Emergencies Flashcards
What NEWS score is considered significant?
> ,5 in total
or
,3 in 1 domain
How do you assess the airway?
Protect c-spine if injury possible
Look inside mouth + remove objects/ dentures
Assess for signs of obstruction
○ Use wide-bore suction under direct vision if secretions are present
If vocalising, can assume airway 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 + percussion (equal?)
Start 15L O2 via a non-rebreather
Use a bag valve mask if there is poor or absent respiratory effort
Monitor SaO2 + RR
Check for tracheal deviation+ cyanosis
If NO respiratory effort –> CALL ARREST TEAM (2222)
○ Intubate + ventilate
If breathing is compromised, give 15L O2 through a non-rebreather mask
How do you assess circulation?
Look for pallor, cyanosis + distended neck veins (JVP)
Feel for central pulse (carotid/ femoral); rate + rhythm
Monitor defibrillator ECG + BP
Gain venous access + 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 O2 (15L through non-rebreather) Give IV fluids (bolus = 20 mL/kg) Take blood cultures Take lactate Monitor urine output Give BS abx
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?
2L Crystalloid
If this fails to resuscitate –> X-match
Give FFP + packed red cells (1:1) aiming for platelets > 100 + 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 4mg per 6h 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 + debrief
Outline the management of a ruptured AAA.
Fast bleep vascular surgery + anaesthetics Take patient straight to theatre Gain IV access Administer O- if necessary Keep SBP <100 mmHg
Outline the initial management of a STEMI.
Morphine 5-10mg IV (repeat after 5 mins if necessary)
Metoclopramide 10mg IV
Oxygen 15L via non-rebreather
Nitrates
Aspiring 300mg 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/h)
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 + observations
Repeat CXR
Switch to oral furosemide or bumetanide
ACE inhibitor if LVEF < 40%
Consider b-blocker + spironolactone
Consider biventricular pacing or transplantation
Consider digoxin + warfarin
Outline the management of broad complex tachycardia in a haemodynamically UNSTABLE patient.
- DC cardioversion
- Hypokalaemia + hypomagnesaemia
- Amiodarone 300mg IV over 10-20mins through a central line
- Procainamide + sotalol in refractory cases
Outline the management of broad complex tachycardia in haemodynamically STABLE patients.
Correct electrolyte abnormalities
Amiodarone 300mg 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 2g 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 12mg bolus
If unsuccessful –> after 2 mins give 12mg 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/ 8h PO or bisoprolol 2.5-5mg/day PO
Start anticoagulation with LMWH
NOTE: cardioversion is only recommended if it can be done within 48h of the onset of Sx
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 (b-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 5mg with oxygen
IV hydrocortisone 100mg (or PO pred 40-50mg)
If it worsens
- add ipratropium bromide nebuliser 0.5mg
- stat dose of magnesium sulphate 1.2-2g 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 4h
Prednisolone 40-50 mg OD for 5-7 days
Monitor PEFR + O2 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 Tx (e.g. IV aminophylline, IV salbutamol)
Outline the management of an infective exacerbation of COPD.
BRONCHODILATOR: nebulised salbutamol 5 mg/4h + nebulised ipratropium 0.5 mg/6h
OXYGEN: 24-28% via venturi aiming for 88-92%
STEROIDS: IV hydrocortisone 200mg (or PO prednisolone)
ABX: 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 + 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 (r/o 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/4h or morphine)
If worsening –> ITU (may need ERCP)
Outline the management of a primary pneumothorax.
No SOB + <2cm rim of air on CXR: consider discharge + repeat CXR in a few weeks
SOB + >2cm rim of air on CXR: aspiration
- if unsuccessful –> repeat aspiration
- if unsuccessful –> insert chest drain
Outline the management of a secondary pneumothorax.
No SOB, age <50y + <2 cm rim of air: aspiration
- if successful –> admit for 24h
- if unsuccessful –> insert chest drain
SOB, age >50y + >2 cm rim of air –> insert chest drain
Outline the management of tension pneumothorax.
Insert large-bore needle partially filled with saline into 2nd ICS MCL on side of suspected pneumothorax
Remove plunger to allow air to bubble through syringe
OR: into the safe triangle
Outline the management of PE in a stable patient.
Oxygen
Morphine 5-10mg IV with 10mg metaclopramide
SC tinzaparin 175 U/kg/24h (or UFH 10,000 IV bolus)
How does the systolic BP affect the management of PE?
