Clinical Emergency Management Flashcards
Coma
A to E assessment IV access Stabilise the cervical spine - blocks and tape Blood glucose measurement Control seizures Treat causes - antidotes/IV glucose Investigations: - ABG, FBC< U&E, LFT, CRP, ethanol, toxicology, drug levels - Blood cultures, urine cultures - CXR, CT head
Sepsis
Life threatening organ dysfunction due to dysregulated host response to systemic infection
Within 1 hour:
SaO2 - high flow oxygen if low - target >94 or 88-92 in COPD
Blood cultures
ABG/VBG for serum lactate
U&E, CRP, FBC< LFT, clotting
Sputum/urine/swabs for MC&S, consider LP - check RICP, joint aspirate, ascitic tap
Urine output/cathetetrisaion
IV fluid challenge - 500ml 0.9% saline over 15 minutes
Antibiotics - broad spectrum - refer to guidelines
Septic screen Sputum/urine/swab cultures LP CXR Joint aspirate Drains/lines
Inform critical care: intropes, ventilation, haemofiltrate, intensive monitoring
Anaphylactic shock
Type 1 IgE hypersensitvity reaction
Secure airway - intubate if respiratoyr obstruction imminent
100% O2
Remove cause
Raise legs
IM adrenaline 0.5mg (0.5ml of 1:1000)
Repeat ever 5 minutes
Secure IV access
Chlorphenamine 10mg IV
Hydrocortisone 200mg IV
IV infusion (0.9% saline 500ml over 15 minutes) up to 2L titrated against BP
Wheeze - treat for asthma with nebulisers
Ventilatory support
Admission to ICU and IV adrenaline 0.5ml of 1:10000 if severe
Then: Admit to ward ECG monitoring Serum tryptase Continue chlorphenamine PO if itching MedicAlert bracelet with allergen Self infection with Epipen 0.3mg Skin prick tests
Acute STEMI
ECG monitor 12 lead ECG IV access Bloods: - FBC, U&E, glucose, lipids, troponin Assessment: CVS disease, risk factors, cardiac assessment CI to PCI/fibrinolysis
Aspirin 300mg PO Ticagrelor 180mg PO or clopidogrel 300mg Morphine 5-10mg IV + anti-emetic Metoclopramide 10mg IV GTN if hypertensive 100% 15L Oxygen if SaO2 <95%
PCI available within 120mins:
Primary Percutaneous Coronary Intervention - Coronary angiography with stent placement
If PCI not available in 120mins
Fibrinolysis (tissue plasminogen activator)
Transfer to primary PCI centre for rescue PCI or angiography
CI: Previous intracranial haemorrhage Ischaemic stroke < 6m GI bleeding < 1m Known bleeding disorder Cerebral malignancy Recent major trauma/surgery Aortic dissection
Cardioprotection:
Antiplatelets: aspiring + clopidogrel for 12m
PPi for gsatroprotection
Beta blocker - bisoprolol
ACE-inhibitor if HTN, LV dysfunction, diabetes
High dose statin - atorvastatin
Echo to assess LV function
Consider CABG if multi-vessel disease
Driving: 1 wk after successful angioplasty
4 wk after ACS without angioplasty
Cardiac Chest Pain
Record ECG
SaO2< 90% or breathless low-flo O2
Analgesia: morphine 5-10mg IV + metoclopramide 10mg IV
Nitrates: GTN Spray or sublingual tablet PRN
Aspirin 300mg PO followed by 75mg /day
Measure troponin and clinical parameters to calculate GRACE score
If rise in troponin, dynamic ST/T wave changes, diabetes, CKD, LVEF<40%, angina, recent PCI, prior CABG:
Fondaparinux 2.5mg OD or LMWH SC Second antiplatelet - ticarelor180mg PO IV nitrate if pain continues Oral beta blocker - biosprolol Prompt cardiologist review for angiography
Pulmonary Oedema
Sit paitent upright hgih flow oxygen if SaO2 if low IV access ECG monitoring Ix while managing Diamorphine IV slowly Furosemide 40mg IV slowly GTN spray 2 puffs SL
If worsening:
Nitrate infusion
Consider CPAP
If BP < 100 treat as cardiogenic shock - refer to ICU
