ED flows Flashcards
ACS
Asthma
after cont mx +Reassessment if mod or severe
use pEFR, ABG, RR, HR, O2 and auscultation
if improving continue, if not then call seniour an back to back nebs
seizure
POST SEIZURE MANAGEMENT
ABCDE Assessment
- Monitor Physical observations / GCS
ABG:
- pH/pO2/Lactate
Bloods:
- FBC/U&E/Magnesium / Calcium/LFT/CRP * Coagulation (if potential intracerebral bleed)
Consider toxicology screen (i.e. Tricyclic / Anti-depressants)
Anticonvulsant medication level (if taking these)
- Cultures (if potential infective cause) - Capillary glucose/VBG glucose (if diabetic / low BM)
Other Investigations (as appropriate):
- Lumbar Puncture
- CT Head * EEG
Review medications:
- Those likley to reduce seizure threshold e.g. Quinolones
- See BNF for further information
A to E approach
General Approach
How do they look?
“How do you feel?”
Look at obs eg overall trends, request ECG?
Airway
Speaking = patent
cyanosed/ accessory breathing muscles, see-saw breathing
check mouth : forceps to remove, not fingers
high flow oxygen and maintain airway;
headtilt/chinlift or jawthrust: consider adjuvent if breathing only clear in this position
Gurgling/Burbling?: turn head to side (gurgling/burbling) and suction
airway adjunct if compromised (try guardal first to see how unconscious, then nasopharyngeal, lubricate, 6 for female and 7 for male)
Give high flow 15l non -rebreath. If bag mask then hold right behind jaw, not under. 12/min or 1/5-6s)
anaphylaxis?
Breathing
Look/listen/feel for resp distress (sweat, accessory muscles, cyanosis)
RR (>25 may deteriate suddenly)- Count for 1m
assess depth and pattern, ueven expansion?
chest deformity? abdominal distension? raised jvp?
record sats and o2 levels (does not detect hypercapnea)
breath sounds (rattle (secretions not clearing), wheeze, stridor)
percussion
Auscultate (bronchiol breathing indicates consolidation)
position of trachea
chest wall crepitas
all critically ill get a non rebreath mask 15L/min
Can step down to Venturi 28% mask (4 L min-1) or a 24% Venturi mask (4 L min-1) initially in COPD and reassess
if depth of breathing inadequate use bag mask and call for specialist help
nebs can give 6 litres max but add 5l via nasal canula
Circulation
Temp
HR - count for 1 min (weak central= poor cardiac output, bounding = sepsis
BP
are they septic?
Quick cardio exam: temp, CRT, Pulse, heart sounds, oedema
Oliguria = sign of poor cardiac output
external/internal bleeding?
cannulate
IX; All get FBC, U&E, LFTs
Major harmorhage protocol = call blood bank or 2222 . . will need trained runner
then specific:
Sepsis: CRP, lactate, blood cultures
Haemorrhage or surgical emergency: Coagulation and cross-match
Acute coronary syndrome (ACS): Cardiac enzymes
Arrhythmia: Calcium, magnesium, phosphate, TFTs, coagulation
PE: D-dimer (depending on Well’s score)
Overdose: Toxicology screen
Electrolyte imbalance: Calcium, magnesium, phosphate
Ruptured ectopic: Coagulation, cross-match, ß-HCG levels
Anaphylaxis: Consider serial mast cell tryptase levels
ECG, Cathetarisation, bladder scan, pregnancy test, swabs/cultures?
3 lead ECG = red/right, lemon/left and green/spleen
Hyovolemic? - MC . . . IVF to all cool peripheries and tachicardic
Lay patient supine and raise legs if appropriate
Give 500ml bolus Hartmann’s solution/0.9% sodium chloride (warmed if available) over 15 mins
In heart failure: Give 250ml fluid as above; check the chest for crackles after each bolus as there is a risk of fluid overload and pulmonary oedema
Repeat up to 4 times (2000ml/1000ml), monitoring response
assess BP q5mins aiming for thir normal or >100
Stop and seek help if the patient has a negative response (e.g. increased chest crackles).
Seek senior help if the patient isn’t responding adequately to repeated boluses.
