Emergencies Flashcards
Anteroseptal MI leads and artery?
V1-4, LAD
Antereolateral MI leads and artery?
V4-6, 1, AvL, LAD or left circumflex artery
Inferior MI leads and artery?
II, III, AvF
Lateral MI leads?
I, AvL, V5-6
Lateral MI artery involvement?
Left circumflex artery
Posterior MI ECG changes?
Tall R waves V1-2
What are the reversible heart attack causes?
Hypoxia, hypothermia, hypovolaemia, hypokalaemia
tension pneumothorax, thrombosis, tamponade, toxins
- Inferior MI mx arrythmia?
medical management (atropine; fatigue of AV nodal cells can be reversed)
- Anterior MI mx arrythmia?
temporary TC pacing permanent pacemaker
Dressler’s syndrome
(2-6 weeks), pericarditis (<48 hours)
S/S: fever, pleuritic pain, pericardial effusion, raised ESR
Mx: NSAIDs
- Complications of an MI
DARTH VADER:
Morphine dose in MI?
o Morphine (5-10mg IV; repeat after 5 minutes if needed) + metoclopramide (10mg IV)
Management of acute pulmonary oedema?
o (1) Sit them up high-flow O2 (if SpO2 decreased)
o (2) IV diamorphine (3mg) + IV metoclopramide (10mg) [caution in liver failure and COPD]
o (3) IV furosemide (40-80mg) [larger dose in renal failure]
o (4) SL GTN spray x2 [if SBP ≥100mmHg, use IV GTN] Ix: ECG ABG, BNP CXR
o (5) Further management:
Further furosemide [40-80mg]
Further nitrate infusion [maintain SBP ≥90, if it drops <100, treat as per cardiogenic shock]
CPAP
Safety borders for needle compression?
Base of axilla, 5th ICS, lateral edge of pectoris major, lateral edge of latissimus dorsi
Doses of drugs in asthma acute management?
5mg salbutamol
0.5mg ipatropium bromide
40-50mg PO prednisolone for 5 days
What to measure in suspected carbon monoxide poisoning?
Carboxyhaemoglobin
Mx of carbon monoxide poisoning
o 100% high-flow oxygen via a NRB mask (continuing for a minimum of six hours) target 100% SpO2
o Hyperbaric oxygen (limited evidence base)
Phaechromocytoma tx?
o 1st: short-acting alpha blockade long-acting alpha blockade phentolamine = phenoxybenzamine
o 2nd: beta blockade
o 3rd (delayed 4-6w) surgery (4-6 weeks after presentation to allow for full alpha blockade to occur)
Information about poisoning?
Toxbase
(haemodialysis indicated in overdoses of which drugs?
-Barbiturates
- Lithium
- Alcohol
- Salicylates
- Theophylline
Remember BLAST
Ix for suspected poisoning?
o All unconscious patient = glucose, paracetamol, salicylate levels (IN ALL POISONING)
o FBC, U&E, LFTs, INR; ABG; ECG
Mx of poisoning?
Activated charcoal > gastric lavage
Activated charcoal (50g every 4 hours, with water): reduces absorption of drug
* Indications: paracetamol, carbamazepine, dapsone, theophylline, quinine, phenobarbital
* CIs: alcohols, metal salts (lithium, iron), petroleum, corrosives, clofenotane, malathion
Gastric lavage: rarely used, if used after 30-60 minutes, may make matters worse
o Haemodialysis
o Antidotes (TOXBASE, Poisons Information Service)
o BDZ (i.e. diazepam, Z-drugs) reversing agent?
Flumazenil (if iatrogenic)
o Opiate (codeine, methadone, heroin) reversing agent?
Naloxone
o Paracetamol reversing agent?
N-acetylcysteine
o Aspirin reversing agent?
Sodium bicarbonate
o TCA (amytriptyline; w/ long QT/arrhythmia) reversing agent?
Sodium bicarbonate
o Beta blockers reversal agent?
Atropine (low HR), glucagon (low BP)
o Ethylene glycol (antifreeze) reversal agent?
Fomepizole
o Iron reversal agent?
Desferrioxamine
o Cyanide reversal agent?
100% O2 + sodium nitrite/thiosulphate
o Organophosphates (inactivate AChE) reversal agent?
Atropine
o Digoxin reversal agent?
