Acute Station Management Flashcards
ACS - STEMI
- ABCDE approach
> A
> B: oxygen if sats < 94%
> C: BP, repeat ECG, ABG
> D: glucose
> E - Management
> GTN
> Stat Aspirin 300 mg
> Morphine - 5mg (up to 10) + metoclopramide 10 mg
> Tacregralor 180 mg > immediate PCI (UfH in lab)
> alteplase if no PCI - Aspirin lifelong 75 mg, clopidogrel 12 months
ACS - NSTEMI/ unstable angina
- Intermediate to high risk > Terofiban (glycoprotein IIb/IIIa inh) > PCI within 96 hours
- Low risk > outpt angioperfusion test and echo 3. Clopidogrel 12/12
Pulmonary Oedema
> sit up, 15 L Oxygen non rebreather
> Morphine (5-10 + metoclopramide 10 mg)
> GTN 2 puffs
> IV frusemide 40-80 mg
> CPAP
> Haemodialysis
Broad Complex tachycardia
- Check pulse - if no pulse begin CPR
- Stable - no signs of HF, syncope, shock
> Check U&Es - Mg and K
> Amiodarone 300 mg
> DC cardioversion - Unstable
> DC cardioversion
> Amiodarone 300 mg
Narrow Complex tachy (not AF)
- Intial approach
> ABCDE + obs
> Valsalva manouvers
> Carotid sinus massage
> Adenosine 6 mg, 12 mg, 12mg (verapamil if asthmatic)
> DC cardioversion if advers signs (shock, HF, syncope, HR > 200) - Next give:
> amiodarone 300 mg
> Digoxin
> verapamil
> atenolol
AF
- <48 hours
> not worried about cardiac thrombus
> unstable - DC cardioversion
> stable - Fleclainide, amiodaron, DC cardioversion - Persistent
> anticoagulate for 3/52 w/ warfarin/doac
> Rhythm control: amiodarone/sotalol
> Rate control:
- bisoprolol
- verapamil, diltiazem
- digoxin
- amiodarone
- ablation - Paroxysmal: flecainide
- CHADVASc and HASBLED
Bradycardia
> HR < 40
> atropine 500 mcg
> more atropine up to 3 mg
> Transcutaneous pacing
> Isoprenaline 5 mcg
> adrenaline 2-10
> Alternative: aminophylline, dopamine, glucagon
Infective Endocarditis
- ABx
> 2 if own valve: Fluclox and Gent
> 3 if prosthetic: Vancomycin, Gent, Rifampicin - Sepsis 6
> 3 IN: O2, Fluid, ABx
> 3 OUT: Urine, blood culture (at least three - if septic 2 cultures within 1 hour from 2 seperate sites), lactate - ABx for 4 weeks
- Dukes Criteria
> Major
- ECHO evidence
-positive cultures
> Minor
- Risk factors
- Shit cultures
- Fever
- Immune phenomena
- Embolic phenoma
Meningitis
> Septicaemic
- IV Cefotaxime
> Meningitic - LP first within 1 hour
- Ceftriaxone
- 10 mg Dex IV
- old (<3/12)/young(>50): amoxicillin
>if in pre-hospital: IM benzylpenicillin
Encephalitis
> Septicaemic
- IV Ceftriaxone 2 g BD
> Meningitic - LP first within 1 hour
- Ceftriaxone
- 10 mg Dex IV
- IV acyclovir 10mg/kg TDS
Status epilepticus
> Seizing continuous or repeatedly for 30 mins
> Step approach
- 10 mg IV Diazepam (OR Lorazepam 0.1 mg/kg)
- repear after 10 mins
- 10 mg/kg IV phenobarbitol (100 mg/min) OR Phenytoin 18 mg/kg (50 mg/min)
- ESCALATE
- RSI (with thiopentone)
Raised ICP
- Initial approach:
> Sit up
> Neuroprotective hyperventilation (High 02 low CO2)
> IV mannitol/ Hypertonic Saline
> Scan head - Treat Cause
> Burr hole/ craniotomy
> CT, LP 12 hours later xanthoxromia
> Nimodipine - prevents vasospasm
> Platinum coiling - Coning, tonsillar, brain stem death
DKA
- Acidosis < 7.3, ketones > 3 mM, glucose > 11.1 mM
- 0.9% NS
> BP < 90 - 1 L stat
> BP > 90 - 1L over 1 hour
> 1L/2 hr (x2). 1L/4 hr (x2), 1L/6 hr