ACS : ECG,po aspirin 300mg, subliguial glyceryle trinitate spray/tablet, oxygen, morphine + antimimetic,
Disability
Consciousness;
repeart AVPU (alert, responds to voice, responds to pain, uresponsive)
assess pupils (pinpoint opioids, dilated = intracranial pathology of TCA overdose)
PEARL = pupils equal and reactive to light
Check for head injury while you are here
calculate GCS (<= 8 = anaethetist or crash team)
Movement: ‘squeeze my fingers
check drug chart (opioids, sedatives, anxiolytics and antihypertensives)
Causes of decreased consciousness:
Hypovolaemia
Hypoxia
Hypercapnia
Metabolic disturbance (hypoglycaemia)
Seizure
Raised intracranial pressure/other neurological insults
Drug overdose
Iatrogenic causes (e.g. administration of opiates for pain relief)
DIABETES Blood glucose (4.0-11.0 mmols/L)
check ketones if >15
<4 give 50ml 10% dextrose - give every minute till 250ml if no response
urine dipstic?
imaging?
Exposure
Any pain?
Bleeding? - rate/ amount .. . . ax for shock
rashes? coagulopathy/infection
calves - red swollen dvt?
Lines - any concerning?
Cathetar- puss or blood?
surgical wound?
drains- pus? blood? high/low output?
Reasses . . . who can help?
Full hx from pt or collateral
r/v notes - esp vital signs and meds
lap results?
What care? HDU? ICU?
Notes and SBAR handover
keep realtivesinformed
AKI Guidelines
Prevention
At risk = elderly, diabetic, hypotensive and septic pt
Keep well hydrated
Recognition
Cr = 1.5x baseline
1 = Increase 1.5-1.9x baseline or < 0.5ml/kg/h for >6 consecutive hours
2 = Increase 2.0-2.9x baselinem or < 0.5ml/kg/h for >12 consecutive hours
3 = Increase > 3x baseline or >354 µmol/L or < 0.3ml/kg/h for > 24h or anuric for 12h
clarify what type and reasoning
presence or absence of immune sx (rashe, new arthritis, nasal crusting/bleeding, haemoptysis, bew deafness, mouth ulcers, alopecia, iritis/episcleritis, mononeuritis or neuropathy)
Obstructive sx? FUD, poor stream, hesitancy,, nocturia, PV bleeding, stones
Examination and Observations
Fluid status exam (inc autoimmune)
Urine Dipstick (all AKI, non dialysis CKD, DVT &PE , oedematous pt and suspected UTI)
fluid input/output (cathetarise if this is hard)
send MSU if urinalysis abnormal
send urine protein creatinine ration if protein >2+
Investigations
daily U&Es, bone profile and bicarbonate until fxn improving
autoimmune screen if glommerulonephritis/vasculitis suspected
urine sodium if oliguric (<20 implies pre-renal)
Renal US:
- urgent if >3x or > 400 or obstructions suspected
- non-urgent if 1.5-3x or suspected GN
- may not reed if recovering function or US in last 6 months
Management
Stop nephrotoxic drugs (NSAIDs, ACEi, ARB, pottassium sparing diuretics)
Diuretics should only be suspended if hypovolemic
Stop metformin if eGFR <30
optimise fluids
treat infection promptly
suspected vasculitis/ renal syndromes are a renal emergency (call nephrologist)
30% increase in Cr acceptable on starting RAAS inhibitor (ARBs/ACEi)
ABG interpretation
Normal Ranges
pH: 7.35 – 7.45
PaCO2: 4.7 – 6.0 kPa || 35.2 – 45 mmHg
PaO2: 11 – 13 kPa || 82.5 – 97.5 mmHg
HCO3–: 22 – 26 mEq/L
Base excess (BE): -2 to +2 mmol/L
Hypoxic?
<10 kPa on air = hypoxaemic
<8 kPa on air = severely hypoxaemic
Type 1 or 2?
Type 1 respiratory failure involves hypoxaemia (PaO2 <8 kPa) with normocapnia (PaCO2 <6.0 kPa).
V/Q (ventilation/perfusion) mismatch>hypoxia + hypercapnaei > increased RR then blows off CO2
causes: alveolar hypoventilation (pneumonia, ARDS, pulmonary oedema), distribution/diffusion) (pulmonary fibrosis), perfusion (pulmonary embolism)
Type 2 respiratory failure involves hypoxaemia (PaO2 <8 kPa) with hypercapnia (PaCO2 >6.0 kPa).