Digifab (Digoxin-specific antibody)
Paracetamol overdose treatment
≤2 hour activated charcoal Ix: paracetamol level ≥4 hours after ingestion NAC if indicated
≥2 hour Ix: paracetamol level ≥4 hours after ingestion NAC if indicated
≥8 hours (+ ingested amount >75mg/kg) NAC Ix: paracetamol level
If ingestion time unknown or staggered overdose (taken over ≥1 hour) NAC
Transplant crtieria post-paracetamol overdose
Arterial pH <7.3, 24 hours after ingestion; OR
PT >100s (INR >6.5) AND creatinine >300mol/L AND grade 3 or 4 HE
S/S of salicylate overdose?
Specific Tinnitus, hyperventilation, vertigo
Non-specific vomiting, dehydration, sweating
o Dose-related response to salicylate overdose?
150mg/kg (mild); 250mg/kg (moderate); >500mg/kg (severe); >700mg/kg (fatal)
Mx of salicylate OD?
o ≤1 hour activated charcoal: further ix:
Bloods: paracetamol level, salicylate level, glucose, FBC, U&Es, LFTs, INR, clotting, ABG
Urine: catheterisation
Acidosis: if >500mg/L salicylate OR severe metabolic acidosis alkalinisation of urine (IV NaHCO3)
Dialysis: if >700mg/L salicylate OR AKI, HF, pulmonary/cerebral oedema, seizures, etc
Mx of hypopituirary coma?
o 1st Hydrocortisone
o 2nd T3
o 3rd prompt surgery (if cause is apoplexy)
Addison’s criteria?
o Initial management:
1st IM hydrocortisone (100mg, STAT)
2nd IV fluid bolus (0.9% saline, >90 SBP) ± glucose
o Continuing management:
IV fluids
IV/IM hydrocortisone (100mg/8h) PO dexamethasone after 72 hours (consider fludrocortisone)
Hydrocortisone delivery is addison’s criteria?
Hydrocortisone = IM IV PO
Myxoedema coma s/s?
Hypothyroid signs (bradycardia, coma, seizures, psychosis)
Hypothermia
Hyporeflexia [LMN sign – less likelihood of head trauma or brain tumour]
Mx of myxoedema coma?
IV T3 (5-20mcg/12 hours) – T3 acts faster than T4 (as T4 is just converted into T3 in the body)
IV hydrocortisone (100mg/8 hours)
Further as needed: warming blanket, fluids (caution), ABx (if infection suspected)
S/s of thyroid storm?
hyperthyroidism (fever, agitation, confusion, coma, tachycardia, AF, D&V, goitre, HF)
Management of thyrotoxic storm?
1st = Propranolol (60mg, QDS, IV) ± digoxin use diltiazem if beta-blockers contraindicated
2nd = Carbimazole (inhibits TPO; 15-25mg, QDS, PO)
3rd = Hydrocortisone (100mg, QDS, IV) OR dexamethasone (2mg, QDS, PO)
Other treat precipitant (i.e. infection, ABx), IV fluids, cooling
HHS criteria?
BM >33.3mmol/L
Hyperosmolar >330mmol/kg
Volume deplete
Mx of HSS?
LMWH (VTE risk high)
Slow rehydration (over 48hrs)
½ RATE OF FLUIDS OF DKA
Deficit = 8-15L for 70kg adult
Replace K+ when UO increases
Criteria for DKA?
BM > 11mmol/L
Ketones >3
Acidosis pH <7.3
Hypoglycaemia treatment, unconsciousness/no swallow
IM glucagon (community, no IV) OR
Glucose 20%, 100mL, IV, over 10 mins
Hypoglycaemia >4, conscious
Long-acting CHO
(two biscuits, one slice of bread, 200–300 mL of milk)
Hypoglycaemia <4, conscious
Glucotabs (4-7) * OR
150-200mL fruit juice OR
4 teaspoons sugar dissolved in water
When to use glucogel?
capable but uncooperative, can swallow
Warfarin requires daily INR monitoring until INR stable with:
Antibiotics Regular tramadol Fluconazole AND Omeprazole Amiodarone Corticosteroids (high dose)
Adenosine dose for narrow complex tachycardia?
6mg, go up to 12mg
Treat for stable broad complex tachycardia?
Amiodarone 300mg IV or 20-60 mins
then 900mg over 24 hours
Treatment for meningitis?