Ix: CXR - ABCDE - alveolar oedema, Kerley B lines, Cardiomegaly, Diversons of upper lobe, Effusions ECG U&E TRopning ABG Echo BNP
Further Mx Change to oral furosemide ACE inhibitor Beta-blocker Spironolactone
Cardiogenic shock
Oxygen - titrate to maintain arterial saturations of 94-98 (88-92)
Diamorphine 1.25-5mg IV for pain/anxiety
Correct arrhthmia, U&E abnormalities, acid/base balance
Optimise filling pressure:
Plasma expander
Inotropic support
CT horax for aortic dissection and PE
Cardiac tamponade
Hypotension, Raised JVP, muffled heart sounds (Beck’s triad)
Raised JVP on inspiration (Kussmaul’s sign)
Pulsus paradoxus (pulse fades on inspiration)
Senior support
Pericardiocentesis
Broad complex tachycardia
DDx:
Ventricular tachycardia (torsade de pointes)
SVT - AF or flutter with BBB
Pre-excisted tachycardia - WPW,
If haemodynamically unstable VT:
Synchronised DC shock
Correct hypokalaemia, hypomagnaesaemia
Then amiodarone 300mg IV
If haemodynamically stable VT:
Correct hypokalaemia
Amimodarone 300mg IV via cnetral line
Narro Complex Tachycardia
DDx:
Sinus tachycardia
Atrial tachyarhythmias - AF, Atrial flutter, atrail tachycardia
Junctional tachycardia
If regular rhythm:
Continuous ECG tract
Vagal manoeuvres (carotid sinus massage, Valsava manoeuver) - transiently increase AV block
Adenosine 6mg IV then 12mg - followed by 0.9% saline flush
— warn about transient chest tightness, dyspnoea, headache, flushing
If sinus rhythm achieved - probably proxysmal re-entrant SVT
If not, possible atrial flutter - control rate with beta-blocker
If irregular rhythm: AF Control rate: Beta-blocker IV Verapamil - rate-limiting Ca blocker Digoxin Amiodarone Anticoagulation with warfarin or DOAC to reduce stroke risk
Bradycardia
O2 if hypoxic
ECG monitoring
IV access
Identify reversible causes - electrolytes
If shocked/syncope/MI:
Give atropine 500mcg IV Repeat every 3-5 mins if necessary Transcutaneous pacing Adrenaline IV Seek expert help and arrange transvenous pacing
Asthma
Severe: Unable to complete sentences Resp rate >= 25/min Pulse rate >= 110bpm PEF 33-50% of best
Life threatening: PEF < 33% best Silent chest Cyanosis Arrhythmia Hypotension Exhaustion Hypoxia < 92%
O2 - SaO2 94-98
Warn ICU
Salbutamol 5mg (or terbutaline 10mg) nebulised with O2
IF severe/LT add in Ipratropium nebuliser
Hydrocortisone 100mg IV or prednisolong 50mg PO
Reassess every 15 minutes
If PEF < 75% repeat salbutamol nebs every 15 min or 10mg/h continuously
Monitor ECG
Consider sigle dose of MgSO4 IV
If not improving: ICU for ventilatory support and aminophylline/IV salbutamol (PEF worsening Hypoxia Hypercapnia Acidosis Exhaustion Respiratory arrest)
IF improving
Continue nebulised salbutamol every 4-6h
Prednisolong PO for 5 days
Monito PEFR and O2 sats
Acute exacerbation of COPD
Nebulised salbutamol
Nebulised ipratropium
CXR ABG
Controlled oxygen therapy if SaO2 < 88%
Start at 24% O2 venturi mask
Adjust acccording to ABG PO2>8kPa
Steroids
IV hydrocortisone 200mg
ORal pregnisolong 30mg OD
Antibiotics if evidence of infection
Amox + clari/dox
Physiotherapy to aid sputum expectoriation
IV aminophylline if no response
NIV Positive pressure ventilation if RR> 30 or acidosis
Intubation and ventilation if pH > 7.26
Pneumothorax
Primary:
SOB and/or rim of air >2cm (at level of hilum) on CXR?
N - discharge and outpatient review in 2-4 weeks
Y - Aspiration, if unsuccessful insert chest drain
Secondary pneumothorax (underlying lung disease or smoker > 50 years old)
SOB or rim of air > 2cm on CXR?
