Acute medicine Flashcards
Management of sepsis
A-E management
Venous blood sample- blood cultures, FBC, U&Es, CRP, venous blood gas (lactate and glucose), creatinine, clotting screen
Broad spectrum anti-microbial according to protocols without delay
Discuss with consultant
IV fluid bolus without delay
Refer to critical care for review of management including vasopressors, inotropes and central venous management
High risk of sepsis
Objective assessment of new or altered mental state
Tachypnoea of >25 or new requirement of oxygen to maintain sats >92
Systolic BP <90 or 40 below normal
Oliguria (<0.5ml/kg/hour) or not passed urine in 18 hours
Mottled/ashen cyanosis of lips
Non-blanching rash
Management of a patient in anaphylaxis
A-E
Comfortable position
1 in 1000 IM adrenaline 500mcg (0.5ml) for an adult
Repeat after 5 mins if no improvement
Remove trigger if possible
Give oxygen at the highest rate possible- 100% 15L non-rebreathe mask
Obtain IV access and give fluid challenge- 500ml of 0.9% saline over 15 minutes
Slow IM or IV chlorphenamine and hydrocortisone
Clinical features of anaphylaxis
Sudden onset and rapid progression of
Looking and feeling unwell
Airway swelling, hoarse voice, stridor, stertor
Breathing difficulties- SOB, wheezing, cyanosis, confusion
Circulatory signs of shock- hypotension, tachycardia, shock, syncope, LOC, cardiac arrest
Status epilepticus management
Make sure the patient is helped to the floor and in a comfortable position
Ensure nothing is in their mouth
When seizure stops ensure patent airway and put into recovery position
Buccal midazolam or rectal diazepam in the community
Continue normal medications
Ambulance if seizure lasts more than 5 minutes
Secure airway, high flow oxygen, respiratory and cardiac function, check BM, secure IV access
IV lorazepam X2
Phenytoin infusion
Burn assessment
Timing, type and cause (flame, scald, chemical, electrical, contact burn) Extent of the burn Risk of inhalation injury Possibility of NAI Assess and document depth of burn Cap refill Tetany
Burn initial management
Do not try and remove tar but remove clothing
Irrigate burn within 20 minutes with cool-tepid water
Wrap patient in blanket to avoid hypothermia
Layer cling film onto the burn or a clean cotton sheet if not available
Elevate area if possible
Analgesia
Transfer
Attempt defibrillation if which rhythms are identified
Ventricular tachycardia or ventricular fibrillation
Do not attempt defibrillation if which rhythms are identified
Asystole or pulseless electrical activity
Reversible cause must be found and corrected
Management of a patient with a shockable rhythm
Defibrillate as soon as possible
Everyone should stand clear and oxygen masks be removed
Immediately resume CPR at a rate of 30:2
2 minutes and then stop for no more than 5 seconds to check the monitor
Up to 3 shocks like this with 2 minutes in between
Then IV 1mg of 1 in 10000 adrenaline and 300mg amiodarone and resume CPR
Shock
Give further IV adrenaline after alternating shocks
Mild hyperkalaemia values
5.5-5.9mmol/L
Aetiology of hyperkalaemia
AKI,CKD, hyperkalaemic renal tubular acidosis Iatrogenic- medications Trauma- burns DKA Addison's disease- lack of aldosterone
Clinical features of hyperkalaemia
General weakness and fatigue
Palpitations, chest pain, SOB
In most cases no signs
Hyperkalaemia management
URGENT if >7.0mmol/L or ECG changes (particularly widening of QRS)
Suspension of potassium containing fluids or medications that may raise
10mls of 10% calcium gluconate solution if ECG changes present to stabilise the cardiac membrane
Insulin glucose infusion and nebulised salbutamol to shift the potassium intracellularly
Calcium resonium to excrete the potassium, correction of the underlying cause
Haemodialysis if refractory and resistant
Haemodialysis acute indications
A- acidosis E- electrolytes- refractory hyperkalaemia I- intoxicants- salicylates, lithium O- overload- congestive heart failure U- uraemic pericarditis or encephalitis
Hs and Ts of reversible cardiac arrest
Hypoxia
Hypovolaemia
Hypothermia
Hyperkalaemia/ hypokalaemia/ other electrolyte abnormalities
Tamponade
Tension pneumothorax
Thrombus
Toxins
Signs of hypercalaemia
Bones- deformity and pain
Groans- n+v, constipation, abdo pain
Stones- renal colic from calculi
Psychic moans- drowsiness, confusion, psychosis
Cardiac- hypertension, shortening QT interval, arrhythmias
Maximum safe dose of paracetamol for an adult in 24 hours
4g
Serious toxicity greater than 150mg/kg in any 24 hour period (21 tablets for a 70kg man)
Therapeutic is usually 75mg/kg in 24 hour
1st investigations for paracetamol overdose
Serum paracetamol concentration
LFTs
Prothrombin time and INR
BM
Management of paracetamol overdose
Plot need for NAC on a measured plasma paracetamol curve 4 hours
If timing is unreliable then consider NAC- nomogram also becomes more unreliable after 15 hours
Staggered overdose then NAC
Activated charcoal in the first hour
Consider liver transplant
Signs and symptoms of an opioid overdose
Drowsiness N+V Confusion Decreased levels of consciousness Hypoventilation Pin-point pupils
Management of an acute opioid overdose
A- remove obstruction, jaw thrust, oropharyngeal airway insertion
B- 100% oxygen 15L via non-rebreath mask
Naloxone- 400mcgs IV if no response then up to another 2 doses
C- BP, cap refill, fluid balance chart, wide bore cannula insertion- 14G or 16G, bloods- FBC, LFTs, U&Es, CRP, serum lactate, coag screen, toxicology screen, IV fluids, CPR