Cefotaxime IV
+ ampicillin if immunocompromised or >55 y/o
Dose of benzylpenicillin
1.2g IM
Treatment for acute ischaemic stroke?
Aspirin 300mg, oral, once only
Treatment for secondary pneumothorax??
<2cm = aspirate
>2cm or SOB or >50 y/o = chest drain
Treatment for primary pneumothorax?
<2cm and no SOB = dishcarge and f/u in 4 weeks
>2cm or symptomatic = aspirate
Acute GI bleed tx?
ABC + O2
Hx and o/e
2 large bore cannula
Catheter + fluid monitoring
Crystalloid bolus
Cross-match 6 units of blood
Correct clotting abnormalities
Endoscopy
Stop culprit drugs (NSAIDs, aspirin, warfarin, heparin)
Call the surgeons if severe
CURB-65 Criteria?
Confusion (AMTS<8)
Urea > 7.5mmol
R = respiratory rate >30/min
Blood pressure systolic <90mm hg
> 65 y/o
Hypoglycaemia treatment unconscious
Glucagon 1mg IM
Acute poisoning tx?
-ABC
-History
-Cannula and catheter (strict fluid balance)
-supportive measures (fluids and analgsia)
-Correct electrolyte disturbance
-Reduce absorption (charcoal, lavage)
-Increase elimination (N-acetylcysteine etc)
-Psychiatric assessment by liasion pysch
Benzodiazepine reversal agent?
Flumenazil
Drug for DVT/PE?
Use enoxaparin (easier to prescribe)
Where to find warfarin INR info?
Oral anticoagulants – warfarin INR stuff here
Good treatment summaries?
Medical emergencies in the community
Prescribing in palliative care
Constipation
Fluids and electrolytes
Venous thromboembolism
Enzyme inducers?
Phenytoin, carbamezapine, rifampicin, alcohol, sulphonylureas,
St John’s wort, smoking, phenobarbital
Enzyme inhibitors?
Z
Azoles
G
DEVICES
Sodium valproate, isoniazid, macrolides, metronidazole, grapefruit juice, omeprazole, ciprofloxacin, sulphonamides,
What not to give with clopidogrel?
Omeprazole
Patients in a fluid deficit; give fluids at what rate?
1L over 4-6 hours
Emergency hypoglycaemia fluids?
10% glucose
150ml over <15 minutes
Emergency hypercalcaemia fluids?
0.9% sodium chloride
1000ml over 4 hours
Maintenance fluids with no deficits?
0.9% sodium chloride + 0.3% potassium chloride
1L over 8-12 hours
Fluids in someone with fluid deficit?
0.9% sodium chloride + 0.3% potassium chloride
1L over 4-6 hours
Common prescription errors?
-Levothyroxine is prescribed in mcg
-Methotrexate is given weekly with folic acid
-Wrong indication
-Incorrect dose
Which drugs can affect the liver?
Statins
Drugs to stop in AKI?
Diuretics, ACEi, NSAIDs, vancomycin, gentamicin, antifungals, cyclophosphamide, contrast
When to give loop diuretics?
Earlier in the day
What does 1% mean?
- 1 g in 100 mL (or 10 mg in 1 mL) for weight/volume (w/v) calculations; or
- 1 g in 100 g for weight/weight (w/w) calculations
Metabolic alkalosis causes?
Vommitting, diuretics and conn’s syndrome
Metabolic acidosis causes?
DKA, renal failure, methanol/ethanol intoxication
Most common cause of leg cellulitis?
Streptococcus pyogenes
To what regional lymph nodes is ovarian cancer most likely to spread initially?
Para-aortic nodes
Management of gallstones?
Laparoscopic cholecystectomy
Treatment for venous ulcers?
Compression stockings
S/S uveitis?
red eye, headache and visual disturbance and is associated with a small pupil.
A 65 year old man has sudden pain and redness in his ﾠright eye. He also has a headache and nausea. Visual acuity isﾠ 6/60 ﾠin the right eye. The eye is congested, with a hazy cornea and mid-dilated pupil.
Acute glaucoma
Ix for probable stroke?
Non-contrast CT head is the most rapid investigation to exclude intracranial haemorrhage and allow thrombolysis.
DPP4 inhibitor drug names?
“gliptins” sitagliptin, saxagliptin, linagliptin, and alogliptin.