N - 1-2cm - aspirate (chest drain if unsuccessful) and admit for 24h obs and O2, <1cm admit for 24h
Y - chest drain
Retyoumove chest drain 24h after lung has reexpanded
Tension pneumothroax
Air is drawn into the pleural space with each inspiration and has no escape during expiration
Mediastinal shift onto contralateral hemithorax, compression of the great veins
Respiratory distress Tachycardia Hypotension Distended neck veins TRacheal deviation away from pneumothorax Hyper-resonant percussion Reduced breath sounds
Remove air with large bore (14-16G) needle with syringe partially filled with 0.9% saline into second intercostal space in midclavidular line (sternal angle)
REmove plunger to allow trapped air to bubble through the syringe
Place a chest drain Safe triangle: posterior to pec major anteiror to lat dorsi superior to horizontal level of nipple
Pneumonia
Treat hypoxia with O2
Treat hypotension/shock from infection
Assess for dehydration
Consider IV fluid support
Investigations: CURB-65 score - Confusion (AMT<8), Urea >7, RR>=30. BP<90/60, Age 65+ 2+ - hospitalise 3+ ICU BEST FBC, U&E, LFT, CRP Blood culture Suptum culture Viral thraot swab Pleural fluid aspiration CXR Bronchoscopy/bronchoalveolar lavage if immunocompormised/ICU
Antibiotics:
Analgesia for pleuritic chest pain
oxygenation if not improving
NIV or invasive ventilation if hypercapnic
Pulmonary embolism
Wells score
Risk factors:
Malignancy, surgery, immobility, pregnancy, COCP, HRT, previous VTE, thrombophilia
CF: Acute dyspnoea Pleuritic chest pain Haemoptysis Syncope Hypotension Tachycardia Raised JVP Pleural rup Tachypnoea RV heave
Ix:
D-dimer for excluding in low probabliity patient - low specificity
FBC, U&E, baseline clotting
ECG: sinus tachycardia, RV strain, RAD, RBBB, S1Q3T3
CTPA - gold standard in high risk patients and low risk patients with a positive D-dimer
VQ scan if unavailable
PE Mx
Oxygen
Morphine 5-10mg IV with anti-emetic metaclopramide 10mg IV
IV access and start LMWH/fondaparinux
If hypotensive give 500ml IV fluid bolus
ICU input
If haemodynamically unstable consider thrombolysis - alteplase 10 IV
If stable, consider vasopressors
Initiate log term anticoagulation Warfarin (with heparin cover until INR > 2) DOAC If provoked - 3m If unprovoked 3-6m Long term if malignancy or recurrent
Upper GI bleed
Causes: Peptic ulcer disease Gastroduodenal erosions Oesphagitis Mallory Weiss tear Varices Malignancy
Signs/symptoms:
Haematemesis, dizziness, fainting, abdo pain, hypotension, tachycardia, low JVP, reduced urine output, shocked
Calculate Rockall score or Glasgow-Blatchford Score to predict severity
Protect airway and NBM
2 large bore cannulae
Bloods: FBC, U&E, LFT,, glucose, clorring, crossmatch 4-6 units
IV infusion up to 1L
If shocked: give blood group specific or O Rh-ve blood until crossmatch done
Continue IV fluids to maintain BP and transfuse if Hb<70
Correct clotting, - vitamin K, FFP, platelet concentrate
If risk of varices, give terlipressin IV and broad spectrum IV abx
Catheterise and monitor urine output
Monitor vital signs every 15min until stable
Notify surgeons
Urgent endoscopy for diagnosis and control of bleeding after resuscitation
Meningitis
If in primary care - benpen IV/IM before admitting
IV fluid resus
Check and correct blood glucose
IF septicaemic - shock and evolving non-blanching rash: Get ICU help Blood cultures IV antibiotics Airway support/intubation Fluid resuscitation delay LP until stable
If not septicaemic
Meningitic - neck stiffness, photophobia without shock
Take blood cultures
If signs of RICP/brain shift - papilloedema, seziures, focal neurology, GCS 12
— Get ICU help:
IV abx, dexamethasone 10mg IV, airway support, fluids, delay LP, nurse at 30 degrees
If no RICP
— Get senior help
- perform LP within 1h
IV antibiotics - ceftriaxone (+amoxicillin in >60 or immunocompromised)
