Emergencies Flashcards
Narrow Complex Tachycardia - with Adverse signs
O2, Iv access, 12-lead ecg
Expert help Sedation Up to 3 synchronised DC shocks Correct any electrolyte disturbances Amiodarone 300mg IV over 20 min, 900mg over 24 h via central line
Narrow Complex Tachycardia - No adverse signs - regular rhythm
O2,
IV access, 12 lead
Vagal manoeuvres (think about digoxin toxicity, ischaemia, carotid bruit)
If fail, give Adenosine 6mg bolus IV, then 12 mg if necessary.
Narrow Complex Tachycardia - No adverse signs - regular rhythmSinus rhythm not achieved by adenosine/verapamil
Possible Atrial Flutter
Seek expert help - possible rate control with beta-blocker
Narrow Complex Tachycardia - No adverse signs - regular rhythmSinus rhythm achieved
Probable paroxysmal re-entrant SVT
ASSESS ECG for WPW
if recurrent consider referall
Narrow Complex Tachycardia - No adverse signs - regular rhythm
Irregular
Probable AF
Anti-coagulate - warfarin or DOAC
Rate control - Beat blocker eg metoprolol 1-10mg IV
Rhythm control – if definitely under 48 or coagulated over 3 weeks consider DC cardioversion
Can cardiovert with Flecanide 300 mg PO or Amiodarone 300 mg IVI over 20-60 min
Function of adenosine in Narrow complex tachy
Transient AV block
Slows ventricles to show underlying atrial rhythm
can cardiovert junctional tachycardia to sinus rhythm
Broad complex tachycardia with adverse signs
Sedate
3x synchronised DC shock
Correct electrolyte disturbances
Amiodarone 300mg IV over 20 in, consider repeat shock then 900mg over 24hFurther cardioversion
Consider procainamide or overdrive pacing
Broad complex tachycardia without adverse signs - regular
If VT or uncertain rhythm - Amiodarone 300mg IV 20 min, then 900mg over 24 hrIf known SVT or BBB treat as narrow complex tachy (i.e. adenosine)
Broad complex tachycardia with adverse signs - irregular
Usually one of :
AF - with BBBP
re-excited AF - amiodarone
Polymorphic VT - Torsade de pointes - Mg 2g IVI
Broad complex tachycardia with adverse signs but cannot stabilise
Sedate
Synchronised DC shock
Bradycardia with Adverse signs
Atropine 500 mcg IV
Bradycardia with Adverse signs - no response to original therapy
repeat atropine every 3-5 mins (max mg)
Transcutaneous pacing
Isoprenaline 5 mcg/min
Adrenaline 2-10mcg/min
Bradycardia with risk of asystole
Atropine 500 mcg every 3-5 mins max 3mg
Transcutaneous pacing
Isoprenaline
Adrenaline
Management of Acute STEMI
12 lead ECG
O2
IV ACCESS - FBC, U&E, glucose, Lipids, Troponin
I/O - CVS disease, pulse, BP, JVP, murmurs, CI to PCI or fibrinolysis?
Aspirin 300mg
Ticagrelor 180mg (or alt. antiplatelet)
Morphine 10 mg plus anti-emetic like metoclopramide 10mg IV
Reperfusion therap
yBeta blocker if no HF/Asthma/BBB
Management of Acute STEMIwithin 120 min, already had aspirin
primary PCI
Management of Acute STEMI>120 min
Fibrinolysis - alteplase Ideally <30 min from admission
If not done within 12h or stemi, fonduparinux or enoxaparin
Anaphylaxis
A-Secure Airway
B-100% oxygen
Remove any known causeC-Raise feet to help restore circulation
Adrenaline IM 0.5mg (0.5mL 1:1000)Repeat every 5 min
Secure IV access
IVI 0.9% saline 500 mL over 15 mins
May need neb Salbutamol, hydrocortisone IV later
Tonsillitis
Infection of the palatine tonsils
pain, fever, dysphagia and cough
a frequency of more than 7 episodes per year for one year, 5 per year for 2 years, or 3 per year for 3 years, and for whom there is no other explanation for the recurrent symptoms), referral to an ear, nose, and throat specialist is advised as this cohort may benefit from tonsillectomy.
