Clinical Emergencies Flashcards
What is the chest compression to ventilation ratio in adults?
30:2
What is the chest compression to ventilation ratio in children?
15:2
What are shockable rhythms?
Ventricular fibrillation
Pulseless ventricular tachycardia
How do you manage cardiac arrest with a non-shockable rhythm?
Start chest compressions at 30:2
1mg Adrenaline 1:10,000 ASAP
Recheck pulse every 2 mins
Repeat 1mg Adrenaline every other cycle
How do you manage a cardiac arrest with a shockable rhythm?
Single shock followed by 2 mins of compressions (UNLESS: Witnessed arrest in a monitored patient, then give 3 shocks)
Check pulse every 2 mins and repeat shock + compressions
1mg Adrenaline 1:10,000 and 300mg Amiodarone after 3rd shock
1mg Adrenaline given every 3-5 mins
Can give 150mg Amiodarone after 5th shock
What are the reversible causes of cardiac arrest?
4 H’s and 4 T’s
Hypoxia, hypothermia, hypovolaemia, hypokalaemia/hyperkalaemia/hypoglycaemia/hypocalcaemia
Tension pneumothorax, tamponade, thrombosis, toxins
How do you manage suspected sepsis?
SEPSIS 6
3 in - fluids, abx, oxygen
3 out - cultures, lactate, urine output
What are paediatric red flag signs?
Pale/mottled skin
Unresponsive/does not wake or stay awake
Continuous cry
Resp: Grunting, tachypnoea >60, chest recessions
Reduced skin turgor
Aged <3 months with a temp of 38 or higher
Non-blanching rash
Bulging fontanelle
Neck stiffness
Status epilepticus
Focal neurological signs
Focal seizures
How does anaphylaxis present?
Symptoms: SOB Itching Abdomina pain Lightheadedness
Signs: Urticaria Angioedema Wheeze Hypotension Tachycardia Stridor due to laryngeal oedema Shock
What type of hypersensitivity reaction is anaphylaxis?
Type 1 Hypersensitivity reaction
How do you manage anaphylaxis
ABCDE
A - secure airway B - provide O2 if required C - provide IV bolus D - lie patient flat to prevent cerebral oedema E - flushing? angioedema? urticaria?
IM Adrenaline - REPEAT AFTER 5 mins
Antihistamines - Oral Chlorphenamine
IV Hydrocortisone
What are symptoms of hypoglycaemia?
Can be split into early ADRENERGIC symptoms and late NEUROGLYCOPENIC symptoms
Adrenergic = sweating, tachycardia, palpitations, pallor, hunger, restlessness
Neuroglycopenic = confusion, slurred speech, drowsiness, numbness of extremities, anxiety, blurred vision
How do you manage hypoglycaemia?
Conscious patient = Oral glucose
Unconscious/drowsy/unable to swallow =
If IV access = IV Glucose 10% or 20%
No IV access = IM Glucagon (only once, then switch to IV)
How do you manage DKA?
Fluid resus:
Adults = 500ml 0.9% NaCl over 15 mins
Children = 10ml/kg 0.9% NaCl over 15 mins
Insulin at 0.1 units/kg/hr
Check potassium regularly - hypokalaemia may occur due to insulin pushing potassium into cells
How fast should the ketones and glucose fall in DKA?
Ketones should fall by 0.5mmol/l per hour
Glucose should fall by 3mmol/l per hour.
Which diabetic drug is most likely to cause DKA?
SGLT2 inhibitors
How to manage HHS?
1L 0.9% NaCl per hour!!
Replace potassium if below 5.5
Aim for glucose reduction of 5mmol/l per hr
Insulin DOES NOT form part of initial management plan
If glucose has stopped dropping with fluids alone can start insulin at 0.05U/kg/hr.
What are causes of metabolic acidosis? (Normal anion gap and raised anion gap)
Normal anion gap = diarrhoea, renal tubular acidosis, Addison’s disease
Raised anion gap = DKA, alcohol, shock, sepsis, hypoxia, renal failure, methanol
In hyperkalaemia, what drug can be used to stabilise the cardiac membrane?
IV Calcium gluconate
In Hyperkalaemia, what can be used to quickly reduce serum potassium?
IV insulin (+Dextrose)
Nebulised salbutamol
In hyperkalaemia, what other drugs can be used to remove potassium from the body?
Calcium resonium
Loop diureics
Dialysis - if AKI and hyperkalaemia is not resolving w/ fluids
What is status epilepticus and how is it managed?
A tonic clonic seizure lasting more than 5 mins OR two or more seizures consecutively without full recovery in between
ABCDE
If IV Access: IV Lorazepam 4mg - can repeat once after 10-20 mins
If no IV access: Buccal midazolam or rectal diazepam
What is a thyrotoxic storm and how is it managed?
Emergency presentation of hyperthyroidism
Fever, Tachycardia, confusion/agitation, nausea+vomiting, HTN
Management = IV Dexamethasone + IV Propranolol + IV Propylthiouracil + fluid resus
What is myxoedema coma and how is it managed?
Emergency presentation of hypothyroidism
Fluid resus + IV Thyroid replacement + IV Hydrocortisone
How does an Adrenal crisis present and how is it managed?
