Acute Care Station Flashcards
STEMI
“ECG, glucose
Bloods: U&E, FBC, Troponin, Glucose, Lipids
CXR
MONA
Primary PCI / Streptokinase 1.5 million U in 100ml saline over 1h
BB + DVT prophylaxis”
NSTEMI
"ECG, glucose Bloods: U&E, FBC, Troponin, Glucose, Lipids CXR MONAC (DAT 12 months) LMWH + BB Consider angiography"
Pulmonary oedema
"Note COPD / asthma / pneumonia / pulmonary oedema can coexist O2 100%, Morphine 10mg + Metoclopramide GTN spray + Furosemide 40-80mg IV CXR, ECG U&E, Troponin, BNP, ABG If BP >100; can start nitrate infusion If no response, NIV If BP <100 = cardiogenic shock = ITU Once stable --> daily weights, obs, CXR, change to oral, ?treat HF "
Broad complex tachycardia
“ECG: HR>100; QRS>120ms; LAD (VT)
Ddx: VT/TDP, SVT with aberrant conduction, AV re-entry tachcardia with WPW
Blood: Esp low K, Mg
Mx: Help, cardiac monitor, O2, Defib, iv access
Unstable: Synchronised DC, KCL & MgSO4, amiodarone 300mg/60min
Stable: KCL & MgSO4, amiodarone 300mg IV/60min, if fails DC shock
After: establish cause, maintenance antiarrythmic
Torsades des pointes: Stop predisposing drugs, KCL & MgSO4. Overdrive pacing or isoprenaline may be needed “
Narrow complex tachycardia
“DDx –> AF, A flutter, WPW reentry tachycardia
O2 + IV access
Rhythm regular? (If not, treat as AF)
Continuous ECG trace
Vagal manoeuvres
Adenosine 6mg bolus (+2 12mg boluses if necessary)
Unstable –> Sedation + synchronised cardioversion + amiodarone 300mg / 60min
Stable –> Amiodarone 300mg IV / 60 min OR verapamil OR digoxin”
Coma
“Ddx: Drugs, poisoning (CO, %, TCA), Sugar (hypo, DKA, HONKC), O2, CO2 (COPD), infection, hypothermia, addison’s, myxoedema, encephalopathy (renal/liver). Neuro (meningitis, encephalitis, tumour, vasc TIA/CVA
ABCDEFG
ABG, FBC, U&E, LFT, ESR, CRP, ethanol, toxic screen, drug levels, cultures, CXR, CT head
Treat underlying cause”
HHS
“TIIDM, dehydration and hyperglycaemia, high osmolality and acidosis
Aggressive rehydration over 48h. Saline, replace K when urine begins to flow.
Avoid rapid changes to electrolytes (central pontine myelinolysis)
Think about insulin
“
Addisonian crisis
“DDx TB, trauma, abrupt stopping of long term corticosteroids, AI
Blood: cortisol + ACTH
Hydrocortisone 100mg IV stat
Fluids: 0.9% saline
Monitor glucose - this is the danger; may need IV glucose
Senior: may need fludrocortisone, gluide steroid replacement”
Phaeochromocytoma
“Hypertensive crisis: pallor, pulsating headache, HTN, impending doom, pyrexia, ST elevation, VT, cardiogenic shock
Senior + ITU
A block + B block + surgery
Phentolamine 2-5mg IV, repeated to maintain BP normal
When ok, phenoxybenzamine 10mg/24h, titrating dose untiil BP normal
BB
Surgery elective @ 4-6wks”
IECOPD
“Investigations: PEF, ABG, CXR, ECG, FBC/U&E/CRP, MCS
Controlled O2 - venturi 24-28%, ABG monitoring. Aim PaO2>8 with rise in PaCO2<1.5
Nebs: Sal + Iptratropium
Roids: IV hydrocortisone 200mg / Pred 40 (7-14 days)
Abx: Local protocol (e.g. doxycycline)
No response: Repeat nebs ± IV aminophylline
No response: NIPPV
No response: Inquire about ITU (unlikely)
Post –> Pulm rehab, stop smoking, LTOT”
Asthma
“Sit up 100% O2, PEF
ABG + IV access + bloods
Salbutamol 5mg + Tiotropium 0.5mg neb + Hydrocortisone 100mg IV
CXR for ? pneumothrax; repeat PEF to monitor response
If life threatening features = ITU informed ASAP; MgSO4 2g IVI / 20 min Salbutamol every 15min (monitor ECG)
If improving = O2 titrate >92% Sat; Prednisolone 40mg OD 5days; neb Sal every 4h; monitor PEF
If not improving 15-30min = Sal every 15min, ipratropium every 4-6h