>Start potassium in 2nd bag
- >5.5 mM - nil
- 3.5-5.5 mM - 40 mM/L
- <3.5 mM - senior review
> fixed rate insulin - Actrapid 0.1u/kg/hr
> Continue giving their basal insulin regimen of their long-acting to prevent rebound hyperglycaemia
>Swap to dextrose once BM < 15 (insulin MUST be continued to turn off ketogenesis) - Resolution
> pH > 7.3
>ketones < 0.3
> If they can eat and drink then you can start basal bolus regimen
HHS
- Hyperosmolarm Hyperglycaemic state
- Give
> NS - may need up to 9L
> may need insulin in one hour
Hypoglycaemia
- Alert and Oriented
> Oral Carbs - Drowsy/Confused + NR swallon
> Hypostop/ Glycogel
> Consider IV access - Unconsious
> 100 m 20% glucose - Insulin induced/ no access
> 1 mg glucagon
Addisonian Crisis
> LOW Bp, confused, drowsy, LOW Na, HIGH K
> Hydrocortisone 100 mg IV QDS
> 0.9% NS
> septic screen
Thyrotoxic storm
- precipitants
> recent thyroid surgery
> infection
> MI
> trauma - Management
> Fluid resus and NGT
> b-blocker
> Carbimazole
> lugol’s iodine
> hydrocortisone
> treat cause
Phaeo
- Presentation
> HTN crisis
> sense of impeding doom
> N&V
> headache - Treatment
> phentolamine (a-blocker) (to avoid unopposed a-agonism and sever vasoconstriction)
> Labetalol (b-blocker)
> 4-6/52 after a-blocker: surgery - 10% rule
> bilateral
> malignant
> part of MEN
> extra-adrenal
IECOPD/ T2RF and NIV - Management
> Oxygen titrated to 88-92% (Venturi mask 24 %)
> Neb salbutamol 5 mg/ Ipratropium Bromide 0.5 mg
> IV hydrocortisone 200 mg/ oral pred 30 mg
> IV theophylline
> BiPAP if pH < 7.37
> invasive vent if pH < 7.26
IECOPD/ T2RF and NIV - Follow up
> oral pred 30 mg 5 days post
> 1/52 review with GP, 1/12 review in clinic
> prescribe amoxicillin 500 mg tds for 5 days
OR if true allergy, doxycycline 200 mg on first day then 100 mg OD (total of 5 days)
OR if both ci’d, prescribe clarithromycin 500 mg BD for 5 days
Asthma - Acute presentation
> O2
> salbutamol neb 5 mg
> IV hydrocortisone 100 mg OR oral pred 30 mg
> ipratropium bromide neb 5 mg
> IV theophylline
> Mg Sulphate 2g IV/20 mins
> ESCALATE
> IV salbutamol
Asthma - Long term Management
> ICS + SABA (serotide)
> add LABA
> increase ICS (± LABA)
> Trial LRA (leukotriene receptor antagonist)
OR LAMA
OR SR Theophylline
> High dose ICS + 4th drug (e.g. above or b-agonist tablet)
> Oral steroids
> REFER
Pneumonia
> CAP: Amoxicillin / Clarithromycin (add Fluclox if suspect Staph infection, e.g. influenza)
> HAP:
- ≤ 5 days admission: Co-amoxiclav OR Cefuroxime
- > 5 days of admission: piperacillin with tazobactam
> Atypicals: Clarithromycin (/Rifampicin)
> PCP: Co-trimoxazole
PE
- ABCDE approach
> ECG, ABG (or else automatic fail)
> Wells Score
- If low: d-dimer (if d-dimer high - CTPA)
- If high: CTPA 2. Treatment
> Thrombolysis if unstable/saddle embolus
- if unstable: give UfH and do CTPA THEN thrombolyse
- don’t give LMWH if trombolyse
- alteplase
> LMWH
- enoxaparin
- tinzaparin
> Warfarin from 24 hours but keep LMWH for 5 days until INR in range
- provoked: 3 months
- unprovoked: 6 months
- ongoing: ongoing
PTX
- Tension
> ABCDE
> large bore cannula 2nd ICS mid clavicular line (upper border of lower rib)
