Acute scenarios

Question 1

Narrow QRS complex (3 or below small squares/0.12s) - regular

Answer 1

SVT

Vagal Manouvres

Adenosine 6mg rapid bolus

if unsuccessful –> 12 mg

If unsuccessful –> 12mg

Adenosine slows conduction through the AV node

Question 2

Narrow QRS complex tachycardia - irregular

Answer 2

AF

Control rate: B-blocker or diltiazem

Digoxin or Amiodarone if evidence of HF

Question 3

Broad complex tachycardia (more than 3 small squares/0.12s) - regular

Answer 3

VENTRICULAR TACHYCARDIA

300mg Amiodarone IV over 20-60mins

then 900mg over 24hrs

Amiodarone is a potassium channel blocker

Question 4

Torsades de pointes

Answer 4

Magnesium IV 2g over 10 mins

Question 5

DKA : presentation

Answer 5

polyuria, polydipsia, abdo pain, vomiting, dehydration

Question 6

DKA: Diagnosis

Answer 6

Serum glucose >11 or known diabetic

Serum ketones >3 urine ketones >3+

Metabolic Acidosis pH <7.3, Bicarb <15

Question 7

DKA: Pathophysiology

Answer 7

Insulin promotes glucose and potassium uptake into cells

Insulin deficiency –> Cells use ketone metabolism instead of glucose. Hyperglycaemia

Hyperglycaemia & ketosis –> osmotic diuresis, metabolic acidosis and deranged electrolytes

Question 8

DKA: High risk patients

Answer 8

Young people & elderly (incr risk cerebral oedema)

Pregnancy

Heart/renal failure

Question 9

DKA: Management

Answer 9

Normalise fluids and electrolytes: 0.9% saline bolus 500ml over 15mins

40mmol potassium replacement

10% glucose infusion if <14

Switch off ketosis: IV fixed rate insulin 0.1U/kg/hour (max 15U/hr)

Continue long acting insulin alongside IV infusion

Identify and treat underlying cause

Monitor: FBC, VBG, U&Es, BM, ketones, GCS

Monitor for signs of cerebral oedema or fluid overload

Use local hospital DKA protocol for fluid and insulin replacement + specific monitoring

Question 10

When is a DKA resolved?

Answer 10

Capillary ketones <0.6

blood pH >7.3

Question 11

Hyperkalaemia: why is it dangerous and what is the treatment aim?

Answer 11

Can cause sudden death from cardiac arrhythmias.

Treament priority is to stabilise the myocardium, reduce potassium levels and address the underlying cause

Question 12

What K+ level would signify hyperkalaemia?

Answer 12

5.5-5.9 = mild

6-6.4 = moderate

>6.5 or >6 & septic = severe

Question 13

Causes of hyperkalaemia?

Answer 13

Failure or potassium excretion +/- inappropriate potassium input

Renal failure +/e precipitating factor e.g. nephrotoxic drugs, sepsis

Potassium sparing diuretics, ACEi, tumour lysis syndrome, rhabdomyelosis, adrenal insufficiency

Question 14

Moderate/severe hyperkalaemia Management:

Answer 14

Stop any K+ sources - meds

Protect the heart: 10ml 10% Calcium Gluconate with cardiac monitoring (No effect on K+ serum level but cardioprotective)

Shift K+ into cells: 10U Actrapid in 50ml 50% dextrose over 10 mins

Salbutamol Neb

Remove K+ from body: Calcium Resonium PO/PR - binds K+ in the gut to prevent absorption (can take up to 12 hrs to work)

Question 15

Hyperkalaemia - ECG Changes

Answer 15

Peaked T waves

Broad QRS

Bradycardia

absent/flattened P waves

Question 16

HYPERKALAEMIA Management

Answer 16

A to E Approach

Stop extra sources : Stop any drugs - Potassium sparing diuretics, ACEi,

Cardiac protection: 10ml 10% Calcium Gluconate with cardiac monitoring (no effect on K+ level) and repeat as necessary

Shift K+ into cells:

INSULIN/DEXTROSE - 10U Actrapid in 50ml 50% Dextrose over 10 mins

SALBUTAMOL NEB

Sodium Bicarb (Renal team/ITU)

REMOVE K+ from body:

CALCIUM RESONIUM - PO/PR to prevent gut absoroption

Dialysis - ITU/Renal

Question 17

Hypoglycaemia: Presentation

Answer 17

any patient with reduced GCS or a seizure

Autonomic Symps: sweating, palpitations, tachycardia, dizzy, pale, tremor

Neuro Symps: fatigue, confusion, reduced consciousness, seizure

Question 18

Hypoglycaemia : who is most at risk?

