:2 1 hand
Adult - 30:2 2 hands
What electrolyte should be replaced first?
Magnesium as this can cause a resistant hypokalaemia
How is someones fluid deficit accounted for in their fluid maintenance.
% dehydration x kg x 10
Spread out over 24-48 hours in addition to normal fluid maintenance
