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
When should reperfusion therapy be carried out for ACS?
- STEMI → within 2hrs
-
NSTEMI or unstable angina
- haemodynamically unstable, arrhythmias or high ischaemic risk (eg. ongoing/recurrent pain, ongoing ECG changes) → ASAP!
- intermediate or high risk GRACE score → within 3 days
- low risk GRACE score → may be treated conservatively or investigated further as outpatient
What is the GRACE score?
- Measure of 6-month mortality
- > 6% → high risk
- 3-6 → intermediate risk
- < 3% → low risk
It takes into account age, HR, SBP, creatine and the presence of ST deviation, troponin, cardiac arrest or LVF
Percutaneous coronary intervention (PCI) is the gold standard.
Reperfusion therapy: What are indications for PCI?
Any ACS:
- STEMI (inc. any amount of ST elevated/new LBBB
- NSTEMI
- Unstable angina
Contraindication = significant comorbidities
Thrombolysis is rarely used now, only if PCI is unavailable within 2 hrs.
Reperfusion therapy: What are indications for thrombolysis?
STEMI with:
-
ST-elevation in two continous ECG leads
- > 1 mm in limb leads
- > 2 mm in chest leads
- OR new LBBB
- Many contraindications
Many contraindications related to bleeding risk. Examples: active internal bleeding, bleeding disorder, aortic dissection, stroke (haemorrhagic at any time or ischaemic < 6 months), surgery/trauma < 2 wks, hx of CNS bleed/aneurysm/neoplasm, GI bleed < 1 month
Other points for ACS short-term management
- All pts should have an echo to assess LV function
- Check electrolytes regularly and ensure pts are on cardiac monitoring while in hospital
- STEMI pts w/ complete revascularisation may be discharged after 2-3 days; low risk NSTEMI pts w/ complete revascularisation may be discharged within 24hrs
What is the long-term management of ACS?
- B-blocker (reduces myocardial demand - continue for 12m, or lifelong if LV systolic dysfunction)
- ACE inhibitor (prevents adverse cardiac remodelling)
- GTN spray PRN if required
- Aldosterone antagonist (eplerenone) if LV function < 40%
- CV risk reduction → aspirin (life) + clopidogrel/ticagrelor (12m); statin; BP control; lifestyle modifications/cardiac rehab + smoking cessation
What is the initial treatment for acute pulmonary oedema management?
- Loop diuretics → furosemide 40-80mg IV slowly
- Morphine (+antiemetic)→ used to cause venodilation + reduce preload
- Nitrates → GTN infusion if SBP > 110, or 2 puffs GTN
- Oxygen → high-flow
- Positioning → sit up
- Positive airway pressure → if hypoxic
Look for + treat any cause (eg. surgery for acute aortic/mitral regurg, PCI for ACS, arrhythmia management, BP management if hypertensive crisis, pericardiocentesis if tamponade). Inotropes +/- intra-aortic balloon pump in ICU if in cardiogenic shock (hypotension + overload)
What is the long-term treatment for heart failure?
- Treat cause where possible
- Core meds → ACEi/ARB, B-blocker, diuretic if periph oedema
- Other meds → spironolactone if unctonrolled w/ core treatments, ivabradine if in sinus rhythm > 70 bpm despite maximum 6-blocker dose
- Non-pharmacological treatments
- Cardiac resynchronisation therapy device → considered if QRS significantly prolonged
- Implantable cardioverter defibrilator → considered if risk of ventricular arrhythmias
