Clinical Emergencies Flashcards
What are key differentials for shortness of breath?
- PE
- Pneumothorax
- Asthma / COPD
- Pneumonia
- Acute LVF
- ACS
What investigations should be carried out for breathlessness?
-
Bloods:
- FBC, CRP, U+Es
- D-dimer
- BNP
- Blood cultures
- ABG
- Orifice tests → sputum culture
- X-rays/imaging → CXR, CTPA
- ECG
What are key differentials for chest pain?
- ACS
- PE
- Aortic dissection
- Pneumonia
- Pneumothorax
Which investigations should be carried out for chest pain?
-
Bloods:
- FBC, CRP, U+Es
- Troponin (STAT + 12hrs)
-
X-rays/imaging:
- CXR
- CTPA
- CT angio
- ECG
What are key things to include for an asthma/COPD assessment?
- History → baseline, severity, exacerbation hx, ICU hx, normal PEFR, infective symptoms, inhaler compliance, home oxygen/nebs
- PEFR regularly (in asthma)
- Investigations:
- ABG (should suggest hyperventilation asthma; if hypoxic/hypercapnic, patient is tiring)
- CXR (exclude pneumothorax)
- Bloods (incl reg potassium monitoring)
How do you classify asthma severity?
- Life-threatening (PEFT < 33%): 33, 92 CHEST
- 33 → PEFR < 33% predicted
- 92 → sats < 92%
- C → cyanosis
- H → hypotension
- E → exhaustion
- S → silent chest
- T → tachycardia
- Severe (PEFR < 50%) → cannot complete sentences, RR > 25, HR > 110
- Moderate (PEFR < 75%)
- Mild (PEFR > 75%)
What is the treatment for acute asthma exacerbation?
- Oxygen → use oxygen-driven nebs
- Salbutamol 2.5-5mg neb → b2b nebs initially (5-10mg/hr)
- Hydrocortisone 100mg IV (or pred 40mg PO) → oral daily, IV 6hrly
- Ipratropium 500mcg neb → 6hrly (if severe/life-threatening)
- Theophylline: aminophylline infusion → usually in ICU (need daily level, U+Es, cardiac monitor)
- Magnesium sulphate 2g IV / 20 mins → one-off dose if poor response/severe/life-threatening (before theophylline)
- Escalate care (intubation + ventilation)
Give the first 4 all together and then give the latter 3 with senior input. If hypoxaemia/hypercapnia is worsening despite maximal therapy, involve senior/anaesthetist with a view to intubation and ventilation
How do you treat a COPD exacerbation?
- O SHIT as in asthma
- But give controlled oxygen → 24-28% (venturi), do regular ABGs to determine further O2 therapy
- Antibiotics → prescribe if any signs of infection as per local guidelines eg. doxycycline
- Chest physio
- Consider BiPAP → if cannot deliver enough O2 to maintain sats of 88-92%, without depressing their resp drive and causing a hypercapnic acidosis
If hypoxaemia/hypercapnia worsening despite max therapy, involve senior/anaesthetist with a view to intubation and ventilation
COPD/Asthma management: What are indications for ITU?
- Requiring ventilator support
- Worsening hypoxaemia/hypercapnia/acidosis
- Exhaustion
- Drowsiness/confusion
Which investigations need to be done for pulmonary embolism?
-
Confirm/exclude diagnosis
- D-dimer → if low PE Wells score
- CTPA (or v/q scan if contraindicated)
- Investigate severity
- ECG may show → tachycardia; RV strain (T-wave inversion in right precordial + inferior leads); RBBB; right axis dev; S1Q3T3; RA enlargement (P pulmonale); RV dilation (dominant R in V1)
- CXR may show → wedge infarcts; regional oligaemia; enlarged pulmonary artery; effusion
- Echo → look for right heart strain / overload
- Consider looking for cause if unknown
- Hereditary thrombophilia testing: if family history
- Anti-phospholipid antibodies: consider if relevant
- Investigate for occult malignancy w/ mammogram (if female + >40yrs) and/or CT abdo/pelvis (if >40yrs)
What is the treatment for PE?
PE Wells score predicts likelihood, takes account risk factors, symptoms of VTE and the likelihood of alternative diagnosis
PE: What are options for therapeutic anticoagulation?
- DOACs → More commonly used for anticoag. Rivaroxaban and apixaban have loading doses; edoxaban and dabigatran do not, and so require 5d of dual therapy w/ LMWH initially
- Warfarin → Usually used where DOACs are contraindicated (eg. renal impairment) or if reversibility is required. If using warfarin, continue LMWH until had >5 d dual therapy and is INR 2-3
- LMWH → Less preferable bc pt will have to give daily injections. Currently the only licensed treatment in cancer pts
When is thrombolysis indicated for PE?
- In massive PE: SBP <90 for >15mins, pulselessness or persistent bradycardia
- → immediate thrombolysis w/ alteplase
- In sub-massive PE: RV dysfunction, myocardial necrosis or large clot burden, eg. saddle PE
- → give unfractionated heparin infusion (usually for 72hrs) so thrombolysis can be considered
Follow the usual ABCDE approach for acute coronary syndrome.
What is the initial management for ACS?
- Morphine → 10mg in 10ml slow IV - titrate to pain (+10mg metoclopramide IV)
- Oxygen → only if sats < 94-98%
- Nitrates → sublingual GTN if not hypotensive (then PRN) - IV infusion can also be used
- Aspirin → 300mg PO loading dose (then 75mg OD)
- Clopidogrel → 300-600mg PO loading dose (then 75mg OD)
Short-term management of ACS: What are other medications to start following initial treatment?
In STEMI patients who should have immediate PCI, cardiologist will decide when to start these
- Statin
- B-blocker
- ACEi (start 6-24hrs after admission)
- ACS-dose anticoagulation (fondaparinux or LMWH or heparin) for 5d - NSTEMI only
- Glycoprotein IIb/IIa inhibitor - very select patients only