Alveolar hypoventilation:
Central (coma, intracerebral haemorhage), Neuromuscular (muscular dystrophy), obstruction (COPD/ Asthma), restriction (pulmonary fibroisis, pneumothorax)
-airway obstruction (COPD) -reduced compliance (pneumonia/rib fracturs/ obesity - reduced respiratory muscle strength (Guilian-barre/MND) -Drugs reducing resp rate (opiates)
pH?
Acidotic: pH <7.35
Normal: pH 7.35 – 7.45
Alkalotic: pH >7.45
imbalance in the CO2 (respiratory) or HCO3– (metabolic).
PaCO2?
Does it correlate or not>
Bicarbonate?
Does this correlate?
(Base Excess)
High base excess = > +2mmol/L = high HCO3- = primary metabolic alkalosis or compensated respiratory alkalosis
Low base excess = < -2mmol/L = low HCO3- =
primary metabolic acidosis or compensated respiratory alkalosis
respiratory compensation is quicker than metabolic (days)
Compensation?
Assess compared to primary disturbance
Anion Gap?
Normal = 4-12 mmol/L
Anion gap formula: Anion gap = Na+ – (Cl- + HCO3-)
An increased anion gap indicates increased acid production or ingestion:
Diabetic ketoacidosis (↑ production)
Lactic acidosis (↑ production)
Aspirin overdose (ingestion of acid)
A decreased anion gap indicates decreased acid excretion or loss of HCO3–:
Gastrointestinal loss of HCO3– (e.g. diarrhoea, ileostomy, proximal colostomy)
Renal tubular acidosis (retaining H+)
Addison’s disease (retaining H+)
Mixed acidosis/alkalsosis
CO2 and HCO3- will be moving in oppositie directions
tx each primary acid/base disturbance
Context
A ‘normal’ PaO2 in a patient on high flow oxygen: this is abnormal as you would expect the patient to have a PaO2 well above the normal range with this level of oxygen therapy.
A ‘normal’ PaCO2 in a hypoxic asthmatic patient: a sign they are tiring and need ITU intervention.
A ‘very low’ PaO2 in a patient who looks completely well, is not short of breath and has normal O2 saturations: this is likely a venous sample.
ECG take 2
What it represents
P wave = depolorisation of atrial muscle
PR interval = time for electricle impulse to spread from atria to ventricles (3-5 small squares)
QRS = depolorisation of the ventricles (<3 squares)
ST segment = period when ventricles are completely activated
T wave = repolorisation of ventricular muscle
U wave = repolorisation of pappilary muscles (abnormal if after flattened T wave)
Context
note BP/HR consciouness when taking ECG
RRPWQST
RATE: 300, 150, 100, 75, 60, 50 (small = 4ms and large = 200ms
RHYTHM: regular = equal distance between QRS complexes
P WAVES: P wave before every QRS = sinus (impulse from SAN to ventricles) - no P = abnormal rhythm. >1 P = heart block (abnormal coduction to the ventricles)
WIDTH: QRS >3 squares = slow ventricle conduction (abnormal conduction or eronously starting in ventricular tissue)
Q WAVE: if QRS starts with deep downward deflection could be old MI
ST segment: should be level with baseline. elevated = MI and depressed = MC Ischaemia
T wave: normally upside down in VR and V1 .. in other leads could be ischamie or ventricular hyertrohy
QT interval: varies with heart rate, prolonged with some drugs (>12 small squares)
Calibration: 1 square wide and two high . . .. . should be included on every record (25mm/s)
AXIS
serves to alert of other pathology eg PE/ conudction abnormality
Normal = +ve I and II
Left leaving = positive in I and Negative in II
Right reaching = -ve in 1 and +ve in 2
90 degrees from isoelectric lead, see if +ve at +90 or -90
RAD ax Right ventricluar hypertrophy (2ary pulmoary conditions causeing right heart strain)
LAD ax wtih conduction abnormalities
V leads
V1,V2 look at right ventricle
V3/V4 look at septum
V5/V6 look at left ventricle
V leads QRS - first septal depolorisation from left to right (intial R wave in V1/V2 but q wave in V5/V6) then ventricular depolorisation
RS trasition point represents the position of interventricular septum (normal V3/V4), right ventricle hypertrophy pushes to V4/V5/V6
Reporting ECG
Always:
- rhythm
- conduction intervals
- cardiac axis
- description of QRS complexes
- description of ST segments and T waves
eg:
- Simus rhythm, rate 50bpm
- normal PR interval (100ms)
- Normal QRS complex duration (120ms)
- Normal Cardiac Axis
- Normal QRS complexes
- Normal T waves (inverted in VR is normal)
Setup
attache electrodes to correct limbs
ensure ggod elecrical contact
check the calibrationand speed settings
make patient comfortable and relaxed
Paeds Hx
Systems Review
Head – History of injury, headaches or infection?
