Clinical Emergencies Flashcards
acute asthma
PEFR
prev ITU admission: admit regardless of severity
o2 salbutamol 5mg neb - monitor ecg, give back to back every 15min hydrocortisone 100mg iv or pred 40mg po ipratropium bromide 500mcg neb escalate, consider mgs04 IV
covid swab: DONT FORGET COVID IN DD
sputum culture
if features of acute severe or life-threatening: warn ICU, seniors
How do you treat a bleeding peptic ulcer?
ABCDE IV fluids blood products if needed: blood transfusion, platelets, FFP, consider vit K blatchford sore high dose PPI IV 40mg omeprazole iv morphine iv antiemetic e.g. 10mg metoclopramide
Upper GI endoscopy:
- clipping +/- adrenaline
- thermal regulation with adrenaline
- sclerotherapy (inject thrombin/fibrin) with adrenaline
- H pylori: amoxicillin (metro) + clarithromycin + PPI
How to treat hyperkalaemia?
10U actrapid/novorapid in 100ml of 20% dextrose of 30min IV = first drug to lower pt’s K+
IV 10% 10ml calcium gluconate
IV 10U insulin + 50% 50ml dextrose
5mg neb salbutamol
calcium resonium
what are some complications of acute pancreatitis?
peripancreatic collections
pseudocysts
pancreatic necrosis, abscess
ARDS
aortic dissection
c - large bore cannulae, abx, analgesia
USS/ct
immediate refer: vascular surgeons, anaesthetist
paracetamol OD
activated charcoal <1h
if <4h, wait till 4h to do levels
4-8hr: do para levels, start nac if over tx line
immediate nac if staggered od, uncertain time, >8hr since presentation
consider transfer to liver uni, call toxicology
psych r/v if suicide attempt
DKA
high bm, ketones >3, acidaemia
ketones
fluid bolus (protocol), senior, DM team
intravenous infusion at a rate that replaces deficit and provides maintenance; see guideline
continuously re-assess
insulin: 0.1U/kg/h
k+ replacement when urine output adequate, monitor u/e every hour
dextrose once bm <15: 10% dex infusion with nacl
heparin/lmwh: prothorombotic state
AECOPD
B - peak expiratory flow rate, sputum culture
C - theophylline levels of on it at home, blood culture, ABX if sputum purulent
O2 salbutamol 5mg neb hydrocortison 100mg iv ipratropium bromide 500mcg neb escalate: bipap (pH <7.35) or I&V (pH<7.25) or doxapram theophylline: seniors
unconscious patient
head injury
trauma call: EM, anaes, ortho, gen surg, radio…
CABCDE
a- 3 point immob, jaw thrust, anaes
15l, o2
c: bloods for alc, salicylate, para, lft, u/e, tft, cortisol, glucose, preg, trop, d-dimer
d;: pupiles for stroke, opiates, glucose, gcs, neuro exam to localise lesion
e: skull: battle’s, raccoon, csf leak, haemotypanum
neurosurg, ct head, tetanus status
septic shock
BUFALO Give 3 - oxygen - broad spectrum antibiotics (within 1hr) - IV fluids
Take 3
- blood cultures (urine, sputum, csf)
- urine output
- ABG (including lactate)
sepsis: qSOFA score
stroke / TIA
CT head aspirin 300mg PO after excluding haemorrhagic stroke thrombolysis: 4.5 hr, if no contraindic sec: clopidogrel / aspirim carotid endarterectomy
PE
also presents with haemoptysis, SOB, pleuritic cp
check leg swelling, ask details of it (DVT)
Well's O2 IV morphine treat: DOAC if delay ctpa: doac until scan
if massive PE (haemodynamic compromise): consider bolus alteplase
future Mx: look for underlying malig
tension pneumothorax
1 way valve: air sucked in, pressure on side, push mediastinum, kink great veins, prevent venous return –> fall stroke vol, fall cardiac output
immediate needle decompression 2nd ICS, MCL
seniors: CXR, chest drain-
pneumonia
- CURB-65 to assess severity 2 = hospital
confusion, urea>7, rr>30, bp <90/60, age>65 - Oxygen (15L 100% NRB) if still hypoxic:
CPAP , NIV, Intubation - Antibiotics (local protocol/contact microbiology)
amox, amox + other, HAP: co-amox or taz - Analgesia (paracetamol/ NSAID for pleuritic pain)
HHS
fluid bolus
insulin only if bm not falling adequately, 0.05u/kg/h
k+ replacement when urine output adequate, monitor u/e every hour
dextrose
heparin/lmwh: prothorombotic state
what are the complications of status epilepticus?