Reduced consciousness
Hyperkalaemia
Hyponatraemia
Hypoglycaemia
Hypotension
Management = IV Hydrocortisone + IV fluids + treatment of hypoglycaemia
How do you manage a major postpartum haemorrhage?
- Oxygen
- Uterine massage + bimanual compression
- Insert 2 large bore cannulas –> Crossmatch
- IV fluids
- Assess patient’s obs and fluid status
- Assess cause (consider 4 T’s)
- IM Oxytocin + Ergometrine
- Tranexamic acid
- Oxytocin infusion
What is the haemoglobin transfusion threshold?
<70
or <80 in ACS
What marker should you test for in anaphylaxis and when should you do it?
Serum mast cell tryptase
within 6 hours
Confirms diagnosis of anaphylaxis
What is the platelet transfusion threshold?
xx
How is malignant hypertension managed?
IV sodium nitroprusside/IV labetalol
What are non-shockable rhythms?
Asystole
Pulseless electrical activity
What is paediatric basic life support?
Give 5 rescue breaths (before starting chest compressions)
Start CPR at 15:2
Which pulse do you check in children?
Infants under 1 years old = Brachial or femoral
Children over 1 years old = Carotid or femoral
What are features of DKA?
X
What are features of HHS?
Severe hyperglycaemia
Hyperosmolality
No ketonaemia or acidosis
How to calculate anion gap?
(K + Na) - (HCO3 + Cl)
Normal = 10-18
What is malignant hypertension and how is it managed?
Sudden onset extremely high BP , systolic >180 or diastolic >120
With acute end-organ damage –> Hypertensive retinopathy, AKI, cardiac failure, stroke, aortic dissection
Management = IV sodium nitroprusside / IV Labetalol
What are risks of status epilepticus?
Neurological - Brian injury
Respiratory - hypoxia, aspiration pneumonia
Cardiovascular - arrhythmias
Other - lactic acidosis, rhabdomyolysis, hypo/hyperglycaemia
How does paracetamol overdose present?
Nausea and vomiting Loin pain/Abdominal pain Haematuria Jaundice Metabolic acidosis
How is paracetamol overdose management?
Less than 1 hour ago = Activated charcoal
Staggered overdose = NAC
Between 1 and 4 hours ago = Wait til 4 hours
>4 hours = Nomogram
Give NAC if indicated by nomogram
How does salicylate overdose present?
TINNITUS Nausea and vomiting Abdominal pain Sweating, fever Confusion
Bounding pulse
Cardiac arrhythmias
Respiratory alkalosis and then metabolic acidosis!!!
How is salicylate overdose managed?
IV Bicarbonate
If severe - haemodialysis
How does opioid overdose present?
Decreased resp drive
Bradycardia
Loss of consciousness
How is opioid overdose managed?
Naloxone
How is benzodiazepine overdose managed?
Supportive care
Within 1 hour = Activated charcoal
if severe - Flumazenil
How does tricyclic overdose present? What is seen on ECG?
Arrhythmias Seizures Metabolic acidosis Coma Hypothermia Hyperreflexia
ECG changes = Sinus tachycardia, Broad QRS, QT prolongation
How is tricyclic overdose managed?
If within 1 hour = Activated charcoal
If more than 1 hour = IV sodium bicarbonate
How dose lithium overdose present?
Coarse tremor Diarrhoea Nausea and vomiting Hyperreflexia Seizure Coma
How is lithium overdose managed?
Supportive care with normal saline
If severe - haemodialysis
How is beta blocker overdose managed?
If bradycardic - atropine
Note: Sotalol can cause QT prolongation
How is ethylene glycol poisoning managed?
Fomepizol
Ethanol
How is methanol poisoning managed?
Fomepizol
How is insecticide poisoning managed?
Atropine
How does lead poisoning present?
Abdominal pain Peripheral neuropathy Blue lines on gum margin Fatigue Constipation
Blood film= basophilic stippling
How is lead poisoning managed?
Chelating agents dimercaptosuccinic acid (DMSA) D-penicillamine EDTA dimercaprol
How does carbon monoxide poisoning present?
Cherry red skin
Confusion
Nausea + vomiting
Tachycardia
Sats probe will show 100%
How is carbon monoxide poisoning managed?
100% oxygen
How is cyanide poisoning managed?
Hydroxocobalamin
How is cocaine poisoning managed?
Diazepam
How is ecstasy poisoning managed?
Diazepam
How is alcohol withdrawal managed?
Chlordiazepoxide or Diazepam
If seizing / delirium tremens = Lorazepam
How is suspected spinal cord compression managed?
Whole spine MRI
Dexamethasone
What triad is seen in raised ICP?
Cushing’s triad
Wide pulse pressure
Bradycardia
Irregular breathing
Other symptoms:
Headache
Vomiting
papilloedema
What is normal ICP?
7-15
How is raised ICP managed?
Elevate head to 30 degrees
IV Mannitol
Controlled hyperventilation
What are indications for BiPAP (NIV)?
COPD
What are indications for CPAP?
Heart failure
Obstructive sleep apnoea
How do you manage someone who is choking?
Mild airway obstruction (they are still able to talk) - encourage them to cough
If severe airway obstruction(unable to talk) but conscious-
give up to 5 back-blows
if unsuccessful give up to 5 abdominal thrusts
if unsuccessful continue the above cycle
If unconscious-
call an ambulance
start CPR