Quinsy
Comp of bacterial tonsillitis
deviating the uvula away
Trismus (difficulty fully opening the jaw), unilateral symptoms and a ‘hot potato’ voice
Admission,
IV abx, drainage
Epistaxis
Anterior or posterior plexus - 90% anterior (Little’s area)
Greater palantine artery in older
Epistaxis emergency management
A-E
Pinch cartilage, 20 mins
Cuaterise with silver nitrate
Pack nose anterior (rapid rhino) or posterior (foley catheter) depending on where bleed is - tamponades
may require surgical ligation
Emergency airway obstruction - causes
Cancers
Oropharyngeal
Laryngeal
Base of tongue
Infections
Epiglottitis
Deep neck space infections
Foreign body
Mostly seen in children
Emergency airway obstruction - red flags
Stridor/Stertor Cyanosis Agitation Respiratory distress Wheeze Decreased breath sounds on auscultation
Emergency airway obstruction - management
Call for help
Nebulised adrenaline/salbutamol
Intubation
tracheostomy
Emergency- epiglottitis
supraglottic tissue infection
Haemophilus
Influenza type B infection usually
Emergency - epiglottitisKey symptomsManagement
3 D’s are the key symptoms:
Drooling
Distressed
Dysphagia
IV abx
Laryngoscopy - lateral neck radiograph
O2,
Steroids - dex, 0.08-0.3 mg/kg/day
Asthma exacerbation - grading
Moderate - PEF 50-75%
Severe - PEF 33-50%, RR 25, HR 110, inability to complete sentences in one breath
Life-threatening - PEF <33%, SpO2 <92%, PaO2 <8 kPa, Normal PaCO2, Altered GCS, cyanosis, hypotension, arrythmia, silent chest, poor respiratory effort
Near fatal - raised PaCO2 or requirement of mechanical ventilation
Asthma exacerbation Management
Sit up 15L O2 Salbutamol neb 5 mg \+/- ipratropium 500 micrograms Prednisolone 40mg PO (or hydrocortisone 200 mg IV)
repeat 2.5mg Salbutamol every 10-15 min, reasses PEFR and sats reg
BIPAP in COPD
COnsider aminophyline 0.5-0.7 mg/kg/h
Mg sulfate 2g IV over 20 min
Croup symptoms
Barking cough
Inspiration stridor
Increased WOB
May have widespread wheeze
Croup treatment
0.3 mg/kg dex or 1mg/kg Pred
Vomiting? Budesone 2mg
AND nebulised adrenaline 0.5 ml/kg (max 5 ml) repeat every 5 min
Stevens-Johnsons syndrome - management
Cease medications, IV fluids, NG access
Flail chest
Multiple rib fractures with > or = 2 rib fractures in more than 2 ribs
Diaphragmatic rupture
CXR changes include non visible diaphragm, bowel loops in the hemithorax and displacement of the mediastinum. In most cases direct surgical repair is the best option.
Syringomyelia
Associated with Arnold-Chiari malformation - fluid filled cyst, expands over time
Buerger’s disease
Young male smoker with symptoms similar to limb ischaemia - inflammatory vasculitis
CREST syndrome
systemic sclerosis comprising calcinosis, Raynaud’s phenomenon, oesophageal dysmotility, sclerodactyly and telangiectasia. - CCB, Prostaglandins
Paediatric Sepsis 6
O2, fluids, ABx, IV access, inotrope support, senior clinician early
Pneumonia follow up
All cases of pneumonia should have a repeat chest X-ray at 6 weeks after clinical resolution
Hepatorenal syndrome mx
vasopressin analogues, for example terlipressin, have a growing evidence base supporting their use. They work by causing vasoconstriction of the splanchnic circulation
volume expansion with 20% albumin
transjugular intrahepatic portosystemic shunt