If still no improvement = As for life threatening, ±aminophylline loading dose “
Pneumonia
“CXR, ABG, FBC/U&E/LFT/CRP, MCS, aspirate, CURB65
O2 + Fluids + Abx + Analgesia
Escalation: ITU with ventilatory support”
PE / DVT
"Assess risk factors in Hx Wells Score 100% O2 Morphine + Metoclopramide *If critical illness immediate thrombolysis (50mg alteplase) IV access + LMWH (trust guidelines) BP: if low rapid colloid infusion (x2 500ml bolus / 15min) If BP ok warfarin loading CTPA to confirm"
Pneumothorax
“DDx idiopathic, asthma, COPD, TB, pneumonia, Ca, CF, IPF, Sarcoid, Marfans, Ehler’s Danlos, trauma, iatrogenic (SVC insertion)
Tension: Neddle decompression + Drain
Non tension: CXR
Rim or air > 2cm - aspirate. If failure, drain. For smaller observe and consider discharge”
Acute GI bleed
“DDx PUD, MW tear, erosions, oesophagitis, varisces
Rockall scoring system for acute GI bleed
O2
NBM + 2 cannulae + urinary catheter
U&E, FBC, LFTs, glucose, clotting, XM 6u
Rapid IV crystalloid, 1L (or 2x 500ml); consider O-ve blood
Transfusion, use Hb as guide
Correct clotting (vit K, FFP)
Monitor + endoscopy ± surgery”
AKI / dialysis
"DDx pre-renal / renal / post renal Catheterise + fluid balance chart Stop nephrotoxic drugs Assess hydration Cardiac monitor (K) Fluid challenge (250-500ml /15 min) If suspicious of sepsis - sepsis 6"
Hyperkalaemia
Recheck - sample may have clotted, use ECG/clinical to guide. Tented T waves, flat P waves, prolonged PR interval; wide QRS. 10ml 10% Ca Glucuronate IV/2min (repeat as necessary); Neb Salbutamol 2.5mg; 10U actarapid in 50ml 50% glucose /30min. If refractory dialysis
Hypernatraemia
Usually fluid loss w/o replacement, DI, Addison’s. Ideally oral hydration, IV 5% dextrose guided by UO and plasma Na. Saline replacement can be considered if hypovolaemic, as this causes smaller fluid shifts.
Hyponatraemia
Euvolaemia / Hypovolaemia / Hypervolaemia. Correct underlying cause. Too rapid correction causes central pontine myelinolysis - lethargy, confusion, pseudobulbar palsy, paresis, locked in syndrome
Anaphylaxis
"Secure Airway + 100%O2 Remove cause Adrenaline 0.5ml 1:1000 IM every 5min PRN (BP, HR, RR - until improved) Chlorphenamine 10mg IV Hydrocortisone 200mg IV Fluids: Saline 500ml / 15 min (BP, HR) Wheeze? Treat for asthma No improvement = ITU + IVI adrenaline Post: Education, EpiPen, Atopy testing"
Cardiogenic shock
“O2
Morphine + Metoclopramide
Arrythmias / Electrolyte abnormalities / Acid/Base
Measure pulmonary capillary wedge pressure. If >15 Ionotrpic support if <15 plasma expander
Consider dopamine, intraaortic balloon pump”
Hypovalaemic shock
Saline or colloid, titrate against BP/CVP/UO. Group O-ve blood, XM asap, correct acidosis, contact surgery if bleeding suspected. XM, clotting, FBC, ABG, glucose, CRP, lactate, blood and urine cultures, ECG, CXR. Consider arterial line, catheterise
Septic Shock
ABCDE, Abx within 1h (right after cultures), 500ml bolus / 15min. Unresponsive - may need inotrope support in ITU
Salicylate poisoning
“Dose related effects. Levels >700mg/L fatal
N&V, dehydration, tinnitus, vertigo, sweating, seizures, coma.
ABG - initially resp alkylosis –> metabolic acidosis with wide anion gap
Activated charcoal <1h
ToxBase
Bloods: U&E, FBC, LFTs, INR, glucose, paracetamol & salycilate levels
ABG, ECG, UO, glucose monitoring
?HCO3 to correct acidosis
If level >500mg/L consider alkalisation of urine with HCO3 and K infusions
Dyalisis may be required “
Paracetamol poisoning
“150mg/kg or 12g in adults potentially fatal.