Dexamethasone 10mg IV
Monitoring:
Discuss abx with microbiology and adjust based on organism and local sensitivities
Isolate for 24h
Inform Public Health
Prophylaxis of household contacts, those who have kissed mouth - ciprofloxacin
LP:
Bacterial vs viral vs TB:
Appearance Cell Count Glucose Protein
Status epilepticus
Seizure lasting for > 30 minutes or repeated seziures without intervening consciousness
Call for anaesthetist
Open and secure the airway
Oxygen 100% and suction as required
IV access and take blood:
FBC U&E LFT Glucose Calcium
Toxicology screen if indicated
Anticonvulsant levels
IV lorazepam 4mg
2nd dose if no response after 10 mins
Buccal midazolam when no IV access 10mg
Thiamine 250mg IV over 30 mins if alcoholism or malnourishement suspected
Glucose 50ml 50% IV unless glucose known to be normal
Correct hypotension with IV fluids
IV infusion:
If seizures continue, start phenytoin IVI
Monitor ECG and BP
Seek ICU help
If seizures continue after 60 min, general anaesthesia (propofol) and ventilation with continuous EEG monitoring in ICU
Dexamethasone 10mg IV if cerebral oedema or tumour possible
Assess cause: Hypoglycaemia Pregnancy Alcohol Drugs CNS lesion Infection Hypertensive encephalopathy Inadequate anticonvulsant dose or compliance
Investigations: Glucose ABG FBC, U&E, LFT, Calcium Anticonvulsant levels Toxicology screen LP Culture blood, urine EEG CT head SaO2 ECG
Head injury
Ensure the patency of the airway, effective breathing and adquate tisssue perfusion
If GCS 8 of less seek urgent anaesthetic and ICU help for intubation and ventilation
Oxygen if SaO2 < 92 or hypoxic on ABG
Intubate and hypeventilate if necessary
Immobilise neck until cervical spine injury is excluded
Stop blood loss and support circulation
Treat seizures with lorazepan ± phenytoin
Rapid examination survey
Involve neurosurgeons early
Ix:
FBC, U&E, glucose, alcohol, toxicology screen, ABG, clotting
Neurological examination
Assess anterograde amnesia and retrograde amnesia
Brief history
Evaluate lacerations of face or scalp
Check for CSF leak - rhinorrhoea, otorrhoea, blood behind ear drum
- if present basilar skull fracture - do CT, give tetanus toxoid and refer immediately to neurosurgery
Radiology:
Cervical spine x-ray/CT neck
CT head/neck Perform <1h if: GCS<13 Focal neurological deficit Suspected open/depressed skull fracture/basal periorbital ecchymoses Post-traumatic seizure Vomiting more than once
Post-operative bleeding
Reactive bleeding - within 24 hours of operation
Secondary bleeding 7-10 days after operaiton - associated with wound infection
CF: Tachypnoea Tachycardia Hypotension clammy Cold peripheries Dizziness Confusion
Evidence of external bleedin Swelling - collection/haematoma Discolouration/bruising Tenderness Peritonism
Classify haemorrhagic shock I - < 750ml II - 750-1500ml III - 1500-2000ml IV - >2000ml
Call crash team if unconscious or unresponsive Prepare: Opreation note Patient notes Drug charts Obs charts
If visible bleeding - direct pressure to site ASAP
C:
Secure intravenous access
The gold standard is to insert 2 large bore cannulas for acutely unwell patients.
If your patient is going to need a blood transfusion they need minimum 18G cannulas so that the blood can run through quickly and without clotting.
Urgent blood transfusion
In moderate to severe post-op bleeds your patient might require blood replacement
Ask for the major haemorrhage guidelines and speak to a senior
Severe bleeding will require more than Packed Red Blood Cell replacement and your protocol will guide Platelet and Fresh Frozen Plasma replacement
Auto-transfusion
Positioning your patients with their legs up is a useful initial step whilst waiting for blood/fluids to be set up. This uses gravity to redistribute your patient’s own blood to their central organs and brain.
