Acute scenarios Flashcards
Narrow QRS complex (3 or below small squares/0.12s) - regular
SVT
Vagal Manouvres
Adenosine 6mg rapid bolus
if unsuccessful –> 12 mg
If unsuccessful –> 12mg
Adenosine slows conduction through the AV node
Narrow QRS complex tachycardia - irregular
AF
Control rate: B-blocker or diltiazem
Digoxin or Amiodarone if evidence of HF
Broad complex tachycardia (more than 3 small squares/0.12s) - regular
VENTRICULAR TACHYCARDIA
300mg Amiodarone IV over 20-60mins
then 900mg over 24hrs
Amiodarone is a potassium channel blocker
Torsades de pointes
Magnesium IV 2g over 10 mins
DKA : presentation
polyuria, polydipsia, abdo pain, vomiting, dehydration
DKA: Diagnosis
Serum glucose >11 or known diabetic
Serum ketones >3 urine ketones >3+
Metabolic Acidosis pH <7.3, Bicarb <15
DKA: Pathophysiology
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
DKA: High risk patients
Young people & elderly (incr risk cerebral oedema)
Pregnancy
Heart/renal failure
DKA: Management
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
When is a DKA resolved?
Capillary ketones <0.6
blood pH >7.3
Hyperkalaemia: why is it dangerous and what is the treatment aim?
Can cause sudden death from cardiac arrhythmias.
Treament priority is to stabilise the myocardium, reduce potassium levels and address the underlying cause
What K+ level would signify hyperkalaemia?
5.5-5.9 = mild
6-6.4 = moderate
>6.5 or >6 & septic = severe
Causes of hyperkalaemia?
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
Moderate/severe hyperkalaemia Management:
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)
Hyperkalaemia - ECG Changes
Peaked T waves
Broad QRS
Bradycardia
absent/flattened P waves
HYPERKALAEMIA Management
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
Hypoglycaemia: Presentation
any patient with reduced GCS or a seizure
Autonomic Symps: sweating, palpitations, tachycardia, dizzy, pale, tremor
Neuro Symps: fatigue, confusion, reduced consciousness, seizure
Hypoglycaemia : who is most at risk?
Patients taking insulin, sulphonylureas (e.g. glicazide)
impaired renal/liver function
sepsis
Hypoglycaemia: Causes
Insulin/Diabetes medication dose too high
Exercise
Alcohol
Hypoglycaemia Management:
Conscious patient
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
Hypoglycaemia Management:
Semi-conscious patient
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
Hypoglycaemia Management:
Unconscious patient
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
Major Upper GI Bleed:
Bloods to be taken
FBC
Clotting
U&E
LFTs
ABG/VBG
Cross match 6 units blood
Major Upper GI Bleed:
Fluid resus
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
What does the MHP contain?
First pack : 4 RBC, 2 FFP
Second Pack: 4 RBC, 2 FFP, 1 platelet
Variceal Bleed:
after resus
Endoscopy immediately after resus
TERLIPRESSIN after resus
IV ABx and sepsis screen
Pabrinex if alcohol dependent
Non-variceal bleed:
after resus
Endoscopy immediately after resus
PPI to patients with non-variceal bleed
ANAPHYLAXIS:
Pathophysiology
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
ANAPHYLAXIS:
Management
- 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
ANAPHYLAXIS:
After resus
- 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
ACUTE ASTHMA:
Pathophysiology
Reversible airway obstruction & airway hyper-responsiveness → bronchoconstriction, air trapping, V/Q mismatch
ACUTE ASTHMA
Assessing Severity
acute severe - life threatening - near fatal
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
ACUTE ASTHMA:
Management
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