permanent cerebral damage cardiac arrhythmia aspiration pneumonia: vomiting hypoglycaemia hyperkalaemia: rhabdomyolysis death
encephalitis
like meningitis but with impaired consciousness, odd behaviour
bc, viral pcr of serum, malaria film
contrast ct
lp: hsv pcr
acyclovir (for hsv)
adjust mx: liaise with micro
upper GI bleed:
what causes to consider?
how to manage?
peptic ulcer disease duodenal erosions oesophagitis varices mallory-weiss
b - erect cxr if perf
c- 2x large bore cannulae, cross match, clotting, lft, calculate blatchford score
iv fluids
blood products: ffp, blood transfusion
e- abdo exam, peritonism, look for peri oedema, ascites in cirrhotic pt, PR for malaena
- Keep patient nil by mouth + notify surgeons
- Bleep endoscopist
varices: abx: cef, quinolone, terlipressin or octreotide if ihd
varices: banding, injection sclerotherapy, TIPS, sengstaken blakemore tube to arrest bleed
peptic ulcer: clipping w adrenaline, sclerotherapy, high dose ppi 40mg omeprazole post endoscopy
- check for/eradicate H pylori - triple therapy amox, clari, ppi
- If massive bleed activate major haemorrhage protocol
rockall score post endoscopy
anaphylaxis
B - neb adrenaline if wheeze
C - 500ml iv nacl stat
HELP: peri arrest team
0.5ml 1:1000 IM adrenaline
200mg iv hydrocortisone
10mg iv chlorphenamine
Additionally, consider nebuliser adrenaline if wheeze. Measure mast cell tryptase at 1-6h and test for igE mediated reaction with RAST test
Tachy: Broad QRS, regular = ?
VT
How to treat VT arrhythmia?
amiodarone 300mg IV over 20-60min
Then 900mg over 24hr
Describe Torsades de points tachycardia
Bit like VT but irregular + wandering baseline, polymorphic
Cause: QT interval prolongation e.g. antiarrhythmics, TCA, antipsychotics, chloroquine, erythromycin, electrolytes
How to treat Torsades de pointes
Magensium 2g over 10min
Tachy: narrow QRS, regular = ?
Atrial flutter –> BB
re-entry parosyxmal SVT
How to treat SVT?
vagal manouvre: valsalva, carotid sinu s mssage
adenosine: slow conduction through AVN
(verpamil in asthmatic)
DC cardioversion
tachy: irreg, narrow complex tachy = ?
AF
BB/diltiazem
consider digoxin, amiodarone if HF
Contraindications for thrombolysis in stroke?
recent surgery
prev intracrnail haemorrhage, brain tumour, aneurysm, head injury, stroke in past 3/12
haemorrhage: GI, urinary tract in past 3/52
>6hr sx onset
severe liver disease
pt on anticoag
acute pulm oedema
/acute HF
B - CXR features of HF (ABCDE)
C - ECG, echo, plasma BNP
Loop diuretic: furosemide 40mg IV diamorphine 1.25mg iv nitrates GTN spray 2 puffs subling; not if SBP<90 o2 position
features of life-threatening asthma
33 92 CHEST: life-threatening asthma features PEF <33% Sats <92% cyanosis hypotension exhaustion silent chest tachycardia
reduced consciousness
normal PaCo2
features of acute severe asthma
pefr 33-50% best/predicted
rr>25
HR>110
inability tco complete sentences in 1 breath
features of moderate acute asthma
increasing sx
pefr 50-75% best/predicted
no features of acute severe asthma
acute pancreatitis
c; iv fluids, titrate to adequate urine output
pain: morphine
calculate mod glasgow score
escalate, ITU early
Status epilepticus
start clock crash call 0min: a-e 5min: 1st dose iv lorazepam/pr diaz/buccal midaz, senior r/v 15min: 2nd dose 25min: iv phenytoin (ecg)/ keppra 45min: RSI: sodium thiopental, itu
preg: eclampsia
correct causes as arise: glucose, elec, sepsis, bp, alcol withdrawal
ACS: STEMI
