Emergencies Flashcards
What NEWS score is considered significant?
5 or more in total or 3 or more in one domain
How do you assess the airway?
Protect cervical spine if an injury is possible
Look inside the mouth and remove objects/dentures
Assess for signs of obstruction
○ Use wide-bore suction under direct vision if secretions are present
If vocalising, can assume airway is patent
Listen for stridor, snoring or gurgling
Establish a patent airway using:
○ Manoeuvres (e.g. chin lift, jaw thrust)
○ Adjuncts (e.g. oropharyngeal airway (Guedel))
If airway still impaired –> CALL ARREST TEAM (2222)
How do you assess breathing?
Look for chest expansion (equal? Fogging of mask?)
Listen for air entry (equal?)
Feel for expansion and percussion (equal?)
Start 15 L oxygen via a non-rebreather
Use a bag valve mask if there is poor or absent respiratory effort
Monitor SaO2 and RR
Check for tracheal deviation and cyanosis
If NO respiratory effort –> CALL ARREST TEAM (2222)
○ Intubate and ventilate
If breathing is compromised, give 15 L oxygen through a non-rebreather mask
How do you assess circulation?
Look for pallor, cyanosis and distended neck veins (JVP)
Feel for central pulse (carotid/femoral) - rate and rhythm
Monitor defibrillator ECG and BP
Gain venous access and send bloods if time allows
12-lead ECG
Treat shock
If NO cardiac output –> CALL ARREST TEAM (2222)
How do you assess disability?
Consciousness (GCS/AVPU)
Pupils
Blood glucose
What are some common causes of peri-arrest?
Arrhythmia
MI
Hypovolaemia
Sepsis
Hypoglycaemia
Hypoxia
Pulmonary oedema
PE
Metabolic (hypo or hyperkalaemia)
Tension pneumothorax
What are the components of qSOFA?
RR > 22
GCS < 15
SBP < 100
What is the difference between severe sepsis and septic shock?
Severe sepsis: sepsis with evidence of organ hypoperfusion (e.g. hypoxaemia, oligaemia, confusion)
Septic shock: severe sepsis with hypotension despite adequate fluid resuscitation
What are the sepsis 6?
Give oxygen (15 L through non-rebreather)
Give IV fluids (bolus = 20 mL/kg)
Take blood cultures
Take lactate
Monitor urine output
Give broad-spectrum antibiotics
ALL WITHIN 1 HOUR
When should sepsis patients be escalated further?
SBP fails to reach > 90 mm Hg
Lactate remains > 4 mmol/L
How should haemorrhagic shock be managed?
2 L of crystalloid
If this fails to resuscitate –> X-match
Give FFP and packed red cells (1:1) aiming for platelets > 100 and fibrinogen > 1
Which medications are used in the management of anaphylaxis?
Adrenaline 0.5 mg IM (0.5 mL of 1:1000)
Repeat every 5 mins as necessary
Chlorphenamine 10 mg IV
Hydrocortisone 200 mg IV
IV fluid bolus if shocked
What should be done after the a patient with anaphylaxis has been stabilised?
Admit to ward
Monitor ECG
Continue chlorphenamine 4 mg per 6 hours PO if itching
Suggest MedicAlert bracelet
Prescribe autoejector
Consider skin-prick testing or specific IgE
Outline the management of aortic dissection.
Fast bleep cardiothoracic surgery
Transfer to ITU
Use hypotensives (e.g. labetalol) to maintain SBP 100-110
Document and debrief
Outline the management of a ruptured AAA.
Fast bleep vascular surgery and anaesthetics
Take the patient straight to theatre
Gain IV access
Administer O- if necessary
Keep SBP < 100 mm Hg
Outline the initial management of a STEMI.
Morphine 5-10 mg IV (repeat after 5 mins if necessary)
Metoclopramide 10 mg IV
Oxygen 15 L via non-rebreather
Nitrates
Aspiring 300 mg PO (with clopidogrel or ticagrelor)
What doses of second antiplatelet agents are used with aspirin in the prevention of atherothrombotic events in ACS?
Clopidogrel 300 mg followed by 75 mg
Ticagrelor 180 mg STAT followed by 90 mg BD
Which medications should patients who have had an MI take home?
Dual antiplatelet therapy (continue for 12 months)
GTN spray
Beta-blocker
ACE inhibitor
Statin
Outline the management of acute heart failure.
Diamorphine 1.25-5 mg IV (caution in liver failure or COPD)
Furosemide 40-80 mg IV
GTN spray 2 puffs sublingual (consider isosorbide mononitrate infusion 2-10 mg/hour)
What should be considered if a patient in acute heart failure deteriorates?