SBP >90mmHg: Warfarin loading regimen (e.g. 5-10 mg warfarin PO)
SBP <90mmHg: IV colloid infusion + contact ICU
–> dobutamine 2.5-10 µg/kg/min IV
–> IV noradrenaline infusion
–> consider thrombolysis
Describe the ongoing management of PE after the immediate situation has been dealt with.
Reduce risk of recurrence (e.g. compression stockings)
LMWH should be continued with warfarin until INR > 2 for 24h or 5 days after starting warfarin (whichever is longest)
If obvious cause of VTE –> 3/12 warfarin
If no obvious cause of VTE –> continue for 3-6 months
How is a massive PE in a haemodynamically compromised patient treated?
10mg alteplase followed by 90mg infusion over 2h
What crucial blood tests should be requested in patients with an acute upper GI haemorrhage?
FBC G+S X-match 6 units blood Clotting screen LFT
Outline the immediate management of shocked patients with an acute upper GI bleed.
Protect airway + keep NBM
Insert 2 large-bore cannulae
Rapid IV crystalloid infusion up to 1L
If grade III-IV shock, give O- blood until X-match complete
Correct clotting anomalies (e.g. PCC, vitamin K)
Consider ICU referral for central venous line
Catheterise to monitor UO (aim > 30 mL/h)
Monitor vital signs
Notify surgeons
Endoscopy within 4h for variceal bleed + within 12-24h if unstable on admission
Outline the medical management of acute upper GI bleeds.
(Major ulcer bleeding and vatical bleeding)
Major ulcer: Omeprazole 80mg IV stat over 40-60 mins followed by 8 mg/h for 72h
Variceal: resuscitate then urgent endoscopy for banding or sclerotherapy + terlipressin 2mg SC QDS
NOTE: if large bleed, Sengstaken-Blakemore tube may be used to tamponade the bleed + lactulose may be given to reduce absorption of nitrogenous products
Outline the management of bacterial meningitis.
Sepsis 6
Cefotaxime 2g IV (add ampicillin 2 g/6h IV if immunocompromised or > 55y)
Call critical care team
If meningitis only: consider adding dexamethasone 4-10mg/ 6h IV
Outline the ongoing management of a patient with bacterial meningitis who has been stabilised.
Discuss antibiotic Tx with microbiology
Isolate in side-room for 24h
Treat contacts with ciprofloxacin 500mg PO
Which drug treatment is used for suspected encephalitis?
IV aciclovir (10mg/kg/ 8h IV)
How much insulin should be given to patients with DKA?
50 u actrapid in 50 mL of 0.9% saline
Infused continuously at 0.1 u/kg/ h
Aim for a fall in ketones of 0.5mmol/L/ h
OR rise in venous bicarb of 3mmol/L/ h with a fall in glucose of 3mmol/L/ h
NOTE: check VBG at 1h, 2h + 2 hourly thereafter
When should glucose be added to the infusion in DKA?
10% glucose at 125 mL/h alongside saline when glucose <14mmol/L
Outline the management of acute abdomen.
Gain IV access
Catheterise + place on fluid balance chart if hypotensive
Analgesia: 100mg diclofenac PR for renal pathology, or 5-10mg morphine IV for intra-abdominal pathology
Send blood sample for FBC, U+E, amylase, LFT, CRP + G+S
IV abx if indicated
NBM
Outline the management of stroke.
15 L/min O2 if low sats or SOB
NBM
100 mL/h 0.9% saline
Treat arrhythmias
Get exact timescale of Sx onset
Request urgent CT
Once haemorrhagic stroke ruled out: Aspirin 300mg STAT + thrombolyse with tPA if <80y + <4.5h or
>80y + <3h
Outline the treatment of hyperkalaemia.
10mL 10% calcium gluconate IV over 2 mins (repeat every 15 mins up to 5 doses)
10 IU Actrapid with 50 mL 50% dextrose IV over 10 mins
Consider 5 mg salbutamol nebuliser
Monitor ECG + have access to crash trolley
Check ABG for acidosis
How are pre-renal and post-renal causes of AKI treated?
Pre-renal: fluid resus with 0.9% saline (250-500mL bolus) followed by infusion of 20mL + last hour’s urine output
Post-renal: catheterise
NOTE: pulmonary oedema should be treated with furosemide IV
List the indications for dialysis in AKI.