> chest drain (safety triangle - (L) dorsi, Pec major, axilla, 5th ICS) - open injury
>3-sided wet dressing
> lets air out but not it - Spontaneous
> Primary:
- <2cm: consider discharge with outpt CXR
- >2cm: Aspirate (if fails chest drain)
> Secondary: admit for 24 hours
- if pt >50 nd rim of air >2cm ∨ SOB - chest drain
- if rim 1-2 cm: attempt aspiration (if fails drain)
- if rim <1cm: oxygen
Acute Upper GI bleed: General
> Resus
> Major Haemorrhage protocol
- Porter gets 0neg blood
- crash team
- surgical team
> Protect airway 100% 02
> Up to 4 litres of fluid before blood
> Glasgow-Blatchford Bleeding Score (if 0 send home - otherwise OGD)
> Rockall score
- Pre-endoscopy score > 3: surgery
- Post-endoscopy score > 6: surgery
Acute Upper GI bleed: Varices
> occur at L gastric and inferior oesophageal veins anastomose
> ABC
> correct clotting: FFP, Vit K
> IV terlipressin
> Sengstaken–Blakemore tube (SB tube)
> OGD: 2 of:
- Band ligation (superior)
- Sclerotherapy
- Adrenaline
> Open surgery (track vein back and sclerotherapy) if:
- rebleed
- bleeding despite transfusion of 6 units
- rockall > 6
- failed endoscopy
> TIPS (trans-jugular intrahepatic portosystemic shunt) - if pt rebleeds
Acute Upper GI bleed: PUD
> OGD:
- clips and adrenaline
- thrombin and adranaline
- thermal coag and adrenaline
> Post endoscopy PPI + H.pylori eradication
- lansoprazole 30 mg
- clarithromycin
- metronidazole or amoxicillin
Acute Upper GI bleed; other causes
> Oesophagus
- mallory-weiss
- oesophageal cancer
- boerhaave syndrome (full thickness tear post heavy vomiting)
- oesophagitis
> Stomach
- cancer
- peptic ulcer
- gastritis
- AVM
Decompensated Liver disease - Sx/Signs
> Jaundice
> Asterixis
> Hypoalbuminaemia
> Bleeding
> Hypoglycaemia
> Ascites + SBP
Decompensated Liver Disease - Investigations
> FBC - elevated WCC
> PT/INR
> Diagnostic parecentesis
- MC+S - SAAG (serum ascites albumin gradient)
*>1.1: portal HTN
*<1.1: cancer, pancreatitis, infection
- absolute neutrophil count > 250 cells/mm3
> blood cultures
> CT/USS, CXR, AXR
Decompensated Liver Disease - Management
> analgesia
> antiemetics
> ABx
- tazocin/ cefotaxime
- cipro long term
> therapeutic paracentesis
> IV albumin
Decompensated Liver Disease associated:
> Hepatorenal syndrome
- IV albumin 20%
- Terlipressin
- TIPS
- Liver transplant
> Encephalopathy
- Lactulose
- Phosphate enemas
- Rifaximine (removes nitrogen-forming bowel bacteria)
- Avoid sedatives
Chronic Liver Disease
> Palmer erythema
> Dupuytren’s
> spider naevi (SVC area)
> Caput medusae
> hepatomegaly
IBD - Cronh’s and UC: Acute flare
- Supportive
> NBM - Parenteral nutrition
> Dietician input (elemental diet in Cronh’s) - Medical acute flare up
> IV hydrocortisone - induction of remission:
> UC
- 5 ASA - sulfasalazine enema/ oral
- pred enema/ oral
> Cronh’s
- pred 1st line
- 5 ASA
IBD - Cronh’s and UC: Maintenance
> UC
- sulfasalazine
- azathioprine
- infliximab
- subtotal/panproctocolectomy
> Cronh’s
- Azathioprine (1st line)
- Methotrexate
- infliximab
- Surgical
> if toxic megacolon/ perf/ haemorrhage/ not responding to medication
> Subtotal/total colectomy: end ileostomy/ ileorectal anastomoses
> panproctocolectomy: ileoanal pouch
> Hartmann’s (cronh’s)