DKA
Ketoacidosis is alternate metabolic pathway in stavation states
CF:
Drowsiness, vomiting, dehydration abdominal pain
Triggers: infection, surgery, MI, pancreatitis, chemotherapy
Diagnosis:
1 Acidaemia VBG pH<7.3
2 Hyperglycaemia BM > 11
Ketonaemia >3
Ensure patent airway, effective breathing and adequate tissue perfusion
2 large bore (14/16G) cannulae
Start IV fluid 1L 0.9% saline over 1h
If shocked give 500ml bolus over 15mins and reassess
Repeat and involve ICU if not improving
Tests: VBG for pH, bicarbonate Bedside and labe glucose and ketones U&E FBC CRP CXR ECG
Insulin
Add 50 units of insulin to 50ml 0.9% saline
Infuse continuously at 0.1 unit/kg/h
Continue pateints’ regular long cting insulin at usual doses and times
Consider initiaiting long acting insulin in newly diagnosed T1DM
Aim for fall in ketones of 0.5/h or rise in bicarb of 3/h
Check bap BM and ketones hourly
Check VBG 2hrly
Continue fluids and assess need for potassium - insulin causes potassium to enter cell
Consider catheter and aim for 0.5/ml/kg/hr urine output
Consider NG tube if vomiting or drowsy
Start all on LMWH
Avoid hypoglycaemia
When glucose <14 start 10% glucose
Continue insulin until ketones <0.6 venous pH >7.3 and venous bicarb >15
Complications: Cerebral oedema Aspiration pneumonia Hypokalaemia Hypomagnaesaemia VTE
RICP
Ensure patent airway, effective breathing and adequate tissue perfusion
Correct hypotension
Treat seizures
Urgent neurosurgery if focal causes - haematoma (craniotomy or burr hole)
Elevate head of bed to 30 degrees
If intubated, hyperventilate to reduce CO2 - this causes cerebral vasodilation and reduces ICP
Osmotic agents e.g. mannitol can be useful but may lead to rebound ICP after prolonged use (12h)
Corticosteroids are not effective except for oedema surrounding tumours
Dexamethasone 10mg IV
Consider other measures - sedation, anti-epileptics
Restrict fluid to <1.5L/d
Monitor patient closely
Causes: Primary tumour/mets Head injury Haemorrhage Infection - menigitis, encphalitis, brain abscess Hydrocephalus Cerebral oedema Status epilepticus
CF: Headache Altered GCS Higstory fo trauma Pupil changes - constriction at first, later dilation Reduced visual acuity Papilloedema
Complication:
Herniation:
Uncal hernaiition - 3rd nerve palsy ipsilateral
Paracetamol poisoning
12g/24 tablets or 150mg/kg may be fatal
Signs/symptoms: None intially Vomiting ± RUQ pain Later: Jaundice, encephalopathy from liver damage ± AKI
Mx:
General measure
GI decontamination in those preseting <4h after overdose: give activated charcoal 1g/kg (max 50g)
Ix:
Glucose, U&E, LFT, INR, ABG, FBC, HCO3
Blood paracetamol level at 4h post-ingestion
If <10-12h since overdose, not vomiting, and plasma paracetamol is above the line on the graph, start acetylcysteine
If >8-24h and suspicion of large overdose (>7.5g) start acetylcysteine, stopping it if level below treatment line nad INR/ALT normal
If ingestion time is unknown or it is staggered or presenation is >15h from ingestion, treatment may still help - seek senior help
Acetylcysteine is given by IVI in 5% glucose over 15-60 min
Rash is a common side effect 0 give Chlorphenamine _ observe
Do not stop unless anaphylaxis reaction with shock, vomiting and wheeze
If acetylcysteine is unavailable, methionine PO
Next day do INR, U&E, LFT
If INR is rising, continue acetylcysteine until <1.4
If continued deterioration discuss with liver team
Consider referral to specialist liver unit - liver transplant (King’s)
Salicylate poisoning
Signs and symptoms:
Vomiting, dehydration, hyperventilation, tinnitus, vertigo, sweating
Patients present initially with respiratory alkalosis due to a direct stimulation of the central respiratory centres and then develop a metabolic alkalosis
Mx:
Correct dehydration
ECG monitoring
Activated charcoal in all <1h
Bloods:
Paracetamol and salicylate level