Hyperkalaemia unreponsive to medical Tx in an oliguric patient
Pulmonary oedema unresponsive to medical Tx
Uraemia (e.g. encephalopathy)
Severe metabolic acidosis (pH < 7.2)
Outline the management of hypokalaemia.
Monitor U+E + ECG
40mmol/L KCl in 1L of 0.9% saline (unless oliguric –> insert catheter to ensure accurate assessment of UO)
Admit to ICU for insertion of central line if >10 mmol/ h needed
If MILD: oral K+ supplementation (SandoK)
Which investigations would be useful in a patient with hyponatraemia?
Hypovolaemic: low urine sodium
Euvolaemic: TFT, SST, plasma + urine osmolality
Hypervolaemic: low urine sodium
Outline the management of hyponatraemia.
Do NOT correct faster than 8-10mmol/L/ 24h
Hypovolaemic: 0.9% saline
Euvolaemic: fluid restriction
Outline the management of hypocalcaemia.
Mild + asymptomatic: monitor, consider vitamin D supplements + calcichew
Severe tetany: 10mL 10% calcium gluconate IV over 10 mins
Outline the management of hypercalcaemia.
Correct dehydration with 0.9% saline (3-6L in 24h with the first 1L going in over 1h)
Furosemide may be needed in elderly patients who are prone to pulmonary oedema
Insert catheter to monitor UO
IV bisphosphonate for bone pain (takes 1w to work)
Which investigations are important to order in patients with status epilepticus?
U+E FBC LFT Glucose Calcium Toxicology AED levels CT/MRI head
Outline the management of status epilepticus.
Secure airway (may need adjuncts)
STEP 1: Slow IV bolus of IV lorazepam 2-4mg
2nd dose if no response within 10 mins
Thiamine if alcoholism is suspected
Glucose 50mL 50% IV if hypoglycaemia is suspected
STEP 2: IV phenytoin infusion 15-20mg/kg at <50 mg/min
STEP 3: rapid sequence induction with thiopental + EEG monitoring
Outline the management of pneumonia.
Treat hypoxia + hypotension if necessary
Abx following local guidelines (e.g. CAP = coamoxiclav + clarithromycin; HAP = tazocin)
Analgesia if pleuritic chest pain
CPAP if no improvement
Which investigations should be requested in suspected pneumonia?
Bedside: O2 sats, ABG, sputum sample, urine sample (Legionella)
Bloods: FBC, U+E, CRP, atypical serology
Imaging: CXR
Which investigations would you request in a patient with delirium?
Bedside: glucose, ABG, ECG, urine dipstick
Bloods: FBC, U+E, LFTs, blood glucose, blood cultures
Imaging: CXR, CT/MRI
Outline the management of bradycardia.
Sit patient up (unless dizzy)
15 L/min O2 if hypoxic
Give 0.5mg atropine IV every 2-3 mins (max 6 doses)
If unsuccessful: isoprenaline 5 µg/min
If unsuccessful: adrenaline 2-10 µg/min
If unsuccessful: transcutaneous pacing
Outline the management of hyperosmolar hyperglycaemic state (HHS/HONK).
Rehydrate slowly with 0.9% saline over 48h (deficit is typically 110-220mL/kg)
Equated to 8-15L for 70kg adult
First 1L may be given quickly over 30 mins
Replace K+ when urine starts to flow
Use insulin sliding scale if glucose NOT falling by 5 mmol/L/h with rehydration
Keep glucose at 10-15 mmol/L for first 24h (avoid cerebral oedema)
If a nurse contacts you regarding a patient who has become unconscious, what should you tell them to do?
Check for respiratory effort/ pulse + begin CPR if absent
How should an Addisonian crisis be treated?
100mg hydrocortisone STAT
Followed by 100mg/ 8h hydrocortisone
NOTE: may need fludrocortisone, glucose + fluids
What are the components of a SOFA score?
RR BP GCS Liver (bilirubin) Coagulation (platelets) Renal (creatinine + urine output)
Sepsis = infection + increase of >,2 on SOFA
Outline the management of NSTEMI.