Eyes – Visual acuity/glasses? History of injury, headaches or surgery?
Nervous system – Fits, faints, or funny turns? History of hearing concerns, seizures (febrile or afebrile), abnormal or impaired movements, tremors or change in behaviour? School performance? History of hyperactivity?
ENT – Earache, throat infections, snoring or noisy breathing (stridor)?
Chest – Cough, wheeze, breathing problems? Smokers in the family? Exposure to smoke?
Heart – Cyanosis, exercise tolerance, chest pain, fainting episodes? History of heart murmurs or rheumatic fever in the child or the family?
GIT – Vomiting, diarrhoea/constipation, abdominal pain? Rectal bleeding?
Genitourinary – Dysuria, frequency, wetting/accidents, toilet training?
Joints/Limbs – Gait, limb pain or swelling, other functional abnormalities?
Skin – General rashes? Birthmarks or unusual marks?
Pubertal development – Age of menarche?
HEEADSSS
Home and relationships
Who lives at home with you?
Do you have your own room?
Who do you get on with best and/or fight with most?
Who do you turn to when you’re feeling down?
Education and employment
Are you in school/college at the moment?
Which year are you in?
What do you like the best/least at school/college?
How are you doing at school?
What do you want to do when you finish?
Do you have friends at school?
How do you get along with others at school?
Do you work? How much?
Eating
Are you worried about your weight or body shape?
Have you noticed any change in your weight recently?
Have you been on a diet? Do you mind telling me, how?
Activities and hobbies
How do you spend your spare time?
What do you do to relax?
What kind of physical activities do you do?
Drugs, alcohol and tobacco
At this stage – reassure about confidentiality
Does anyone smoke at home?
Lots of people your age smoke. Have you been offered cigarettes? How many do you smoke each day?
Many people start drinking alcohol around your age. Have you tried or been offered alcohol? How much/how often?
Some young people use cannabis. Have you tried it? How much/how often?
What about other drugs, such as ecstasy and cocaine?
Sex and relationships
Are you seeing anyone at the moment?
Are they a boy or a girl?
Young people are often starting to develop intimate relationships? How have you handled that part of your relationship?
Have you ever had sex?
What contraception do you use?
Self-harm, depression and self-image
How is life going in general?
Are you worried about your weight?
What do you do when you feel stressed?
Do you ever feel sad and tearful?
Have you ever felt so sad that life isn’t worth living?
Do you think about hurting or killing yourself?
Have you ever tried to harm yourself?
Safety and abuse
Do you feel safe at school/at home?
Is anyone harming you?
Is anyone making you do things that you don’t want to?
Have you ever felt unsafe when you’re online or using your phone?