Glucose, U&E, LFT, INR, ABG, HCO3. FBC
Salicylate repeated after 2h due to continuing absorption
Monitor blood glucose
Urine
Check pH and consider catheterisation to monitor output and pH
Correct acidosis
Consider alkalinization of the urine with sodium bicarbonate IV
Dialysis - if AKI, heart failure, prulmonary or cerebral oedema
Contact nephrologist early
Thyrotoxic Storm
Severe hyperthermia, agitation, confusion, coma, tachycardia, AF, D&V, goitre, bruit, heart failure
Seek endocrinology advice
- Counteract peripheral effects of thyroid hormone
- Inhibit thyroid synthesis
- Treat systemic complications
- If no headway in 24h, throidectomy
IV access
Fluids
NG if vomiting
Take blood for T3, T4, TSH, cultures
Sedate if necessary (chlorpromazine IM)
Monitor BP
Give propanolol PO/IV if no CI and cardiac output OK
In asthma/poor cardiac output, ultra-short-acting beta-blockers (esmolol)
High dose digoxin to slow heart - give with cardiac monitoring
Antithyroid drugs:
Carbimazole PO or via NGT
After 4h give Lugol’s solution (aqueous iodine) to block thyroid
Hydrocortisone 100mg IV
or dexamethasone 2mg PO to prevent peripheral conversion of T4 to T3
Treat suspected infection
Adjust IV fluids as necessary
Cool with tepid sponging ± paracetamol
After 5d reduce carbimazole
After 10d stop propanolol and iodine
Addisonian Crisis
CF:
Shock
Known Addison’s with trigger such as pneumonia, trauma, surgery, missed medication
Long term steroid use who has forgotten about their tablets
Mx:
Bloods for cortisol and ACTH - straight to lab
U&E
Hydrocortisone 100mg IV stat IV fluid bolus to support BP Continue as necessary Monito BM for hypoglycaemia Blood, urine, sputum for culture Abx if infection
Glucose IV may be needed if hypoglycaemic
IV fluids to correct BP and U&E
Continue hydrocortisone
Change to oral steroids after 72h if in good condition
Fludrocortisone may be needed if cause is adrenal
Get endocrine help
Poisoning
ABC clear airway
Consider ventilation if RR<8/min
Treat shock
If unconscious, nurse semi-prone
Assess patient
History from patient, firends or family
Features from examination
Ix:
Bloods:
Glucose, U&E, LFT, INR, ABG, ECG, paracetamol, salicylate levels
Urine/serum toxicology
Empty stomach if appropriate - gastric lavage
Consider specific antidote or oral activated charcoal
Consider naloxone if reduced GCS and pin-point pupils
Consider Pabrinex and glucose if drowsy/confused
Get more info from Toxbase.org
Phone posions informaiton service
Monitor temperature, HR, BP and BM regularly
Keep on ECG monitor
Catheteris if bladder is distended or AKI is suspected
Psychiatric assessment:
Intentions at time - suicide, planned? Precautions against being found? Seek help? Final act (suicide note)?
Present intentions - still suicidal? Wish it had worked?
What problems led to act?
Psychiatric disorder - depression, alcoholism, personality disorder, schizophrenia
Patient resources - friends, family, work, personality
Referral to psychiatrist
Hypothermia
Core rectal temp < 35
A-E
Warm humidified O2
Ventilate if comatose or respiratory insufficiency
Remove we clothing
Slowly rewarm - risk of 0.5C/h
Blankets or active external warming
Rapid rewarming causes peripheral vasodilation and shock - monitor BP
Warm IVI
Cardiac monitor
Consider antibiotics to prevent pneumonia
Consider unrinary cather
What to do when you answer the bleep?
i) Ask for patient name, DOB, Hospital Number and location
ii) NEWS score –> Trend of the NEWS score
iii) Why is the patient in hospital?
iv) How long have they been in hospital
v) Who are they under the care of?
vi) What medications are they on? anything been added/changed recently?
vii) Have fluids and oxygen been perscribed?
viii) Ask nurse to —> Cannulate, ECG, Take bloods, Check catheter, flush catheter, check BM
ix) Im on my way –> can you get drug chart, patient notes, fluid chart and relevant investigations