Initially asymptomatic, vomiting + RUQ pain, jaundice + liver failure + encephalopathy + ARF
Lavage / Charcoal if <1h
Plasma concentration graph - NAC 150mg/kg in 200ml 5% dex over 15 min initially
Blood: INR, FBC, U&E, LFTs,
Specialist unit: Encephalopathy / ICP+, INR high, ARF, pH persistently low
Liver Tx”
Bradycardia
"Bradycardia HR<40 Atropine - 500microg Then more atrpoine up to 3mg Transcutaneous pacing Isoprenaline 5mcg Adrenaline 2-10 Alternative drugs - Aminophylline, dopamine, glucagon"
IE
“Infective endocarditis
2 if own valve Fluclox and Gent
3 if prosthetic Vanc, gent, rifampicin
Sepsis 6
3 out - Urine, 1 million blood culture, Lactate
3 IN - O2, Fluid, ABX
If septic 2 cultures within 1 hour from 2 seperate sites
ABX for 4 weeks
Dukes Criteria
Major - Blood, ECHO evidence
Minor - Predisposition, Shit cultures, Fever, Immune phenomena, Embolic phenomena”
Thyrotoxic storm
"Increased Temp, sweat, agitation, confusion, coma, Tachy, AF, Acute abdo, HF Precipitants --> Recent thyroid surgery or radioiodine Infection; MI; Trauma Fluid resus, and NGT Bblocker Carbimazole Lugol’s Iodine Hydrocortisone Treat cause"
Decomp CLD
“Jaundice, Asterixis, Ascites + SBP
Invx –> FBC, PT/INR, Diagnostic paracentesis (MC+S,SAAG
>1.1 - portal HTN; <1.1 - Cancer) Amylase, U&E, LFTs, Blood cultures. CT/USS, chest abdo xray
Mnx –>Analgesia, Antiemetics, ABX (Taz/cefotaxime, cipro Long term prophylaxis), Therapeutic paracentesis, IV albumin
Complications –> Hypoalbuminaemia, Bleedin, Hypoglycaemia, Hepatorenal syndrome (Iv albumin, terlipressin, haemodialysis
Liver transplant
Encephalopathy –> Lactulose, Phosphate enemas, get rid of nitrogen-forming bowel bacteria. Appropriate nursing, Avoid sedatives”
IBD
“Supportive –> NBM, Parenteral nutrition, Dietician input (elemental diet in crohns)
Medical Acute Flare Up –> IV Hydrocortisone
Surgical –> If toxic megacolon, perf, haemorrhage, not responding to medicines. Subtotal/total colectomy - end ileostomy/ileorectal anastomoses. Panproctocolectomy - Ileoanal pouch. Hartmanns crohns
Induction of remission –> UC (5 ASA PR/PO, Prednisolone PR/PO) vs Crohns (Pred, 5 ASA)
Maintenance –> UC (5ASA, azathioprine, biologics, surgery), Crohn’s (Azathioprine, Methorexate, Biologics)”
Alcohol detox ± delirium tremens
"Alcohol detoxication e.g. delirium tremens Pabrinex (B12, vitamin C, Thiamine) Chlordiazepoxide (2wk Tappering regime) Acamprosate/baclofen - decrease cravings Disulpharam - Aversion therapy"
Meningitis
"Septicaemic - IV Ceftriaxone 2g BD Meningitic - LP first within 1 hour Ceftriaxone 10mg Dexamethasone IV (swelling) Old/young - Ampicillin"
Encephalitis
As meningitis Plus IV acyclovir 10mgs/kg TDS
Status epilepticus
“Seizing continous or repeatedly for 30 mins
10mg IV Diazepam (Lorazepam 0.1mg/kg)/ buccal midaz 10mg
repeat after 10 mins
10mg/kg iv phenobarbitol 100mg/minutes OR Phenytoin 18mg/kg at 50mgs/min
ESCALATE!
RSI”
Raised ICP
"Sit up Neuroprotective hyperventilation - High o2 low co2 IV Mannitol/hypertonic saline Scan head and Treat cause Burr holes/craniotomy; coiling if SAH Keep BP above 160 CT, LP 12 hours later xanthochromia Nimodipine - prevents vasospasm Platinum coiling Coning - Tonsilar - brain stem death "
DKA
“Acidosis <7.3, ketones >3mM, glucose >11.1mM
0.9% NS
BP<90 1L stat; BP>90 1L over 1 hour; 1L/22, 1L/4h2, 1L/6hrs
Start Potassium in 2nd bag –> >5.5mM - Nil; 3.5-5.5mM - 40mM/L; <3.5 Senior review
Fixed rate Insulin - Actrapid 0.1u/kg/h
Continue giving them their basal insulin regimen too of their long acting to prevent rebound hyperglycaemia.
Swap to dextrose once blood sugar gets below 15
It takes longer to turn off ketogenesis than it does to bring the blood sugar down. So Insulin Must be continued in order to stop ketone production
Resolution when: pH above 7.3; Ketones less than .3
If you can eat and drink then you can go on your basal bolus regime
“
Hypoglycaemia
“Alert and orientated - Oral Carbs: Rapid acting - Lucozade
Long Acting - Sandwich
Drowsy/confused, swallow intact - Hypostop/ Glucogel; Consider IV access
Unconscious: 100mls 20% glucose
Insulin induced/no access: 1mg Glucagon
“