Alcohol detoxication (e.g. delirium tremens)
> Pabrinex
- b12
- vit C
- thiamine
> Chlordiazepoxide: tappering regimen
> Acamprosate/baclofen: decrease cravings
> Disulfiram: aversion therapy
Gastroenteritis
Supportive
AKI and Dialysis - Management
- RIFLE Criteria
> Urine output < 0.5 ml/kg/hr over 12 hours
> Serum creatinine x 2-3 baseline
> GFR decreased
> 50% - Treat complications
> Acidosis and Uraemia: dialyse
> Hyperkalaemia (other card)
> treat pulm oedema - Investigations
> helical CT KUB - stones
> USS
AKI and Dialysis - Causes
> pre-renal
- dehydration
- shock
- drugs (NSAIDs - afferent/ ACEi - efferent)
> renal
- Glomerular nephritis
- Tubular interstitial nephritis
- pyelonephritis
- ATN (e.g. rhadbo)
> post-renal
- retention
- stone, prostate, bladder Ca
- blocked catheter
- neurogenic (cauda equina)
Hyperkalaemia
> ECG:
- Tented T waves
- Prolonged PR
- Broad QRS (± VT)
> 10 ml 10% Calcium gluconate
> 10 U actrapid and 100 ml 20% glucose
> neb salbutamol 5 mg
> calcium resonium
Hypokalaemia
> Treatment K level:
- >3: Sando-K oral (x2)
- <3: 20-40 mmol/L over 3-4 hours (central line)
> Features
- U waves
- small/absent t waves (occasionally inversion)
- prolong PR interval
- ST depression
- long QT
Hypernatraemia
> 0.9% NS or Dextrose
> Decrease by < 12 mmol/day
> hydrate
> treat cause
- dehydration
- GI/ renal losses
- DI
- RAAS (Conn’s, Cushing’s)
Hyponatraemia
- Hypovolaemia:
> Tx: 0.9% NS
- N&V
- Diuretics
- Salt-losing enteropathy - Euvolaemic:
> Tx: fluid restrict, tolvaptan in SIADH
- SIADH
- Hyperthyroid
- Addison’s - Hypervolaemia
> Tx: fluid restrict
- HF
- Renal failure
- Liver failure
Anaphylaxis
> O2/intubate + legs up
> 0.5 ml of 1:1000 IM (repeated every 5 mins if necessary)
> IV access
> IV chlorphenamine 10 mg
> IV hydrocortisone 200 mg
> salbutamol/ipratropium bromide nebs
> mast cell tryptase
Acute poisoning - TCA
> Sx
- Long QT
- Metabolic acidosis
- Anticolinergic effects
> IV bicarb
> Treat arrhytmia: Mg 2 mg
Acute poisoning - Digoxin
> Sx
- YELLOW GREEN haloes
- ST depression
- inverted t waves
- Inverted tick
> Digibind
> Correct hypokalaemia
Acute poisoning - Benzo
> Flumenazil: often used in iatrogenic OD
> Other ODs managed supportively because giving Flumenazil in chronic user can cause withdrawal seizures
Acute poisoning
> B blockers
- Atropine
> Cyanide
- 100% O2
- Almonds
> Iron
- Desferroxamine
- Bleed
>Opiates
- Naloxone
> Organophosphate poisoning
- atropine
- S/Es: Salivary, Lacrimation, Urination, Diarhhoea (SLUD)
Acute poisoning - Warfarin
> STOP WARFARIN
>vitamin K 1-3 mg
> Immediate reversal: prothrombin complex concentrate (PCC) (if not available then fresh frozen plasma (FFP)
> restart warfarin when INR < 5
Acute poisoning - Paracetamol
> NAPQI: bad metabolite of paracetamol
> Plot on a nomogram: 4h and 15 hr
- plasma level falls above the line then give acetylcysteine as detailed below.
> NAC: 150mg/kg 1st infusion
> Signs for transplant: King’s college criteria
- pH <7.3
- OR ALL 3 of:
* Creatinine > 300
* PT > 100
* Grade 3/4 encephalopathy
Acute poisoning - Salicylate
> Gastric lavage/irrigation
> Monitor UO
> Correct acidosis with bicarb: IV with 1.26% solution
> Dialysis: > 700mg/L
> Resp alkalosis