A-E: troponin, d-dimer, BNP MONARTH: morphine 5mg iv + metoclopramide 10mg iv O2: sob or <94% nitrates: gtn sublingual aspirin 300mg reperfusion: PCI ticagrelor 180mg po heparin: unfractionated/lmwh
ACS: NSTEMI
A-E: troponin, d-dimer, BNP MONARCH: morphine 5mg iv + metoclopramide 10mg iv O2: sob or <94% nitrates: gtn sublingual aspirin 300mg reperfusion: depending on GRACE/TIMI score clopidogrel: 300mg PO heparin: unfractionated/lmwh - continue until discharge
low risk: coronary angio elective
high risk: coronary angio + PCI
pneumothorax
primary:
<2cm: home, safety yet, f/u cxr, senior advice
>2cm: senior, aspirate (cannula), if not successful chest drain
Secondary pneumothorax
- <1cm = Admit for 24hr observation
- 1-2cm = Admit and attempt aspiration
- 2cm+ or symptomatic = chest drain
haemorrhaging shock
- Stop bleeding (may require referral to surgery)
- Raise legs, give fluids (titrated to HR BP and urine output), lease with seniors regarding escalation
- haemorrhage estimated at >30% total blood volume = activate massive haemorrhage protocol (administering O Rh -ve blood until units are cross matched)
- speak with seniors/haematology regarding replacement of RBC and FFP
Broad complex tachycardia
VT, SVT, AF
Pulseless VT > follow arrest protocol
Are there adverse signs? - HF, chest pain, shock
YES - immediate cardioversion (call anaesthetist)
NO - is QRS regular?
Regular = 300mg IV amiodarone Irregular = try IV adenosine (if polymorphic VT try IV mgso4)
Narrow complex tachycardia
Sinus tachycardia, atrial tachyarrhythmia
If irregular - manage as AF
Stable
<48h - synchronised dc shock
- pharmacological cardioversion with Flecainide (or amiodarone if structural abnormality - do echo)
> 48h
- electrical cardioversion if patient has been anticoagulated for 3 weeks on warfarin
- betablocker/calcium channel blocker/ digoxin - if patient is over 65 or has Hx of IHD
Unstable
- Heparinise + sedate + DC cardiovert
Regular
- valsalva manoeuvre or carotid massage
- adenosine (or verapamil if they have asthma)
- if adverse signs = DC cardiovert > amiodarone
- no adverse signs = b-blocker, Ca-b, amiodarone
Bradyarrythmia
If adverse features or risk of asystole:
- 1st: IV atropine
- 2nd: repeat IV atropine to max 3mg, transcutaneous pacing, IV isoprenaline or IV adrenaline
No adverse features - just observe
meningitis
CT then LP (normal pressure = 10-20cmH2O
- IV Cefotaxime + Ampicillin
(Outside hospital administer IM Benpen) - IV fluids
- Escalate (seniors, ITU, microbiology)
- Consider IV dexamethasone
aki
urgent + fluids
seniors, nephrologists if hyperkalaemia, pulm oedema, uraemic cx, metab acidosis
fluid bolus if dehy, low bp
urinalysis
imaging: renal uss if obstruction or no clear cause of aki
stop nephrotoxic ddrugs: nsaids, nephro abx: gent, nitro, diuretic, acei/arb, metformin (lactic acidossis)
hypoglycaemia
bm <4 + conscious: glucojuice bottles <4 + confused: glucogel in gums/cheecks <4 + unconscious: iv dextrose 50ml 50-%, im glucagon: NOT if alcohol, malnutrition once conscious: sugar drinks, meal
overdose/poisoning
tictac system to identify pills discuss with toxicology b: anaesthetist if po2<8, rr<8, gcs<8 c: toxicology screen:urine, serum liaise w seniors, consider act charcoal, gastric lavage, haemofiltration, specific antidotes
benzodiazepine antidote
iv flumazenil
co antidote
100% o2, hyperbaric o2
bb antidote
iv atropine, iv glucagon/dextrose, cardiac pacing
ecg features: hyperkalaemia
tall t waves
small p waves
broad QRS
vent fib
SBO/LBO
IV fluid resus analgesia anti-emetic abx NG tube: bowel decomp VBG NBM surgeons to r/v E-CXR, abdo XR
