Common ACUTE presentations treatments (ABCDE) Flashcards
PE with haemodynamic instability
Thrombolysis
Tension pneumothroax
Needle decompression 2nd intercostal space
mid-clavicular line
Pneumonia
CURB65 score
CXR - in intermediate or high-risk patients -> blood and sputum cultures, pneumococcal and legionella urinary antigen tests
CRP monitoring is recommend for admitted patients to help determine response to treatment
WHat makes up a CURB65 score
Confusion
Urea >7
Respiratory rate >30
Blood pressure <90 systolic
>65 yrs
Intensive care for those w/ score 3 or more
Cushing’s reflex - triad of:
Hypertension - widening pulse pressure
Bradycardia
Irregular breathing
Holding measure for increased intracranial pressure
Mannitol
Anaphylaxis - dose of adrenaline
0.5 ml/mg 1:1000 IM
How often should adrenaline be repeated
Every 5 minutes
Adult bradycardia treatment:
Atropine 500 mcg
Repeat up to 6 times (3mg total)
Bradycardia if atropine not working:
Isoprenaline - 5 mcg IV
Adrenaline IV 2-10 mcg
Transcutaneous pacing
If these don’t work - transvenous pacing
Adult tachycardia w/ pulse:
Amiodarone - 300 mg IV over 10-20 mins
900 mg IV over 24 hours
Indications for AMIODARONE in tachycardia
Three failed DC shocks in unstable pt.
Regular BROAD COMPLEX TACHYCARDIA
When to use Adenosine in SVT
When vagal manoeuvres fail
Adenosine dose
6 mg IV
12 mg IV
18 mg IV
4Hs - reversible causes of cardiac arrest
Hypovolaemia
Hypo/hyperkalaemia (electrolyte)
Hypothermia
Hypoxia
4Ts - reversible causes of cardiac arrest
Tension pneumothorax
Tamponade
Toxins
Thrombosis
Cardiac arrest adrenaline dose
10 ml 1:10000 Adrenaline IV every 3-5 minutes
Paediatric BLS algorithm
start with 5 rescue breaths
Then 15:2 at a rate of 100-120 BPM
Lactate level in shock
> 2.2
Pre-operative period: when to stop ACEi/ARBs
1 day before surgery
When to stop Warfarin before surgery:
5 days before surgery
When to stop LMWH before surgery
24 hours prior
Anti-platets drugs: when to stop before surgery
7 days before surgery
What to do for anticoagulation if pt. is high risk after stopping warfarin (5 days)
Bridge with LMWH
Acute heart failure management
Upright position
O2
Loop diuretics
Morphine - do not give routinely but if necessary
nitrates if concomitant cardiac ischaemia (contraindicated in hypotension)
Ventricular tachycardia Mx. in pt. stable vs. unstable pt.
If stable: Antiarrhythmics may be used
If unstable (hypotensive, chest pain, heart failure, syncope) immediate cardioversion is indicated
Pre-eclampsia tx.
Referral to secondary care
Oral Labetalol
(Nifedipine if asthmatic)
Delivery is definitive management -> timing is situation dependent
Acute asthma - Ix.
Clinical diagnosis
CXR to rule out infection and pneumothorax
ABGs - usually normal
Bloods and sputum cultures if evidence of infection
ACS investigations:
Bloods - FBC, UEs, LFTs, Mg, Ca, TROPONINS, Glucose, Coagulation profile, cross-match
O-
X - CXR (signs of heart failure)
E - ECG
S - specials = Coronary angiography
Acute LVF investigations:
Bloods - FBC, UEs, LFTs, Mg, Ca, TROPONINS, Glucose, Coagulation profile, cross-match, phosphate, lipids, BNP
O -
X- CXR (ABCDE) kerley b-lines, alveolar shadowing etc.
E - ECG
Special tests: Echocardiography, BNP
Ruptured AAA ix.
Bedside US if available
CT angiography
Gallstones Ix.
LFTs
Abdomonal USS
CT for surgical planning
CBD stone Mx.
IV hydration (prevent renal injury)
ERCP
Acute pancreatitis Mx.
Supportive
NBM
IV hydration - 1L/4 hours (Hartmann’s)
IV antibiotics only if infection/free air on AXR
May need ICU
Acute pancreatitis Ix.
Amylase/lipase
Abdominal USS (exclude other causes/ check for cause stones etc.)
CT if diagnostic uncertainty
LFTs derranged
Apache II/Glasgow scoring
Acute mesenteric ischaemia Ix.
VBG: Increased Lactate
Abdominal CT
Angiography
Renal colic Ix.