Give O2 if breathless or SaO2 < 90%
Morphine 5-10mg IV + antiemetic
Nitrates (GTN spray or sublingual)
Aspirin 300mg PO + second antiplatelet agent (clopidogrel, ticagrelor, prasugrel)
Oral b-blocker (e.g. metaprolol) if hypertensive/ tachycardic/ low LV function
Fondaparinux 2.5mg OD SC or LMWH 1mg/kg/12h SC
IV nitrate if pain continues
HIGH RISK PATIENT
- Features: rise in troponin, dynamic ST or T wave changes, RFs
- Begin infusion of tirofiban + refer for inpatient angiography (within 72h)
- Angiography may need to be within 24h if GRACE score >140
Which additional measures may be used during the A to E approach of a trauma patient?
Check for blood on the floor
Arrange FAST scan/ pelvic X-ray
For unstable pelvic fractures use a pelvic band to reduce blood loss
Outline the algorithm for the major haemorrhage protocol.
Take baseline blood samples (FBC, G+S, X-match, Clotting, fibrinogen)
If trauma <3h: give tranexamic acid (1g over 10 mins, then 1 g/ 8h infusion)
Limit use of O-negative blood + use group-specific blood ASAP
What is the definition of major haemorrhage?
Loss of >1 blood volume in 24h
Loss of 50% blood volume in 3h
Bleeding in excess of 150 mL/minute
Which extra parts of an A to E would you do in a patient with suspected spinal cord compression?
D: palpate for spinal tenderness + perform a lower limb neuro exaM to assess tone, power, reflexes + sensation
E: percuss bladder (urinary retention), perform DRE (tone + saddle anaesthesia); important to consider cauda equina as a differential
Outline the management of cord compression.
Ix: urgent MRI whole spine within 24h
Rx: dexamethasone 16mg PO
Discuss with neurosurgery
Definitive: RADIOTHERAPY or decompressive surgery
What must be done before a CTPA is performed in a patient with suspected PE?
Check renal function + ask about allergy to contrast
What must always be done before thrombolysing a patient?
Discuss with a senior
What is Cushing’s reflex?
Irregular breathing (Cheyne-Stokes)
HTN
Bradycardia
Who could angry patients be directed towards?
PALS
NOTE: always gain consent from the patient before discussing their care with a family member
What is the first step in managing a patient with VT?
Put out a peri-arrest call
What are the 4 Hs and 4 Ts of cardiac arrest?
Hypoxia Hypovolaemia Hypokalaemia/ hyperkalaemia Hypothermia Toxic Thromboembolic Tamponade Tension pneumothorax
Which medications should be continued after correction of VT?
Establish + treat the cause
Maintenance: amiodarone infusion for 12-24 hours followed by oral sotalol or amiodarone
How can recurrence of VT be prevented?
Ablation of arrhythmogenic area OR ICD
Outline the management of hypothermia.
Prepare crash trolley Confirm temperature with low-reading thermometer (PR) + check every 30 mins Set up ECG (bradycardia + J waves) Remove wet clothing Give warmed humidified oxygen Slowly rewarm at 0.5 degrees per hour CARDIAC MONITORING IS ESSENTIAL
What is the difference between the Glasgow Blatchford and Rockall scores?
Blatchford: used at first presentation
Rockall - used after intervention to determine risk of re-bleed/death
Which investigations are important to request in someone who has taken a paracetamol overdose?
Paracetamol levels (4h post-dose) LFTs Clotting studies U+E FBC Bone profile ABG (acidosis + lactate)
Outline the management of bowel obstruction.
IV 0.9% saline 5-10 mg morphine IV NBM NG tube aspiration Correct electrolyte imbalance Consider giving Abx if septic/ perforated (co-amoxiclav + gentamicin)
Outline the management of acute limb ischaemia.
URGENT open surgery + angioplasty
ALERT vascular surgeons
If embolic: surgical embolectomy or thrombolysis (tPA)
Anticoagulate with LMWH after either procedure + look for source of emboli (e.g. AF, aneurysms)
WARNING: post-op reperfusion injury can lead to compartment syndrome
Compartment syndrome is treated with fasciotomy
Very painful so patients should be given morphine
Who is part of the cardiac arrest team?
Medical team on call (Med reg, SHO, FY1) Anaesthetist Nurse Porters CCOT
What are some contraindications for NIV?
Pneumothorax
Drowsiness
For the treatment of hyperkalaemia, what do you mix the insulin in?
10U Actrapid in 100mL of 20% dextrose given over 30 mins