Falls History
PC
When (time and what they were doing)
Where (inside/outside)
What (before, during and after)
- Before: any warning/ dizziness/chest pain/ palpitations*
- During: LOC/incontinence/ tongue biting/ palor/ what hit the floor*
- After: Got up/ long lie/ how long till back to normal/ weakness/numbness/ speach/ confusion*
Why: why do you think? (trip/medication)
How: How many over the last month (seriousness of problem)
Sysyems Review (inc joint pain/muscle weakness)
PMH
Dhx
Beta-blockers (bradycardia)
Diabetic medications (hypoglycaemia)
Antihypertensives (hypotension)
Benzodiazepines (sedation)
Antibiotics (intercurrent infection)
SHx
Alcohol
Support at home: friends/family/.carers
Mobility: aids and when they are used
ICE
DDx
WOMAN PE, also strokes, vertigo
IX
Exams: AtoE (murmurs, stenosis, injuries, eyes and ears, , timed up and go test, BP)
Bedside: obs, sitting/standing BP, urine dip (infxn/abdo), ECG, cognitive screening, blood glucose
Bloods: FBC (infxn/anaemia), U&Es (hydration, electrolytes, abdo), LFTs (chronic alcohol), Bone profile (malignancy/over supplementation)
Imaging: CXR, CT Head, Echo(valvular)
Specialist: Tilt table test, epley, cardiac monitoring (48hr tape)
Management
Get your ears and eyes checked, good light, good shoes, review medication and reduce alchohol
1Gait
Physiotherapy
2Visual problems
Eye test and ensure wears glasses
3Hearing difficulties
Remove earwax
Hearing assessment
4Medications review
Reduce unnecessary medication
5Alcohol intake
Alcohol cessation advice
Alcohol service referral
6Cognitive impairment
Referral to a psychiatric team
7Postural hypotension
Review medication
Improve hydration
8Continence
Treat or rule out infections
Continence assessment
9Footwear
Ensure good fitting footwear
10Environmental hazards
Turn on lights
Take up rugs
COPD
HISTORY
-SOB
- Productive cough: White / Yellow-Green sputum
- Fevers: Infective v Non-infective
PMH:
Known COPD
Previous NIV or ICU
- Frequency of exacerbations or hospital admissions
Home nebulisers Home O₂
EXAMINATION
Physical observation: High RR / reduced SaO Temperture: Infective v Non-infective
- Auscultation: Wheeze/ Crackles / Decreased air entry
Sputum: White/Yellow-Green
INVESTIGATIONS
- Bloods: Raised CRP/WBC
ABG: Hypoxia / Raised CO₂/ Raised HCO,
- CXR: Hyperinflation/Clear/Consolidation
Stroke Basic Approach
<4 hours symptom onset?(think FAST, Rosier Score, BM)
- AtoE (ensure stable or take to resus), hx, time onset, neurological assessment,
- Fast +ve > Rosier +ve > bleep stroke team ?999 ambulance transfer
- In the meantime: NBM, 2 cannulas, stroke/tia bloods (fbc, u+e, glu, coag, lipids , G+S, ECG, no aspirin
> 4hrs, consider bm, fast, rosier and contact stroke for advice.
NIHSS (national institue of health and stroke score) - more in depth score predictive of outcomes
Image considerations are ROH specific (?avoid CT if going to send to Stroke anyway)
GI Bleed ROH mx
A to and oxygen
2 large bore cannulas : FBC, U+Es, LFRs, Clotting, VBG, crossmatch 6 units
arrange blood transfusion/ give crystalloid vs major haemorhage protocol
correct coagulopathy (plts > 50, vit/ffp, reverse anti-coags)
Varicell bleed + 2mg IV terlipressin, 4.5g pip-tazo, metoclopromide 10mg
escalate to med reg or GI consultant
discontinue NSAIDs, aspirin and antiplatelets
Epistaxis mx
apply pressure to soft part of nose, lean forward, ice pack to forehead or neck. only seek medical attention after 20 mins
Box 1: 1st Aid
Sit patient with upper body tilted
forward and mouth open. Pinch the soft
cartilaginous part of the nose firmly and
hold for 10-20 minutes
Box 2: History
Estimated blood loss/severity of bleeding
Recurrent bleeding?
History of trauma/surgery?
Symptoms of hypovolaemia
Symptoms of underlying causes of causes of
epistaxis
Past medical history
Drug history (esp anticoagulants)
1
st aid already received
Box 3: Cautery
Clear clots by blowing nose
Use topical LA spray with
vasoconstrictor
Wait 3-4 minutes
Identify bleeding point and lightly
apply silver nitrate stick for 3-10
seconds
Only cauterise one side of nasal
septum to avoid perforation
Avoid touching areas which do not
need treatment
Box 4: Nasal Packing
Ensure topical LA with vasoconstrictor
Wait 3-4 minutes
Insert nasal pack (eg rapid rhino) as per
manufacturers instructions
