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