Urine dipstick
CT KUB
X-ray KUB
Renal colic Mx
Analgesia (IM Diclofenac)
<1 cm muscle relaxants
> 1 cm uteroscopy/ESWL
> 2 cm - in renal pelvis percutaneous nephrolithomtomy
Ectopic pregnancy Ix.
bHCG urine
bHCG serum
Transvaginal US
Ectopic pregnancy Mx.
Methotrexate if uncomplicated
Laparoscopic salpingectomy
Laparotomy
Anti-D prophylaxis
Ovarian cyst rupture/torsion Ix.
Transvaginal or trans abdominal USS
Pelvic inflammatory disease Ix.
Inflammatory markers raised
Gynaecological swabs
Pre-eclampsia Ix.
BP
Urine dipstick: Proteinuria, HELLP
Cardiotocography Fetal USS
Pre-eclampsia Mx.
Delivery is only definitive mx.
Labetalol for BP
Magnesium sulphate will prevent fits
Aspirin may be used for prevention
Suspected TIA/stroke Ix.
CT head
ECG
Carotid artery dopplers
Coagulation profile
CVA Mx.
Acute: Aspirin or thrombolysis/thrombectomy
Long term: clopidogrel + statin
BP control
Carotid endarterctomy if >50-70% stenosis (depending on criteria used)
Definitive investigation Aortic stenosis
Echocardiograph
Torsades de pointes Mx.
ABCD -
Magnesium sulphate
Ventricular tachycardia mx.
Amiodarone if haemodynamically stable
DC cardioversion if not
Atrial fibrillation mx. When to use rate
Rate control if >65 years w/ IHD and no Sx/not suitable for cardioversion
Rhythm control - AF.
When can this be used
Acute setting if clear onset <48 hours ago
Otherwise, pt. must undergo 4 weeks of therapeutic anticoagulation and rate control
Blood to consider in acute GI bleed
G&S crossmatch
FBC (Blood loss)
UEs (Increased urea in GI bleeds)
LFTs (varices risk)
Clotting (coagulopathy common in liver disease)
Glucose
Acute variceal bleed mx.
Terlipressin
Prophylactic IV antibiotics
Endoscopic intervention (variceal band ligation)
Non-variceal bleed mx.
IV PPI
Endoscopic intervention
Hypoglycaemia blood glucose level
<4
Hyperglycaemia blood glucose level
> 11
Normal capillary ketones
<0.6
Means of confirming diagnosis in suspected DKA
VBG
Capillary/URINE ketones (>3 mmol/L)
Glucose
Insulin infusion rate and type for DKA
IV FIXED RATE 0.1 unit/kg/hour insulin from 50 units human soluble rapid-acting in 50 ml saline
DKA - when capillary glucose is <14 mmol Mx.
Give 10% IV glucose at 125 ml/hour in addition to 0.9% saline
When should insulin be given in HHS
IF glucose is not falling with fluids alone or there is ketosis
HHS Insulin rate
0.05 units/kg/hour
Hypoglycaemia Mx. unconscious
200 ml 10% glucose or 100 ml 20% glucose IV
1mg IM GLUCAGON if no IV access
Hypoglycaemia Mx. conscious
Cannot swallow:
Can swallow:
Cannot swallow: 2 tubes 40% glucose gel around teeth
Can swallow: 15-20g fast acting carbohydrate plus long acting carbohydrate
Stroke scoring system
ROSIER score
Classifying life-threatening asthma severity mnemonic
33, 92 CHEST
33, 92 CHEST Mnemonic components
33 = PEFR <33% predicted
92 = Sats <92%
Cyanosis
Hypotension
Exhaustion
Silent chest
Tachycardia
Acute pulmonary oedema Mx.
POND
Position (sit up)
Oxygen (high-flow initially aim for 92-96%)
Nitrates (in SEVERE pulmonary oedema)
Diuretic if fluid overloaded (furosemide 40 mg IV)
Further interventions if POND unsuccessful for pulmonary oedema:
CPAP - if hypoxaemic despite above interventions
Inotropes +/- intra-aortic balloon pump in ICU if in cardiogenic shock (hypotension + overload)
Pulmonary oedema Ix.
B - baseline blood plus B-type Natriuretic peptide and Troponin PLUS ABG
O -
X- CXR
E - ECG and echocardiography
S - special tests = BNP, catheterise and implement strict fluid balance charting
Anaphylaxis: specific component to ask for in blood test
Mast cell tryptase
Pharmacological seizure management:
If seizure on going w/in
10 mins:
20 mins:
30 mins:
60 mins
10 mins: 4mg lorazepam IV or 10 mg DIAZEPAM PR
20 mins: repeat as above
30 mins: Phenytoin 20 mg/kg IV or Levetiracetam 40 mg/kg IV
60 mins: General anaesthesia in intensive care