Answer 18

Patients taking insulin, sulphonylureas (e.g. glicazide)

impaired renal/liver function

sepsis

Question 19

Hypoglycaemia: Causes

Answer 19

Insulin/Diabetes medication dose too high

Exercise

Alcohol

Question 20

Hypoglycaemia Management:

Conscious patient

Answer 20

15-20g short acting carbohydrate e.g. glucose tab, fruit juice, sweets

If BG remains <4, repeat up to 3 times then move to IV Tx

RECHECK after 10-15 mins.

REPLACE long acting carb - banana, yoghurt, 2 biscuits

Remember WARD HYPO BOX

Question 21

Hypoglycaemia Management:

Semi-conscious patient

Answer 21

If able to swallow: 1.5-2 tubes glucogel or 1mg IM glucagon

If BG remains <4, repeat up to 3 times then move to IV Tx

RECHECK after 10-15 mins.

REPLACE long acting carb - banana, yoghurt, 2 biscuits

Remember WARD HYPO BOX

Question 22

Hypoglycaemia Management:

Unconscious patient

Answer 22

Support the airway

160ml IV 10% glucose or 1mg IM glucagon.

Stop IV insulin if running

If remains <4, repeat bolus

RECHECK after 10-15 mins.

REPLACE long acting carb - banana, yoghurt, 2 biscuits

Remember WARD HYPO BOX

Question 23

Major Upper GI Bleed:

Bloods to be taken

Answer 23

FBC

Clotting

U&E

LFTs

ABG/VBG

Cross match 6 units blood

Question 24

Major Upper GI Bleed:

Fluid resus

Answer 24

Blood is best (cross matched/ group compatible/O neg in emergency)

otherwise FFP / colloid / crystalloid at appropriate level to maintain systolic BP above 100

ACTIVATE MHP

Question 25

What does the MHP contain?

Answer 25

First pack : 4 RBC, 2 FFP

Second Pack: 4 RBC, 2 FFP, 1 platelet

Question 26

Variceal Bleed:

after resus

Answer 26

Endoscopy immediately after resus

TERLIPRESSIN after resus

IV ABx and sepsis screen

Pabrinex if alcohol dependent

Question 27

Non-variceal bleed:

after resus

Answer 27

Endoscopy immediately after resus

PPI to patients with non-variceal bleed

Question 28

ANAPHYLAXIS:

Pathophysiology

Answer 28

Allergen sensitisation: specific IgE is produced to an allergen

Allergen exposure → Type I Hypersensitivity reaction

Cross-linking of IgE antibodies → rapid mast cell activation → release of histamine/inflammatory mediators → increased vascular permeability → smooth muscle spasm, mucosal oedema and inflammation

Distributive shock +/- airway compromise +/- bronchospasm

Question 29

ANAPHYLAXIS:

Management

Answer 29

• REMOVE TRIGGER e.g. ABx
• High flow oxygen
• 500micrograms IM adrenaline : 0.5ml of 1:1000
• FLUID RESUS, can raise legs to improve venous return
• salbutamol nebs if wheeze

HYDROCORTISONE 200mg IM or slow IV

CHLORPHENAMINE 10mg IM or slow IV

Question 30

ANAPHYLAXIS:

After resus

Answer 30

• Serum mast cell Tryptase → record at 1-2hrs from start of symptoms + 24hrs after/F/up clinic
• Observations for a minimum of 6 hours. 24hrs if severe reaction → beware BIPHASIC RESPONSE
• Dischard → prescribe epipen, refer to allergy service. Safety net on recognition of anaphylaxis

Question 31

ACUTE ASTHMA:

Pathophysiology

Answer 31

Reversible airway obstruction & airway hyper-responsiveness → bronchoconstriction, air trapping, V/Q mismatch

Question 32

ACUTE ASTHMA

Assessing Severity

acute severe - life threatening - near fatal

Answer 32

ACUTE SEVERE:

• PEF 33-50% predicted
• RR>25
• HR >110
• cant complete sentences

LIFE-THREATENING

• PEF <33% best
• Hypoxia: PaO2 <8kpa, cyanosis
• Hypoventilation: ‘normal PaCO2’, exhaustion, silent chest, poor resp effort
• Hypotension
• Reduced GCS

NEAR-FATAL

• Raised PaCO2
• requiring mechanical ventilation

Question 33

ACUTE ASTHMA:

Management

Answer 33

O SHIT ME

Sit patient up

O - Oxygen 15L NRM

S- Salbutamol 5mg nebs

H- Hydrocortisone 100mg IV (if very breathless, vomiting etc.) If can tolerate PO 40-50mg Predisolone

I- Ipratroprium - 500 micrograms given with salbutamol in mixed neb

(T- Theophylline)

M- Magnesium Sulfate 1.2-2g IV - SENIOR HELP

E- ESCALATE