Further dose of 40-80 mg furosemide
Consider CPAP
Increase nitrate infusion
Refer to ITU
How should a patient with acute heart failure be managed once they have been stabilised?
Monitor daily weight and observations
Repeat CXR
Switch to oral furosemide or bumetanide
ACE inhibitor if LVEF < 40%
Consider beta-blocker and spironolactone
Consider biventricular pacing or transplantation
Consider digoxin and warfarin
Outline the management of broad complex tachycardia in a haemodynamically UNSTABLE patient.
- DC cardioversion
- Hypokalaemia and hypomagnesaemia
- Amiodarone 300 mg IV over 10-20 mins through a central line
- Procainamide and sotalol in refractory cases
Outline the management of broad complex tachycardia in haemodynamically STABLE patients.
Correct electrolyte abnormalities
Amiodarone 300 mg IV over 10-20 mins
If it fails –> DC cardioversion
NOTE: after correction of VT, patients should be given maintenance antiarrhythmic therapy (e.g. sotalol)
Outline the management of torsades des pointes.
Stop predisposing drugs (e.g. TCAs)
Correct hypokalaemia
Give magnesium sulphate 2 g over 10 mins
Outline the management of narrow complex tachycardia.
Vagal manoeuvres
Adenosine 6 mg IV bolus (followed by 0.9% saline flush)
If unsuccessful –> after 2 mins give 12 mg bolus
If unsuccessful –> after 2 mins give 12 mg bolus
Alternative: verapamil 2.5-5 mg over 2 mins
How should AF in an unstable patient be treated?
Emergency cardioversion
If unavailable –> IV amiodarone
Control ventricular rate: verapamil 40-120 mg/8 hrs PO or bisoprolol 2.5-5 mg/day PO
Start anticoagulation with LMWH
NOTE: cardioversion is only recommended if it can be done within 48 hours of the onset of symptoms
Which medications should patients with AF be given to take away?
Use CHADS-Vasc to calculate need for anticoagulation (1 or more requires warfarin)
Rate control (beta-blocker or CCB)
Rhythm control (flecainide if no structural heart disease, otherwise amiodarone)
Outline the investigations that you would request for a suspected acute asthma attack.
Bedside: PEFR, ECG, ABG, SaO2
Bloods: FBC, U&E
Imaging: CXR?
Outline the management of severe acute asthma.
Nebulised salbutamol 5 mg with oxygen
IV hydrocortisone 100 mg (or PO prednisolone 40-50 mg)
If it worsens
- add ipratropium bromide nebuliser 0.5 mg
- stat dose of magnesium sulphate 1.2-2 g IV over 20 mins
If a patient with a severe asthma is showing signs of improvement, how should they be cared for?
Nebulised salbutamol every 4 hours
Prednisolone 40-50 mg OD for 5-7 days
Monitor PEFR and oxygen saturations
How should a patient with life-threatening acute asthma be escalated if initial treatment fails to cause an improvement?
Refer to ICU
May need ventilatory support (e.g. intubation)
May need intensified treatment (e.g. IV aminophylline, IV salbutamol)
Outline the management of an infective exacerbation of COPD.
BRONCHODILATOR: nebulised salbutamol 5 mg/4 hr + nebulised ipratropium 0.5 mg/6 hr
OXYGEN: at 24-28% via venturi mask aiming for 88-92%
STEROIDS: IV hydrocortisone 200 mg (or oral prednisolone)
ANTIBIOTICS: trust guidelines (e.g. amoxicillin or doxycycline)
How should the treatment of a patient with an infective exacerbation of COPD be escalated if they fail to respond to initial treatment?
Consider IV aminophylline
Consider NIV
Consider intubation and ventilation
Consider respiratory stimulant (e.g. doxapram)
Which investigations may be useful in patients with acute pancreatitis?
Bedside: glucose
Bloods: amylase, lipase, FBC, U&E (calcium), LFTs, ABG, glucose
Imaging: USS, erect CXR, AXR (rule out other causes of acute abdomen), ERCP
Outline the management of acute pancreatitis.
Assess severity using Modified Glasgow Criteria
NBM
IV fluids to achieve normal vital signs (3rd spacing)
Insert catheter to monitor urine output
Analgesia (IM pethidine 75-100 mg/4 hr or morphine)
If worsening –> ITU (may need ERCP)
Outline the management of a primary pneumothorax.
No SOB + < 2 cm rim of air on CXR –> consider discharge and repeat CXR in a few weeks
SOB + > 2 cm rim of air on CXR –> aspiration
- if unsuccessful –> repeat aspiration
- if unsuccessful –> insert chest drain