D- GCS, pupillary response, BM, ketones, medication chart review, imaging- CT head
E- inspection, temperature, catheterisation,
REASSESS- senior help
Management of salicylate overdose
Consider activated charcoal if presenting within an hour and second dose if levels continue to rise
Gastric lavage if levels >500mg/kg in an hour
Aggressive rehydration
Low threshold to give glucose
Alkalisation of the urine increases excretion
Haemodialysis
Mechanical ventilation if reducing conscious level
Management of hypercalcaemia
IV rehydration and bisphosphonates
Investigation for underlying cause- malignancy or hyperparathyroidism
Investigations for cellulitis
Wound swab
FBC, U&Es, LFTs, ESR, CRP
USS
Skin biopsy
Differentials for cellulitis
Cutaneous abscess, septic arthritis, acute gout, DVT, malignancy, pre-malignant eg. Bowen’s disease, erysipelas
Management of cellulitis
High dose oral antibiotics- flucloxacillin or if allergic then oral macrolide
IV rehydration
Elevation of the leg
Analgesia
Identification and management of co-morbidities
Management of life-threatening asthma
Admission
Oxygen- 100% 15L via a non-rebreathe mask
Bronchodilation with SABA
Oral corticosteroid (and continued for 5 days or until recovery)
SAMA if not improved- ipratropium bromide
IV magnesium sulphate
IV aminophylline following senior review
What is hypoglycaemia
Blood glucose <4mmol/L
Treatment of suspected hypoglycaemia
If patient is conscious and can swallow then 15-20g of fast-acting carbohydrate (roughly 3-4 teaspoons of sugar)
If patient has had hypoglycaemic episode before then they may have a glucose 40% gel to hand
Repeat after 10-15mins up to 3 times in total
Long acting carbohydrate once blood glucose is above 4mmo/L
If not responding to above or emergency then:
IM glucagon or glucose 10% IV infusion
If insulin injection is due then it should not be omitted but may need reviewing
Diabetic ketoacidosis management
Replacement of fluid and electrolytes and administration of insulin is the basics
500ml of sodium chloride 0.9% over 10-15 minutes
When BP is over 90mmHg then NaCl at a rate that replaces deficit and maintains pressure
Include KCl and adjust according to plasma-potassium concentration
Start insulin infusion, mixed with sodium chloride at a fixed rate of 0.1units/kg/hour
Monitor blood glucose and ketones hourly and adjust rates accordingly
Once blood-glucose falls below 14mmol/L, 10% glucose should be given IV
What is shock?
Circulatory failure (either pump or peripheral) resulting in inadequate organ/ tissue perfusion
Management of heart failure acutely
Position upright Oxygen 100% 15L non-rebreathe Diuretics- IV furosemide Morphine slowly IV Anti-emetics Nitrates
Signs of heart failure on a CXR
Alveolar oedema- bat winging
Kerley B lines
Cardiomegaly
Effusions (pleural), loss of costophrenic angles
Management of heart failure once stable from acute
Monitoring and repeat CXR
Switch IV furosemide to oral
ACE-i, beta-blocker (consider hydralazine and nitrate if ACE-i contraindicated)
Spironolactone
Optimise management of AF if this is present
Consider biventricular pacing/ cardiac transplantation
Investigations for heart failure
ECG U&Es, troponins ABG CXR, Echo Consider BNP- good negative predictive value
Status epilepticus management
Ensure airway is patent and patient is in a comfortable position where they will not be hurt
A-E approach
Airway and oxygen 100%
Suction where required
In community buccal midazolam
IV access
Take bloods- FBC, U&Es, LFTs, toxicology, glucose, calcium
Lorazepam IV- and repeat after 10-20 minutes
Thiamine infusion if suspected alcoholism or malnourishment, glucose 50% 50ml if hypoglycaemic
Phenytoin IV
After 60-90 minutes seek ICU help, with anaesthetic help-propofol infusion
Anaesthetics after 20 minutes into status epilepticus
When to perform a CT head in <1hr
GCS <13 on initial inspection or decreasing
Focal neurological deficit
Suspected open or closed depressed skull fracture or signs of basal skull fracture
Post-traumatic seizure
Vomiting more than once
Signs of a basal skull fracture
Battle’s sign- post-auricular ecchymosis
Panda eyes- periorbital ecchymosis
CSF leak through ears or nose
Haemotympanum
Management of raised intracranial pressure of unknown cause
A-E assessment Position the patient at 30-45 degrees Correct hypotension and treat seziures If intubated then hyperventilate to reduce the partial pressure of CO2 as this will cause cerebral vasoconstriction Osmotic agents such as Mannitol Fluid restriction Monitor patient closely Aim to make a diagnosis and treat the cause or exacerbating factors
Upper GI bleed management
A-E assessment
Protect the airway and keep NBM
Insertion of 2 wide bore cannulae
Bloods- FBC, U&Es, LFTs, glucose, cross-match 4-6 units of blood
If haemodynamically unstable and cross-match not complete then use O neg blood
Correct clotting abnormalities- platelets, FFP, vitamin K
Fluid challenge of 1L crystalloid- 0.9% saline
Urgent endoscopy as soon as adequately resuscitated- for diagnosis and management- cauterisation, adrenaline or banding to stop the bleeding
If suspected variceal bleeding then broad spectrum antibiotics and terlipressin IV
ICU referral considered and use of a central line for fluid resuscitation
Sengstaken-Blakemore tube for uncontrollable variceal bleeding
Management of acute epiglottitis
Secure airway
IV antibiotics
Supplemental oxygen
Corticosteroids
Management of severe hypocalcaemia
Monitor ECG and bloods
Calcium gluconate
Supplementary calcichew going forward
