Emergencies Flashcards
Adverse features of arrythmia?
Shock/hypotension
Heart failure
Myocardial ischaemia
Syncope
Management for unstable arrhythmia
Synchronised DC shock up to 3 times-> amiodarone 300mg IV over 10-20 min and repeat shock. followed by amiodaron 900mg over 24 hrs
Stable arrythmia. Broad complex, irregular. management
irregular- could be VF (cardiac arrest protocol), AF with abberancy/AF with BBB, Pre-excited AF (DC cardiovert or chemically cardiovert- DO NOT GIVE AVN BLOCKER), Polymorphic VT (e.g. TDP- MgSO4 2g over 10min IV)
Stable arrhythmia. Broad complex, regular. management
Regular- VT or uncertain rhythm?- Amiodarone 300mg IV over 20-60 min, then 900mg over 24 hrs.
Could be SVT with BBB/SVT with abberancy, WPW antidromic AVRT. Giving adenosine will correct the former 2, will slow down the latter to show delta waves. WPW antidromic can be treated with DC or chemical cardioversion.
Stable arrhythmia. Narrow complex. Regular
Vagal manouveres. Adenosine 6mg IV bolus. If unsuccessful give 12mg, then further 12mg if needed. If does not restore to SR, consider flutter or ectopic atrial activity and rate/rhythm control
Stable arrhythmia. Narrow complex. Irregular
Probably AF.
>48hrs- rate control and anticoagulate for 3 weeks (or do TOE looking at left atrial appendage). Cardioversion (electrical/chem with flec/amio). Anticoag for minimum of 4 weeks.
<48hrs- LMWH, cardiovert, anticoag for 4 weeks.
Or can just rate control them forever (beta blocker/diltaziem/digox if HF).
Pill in the pocket flecanide for paroxysmal AF
Bradycardia, adverse features vs non-adverse
Adverse- Atropine 500mcg IV. Can repeat up to 3 times. If not, consider alternative drugs or temporary pacing. If Stable- temporary pacing if at risk of asytole. Otherwise observe. If unsymptomatic and >40bpm, do nothing. If symptomatic/<40bpm- atropine+/- pacing. Gucagon for b-blocker/CCB overdose. Digibind for digoxin overdose.
ACS protocol
· ABC -> IV access and bloods -> 12 lead ECG -> GONAD
o FBC (acute anaemia), U&E (renal failure, contrast in angio, baseline for drug therapy, K+ ), LFTs if right-sided heart failure, random glucose and Hba1c, Lipids, Troponin, CK, ( clotting (thrombophillia), TFTs on selected patients with AF and those on/about to receive amiodarone, Drug screen (cocaine, amphetamines, ectasy, weed) in younger patients
o ABG (acidosis, hypoxaemia)
o ECG
· Give:
o Oxygen (only if sats are <94%)
o Nitrate (GTN spray 2 puffs SL)
§ Not if hypotensive. May rarely abort chest pain if due to coronary vasospasm (prinzmetal angina)
§ Indications: hypertension, acute LVF, pain not controlled by opioids, known angina and already take it PRN
o Aspirin and clopidogrel/ticagrelor/ prasugrel
§ 300mg followed by 75mg/day for 12 months
· Prasugrel- STEMI (CI if >75yrs or <60kg or prior stroke/TIA)
· Ticagrelol- NSTEMI (bleeding risk)
· Clopidogrel- if bleeding risk, >75yrs, <60kg)
o morphine (5-10mg IV) plus anti-emetic (metclop)
§ Decreases pain (lowers BP), decreases symp activity (which increases o2 demand)
o Anticoagulation
§ STEMI- for PCI
· unfractionated heparin/biliverdin/abciximab.
· GIIb/IIIa inhibitors if high bleeding risk
§ NSTEMI
· LMWH if angio planned
□ Add in GIIb/IIIa inhibitor if high risk patient
· Fondaparineux if angio not planned (continue until discharge)
§ If no PCI or thrombolysis- fondaparineux
· Further investigations (not to delay revasc)
o Portable CXR (to exclude other causes of chest pain)
o Echo (regional wall motion abnormalities, valve disease, LV thrombus (after extensive anterior MI))
Outpatients or inpatients- Stress MRI
Acute cardiogenic pulmonary oedema management
· ABCDE -> IV access and monitor ECG
· Sit upright
· Controlled oxygen to sats 94-98%
· Morphine 2.5-5mg IV slowly (caution in liver failure and COPD) with antiemetic (metclop) to relieve pain, anxiety, distress
o Balance with risk of depressing resp drive, which may increase need for invasive ventilation
· Furosemide 40-80mg IV slowly (larger doses in renal failure)- only enough for symptomatic relief (can make hypotensive if too much)
o Monitor urine output
· If in the ambulance- can give GTN sublingual spray/tablet
· GTN IV infusion (if SBP>100mmHg)- most important. To offload preload.
o If BP too low- consider a vasopressor/inotrope and refer to ITU
§ Inotropes can cause sinus tachycardia and myocardial ischaemia so use with caution
· CPAP ( (recruits smaller airways for ventilation by driving fluid out of interstitium)
o Caution- Lowers BP (increases intra-thoracic pressure, pressure on heart and vessels so CO drops). Patient must be conscious, able to tolerate a tight fitting mask
· Others:
o If patient is worsening consider:
§ Another dose of furosemide
§ Increase nitrate solution
o Neb salbutamol if wheeze
o TE proph (dalteparin)
o Consider reversible causes (uraemia, ischaemia, valves)
o Mechanical help- IABP- bridging and stabilise patient before definitive management
Hypoglycaemia
glucose <4mmol/L. Patient conscious- yes- if able to help self given glucojuice, glucose tablets or fruit juice. If unable to help self give dextrogel (1.5-2 tubes). Recheck glucose in 15 min. Can repeat cycle 3 times.
Not conscious. Get help. A-E. Able to secure IV access- 20% glucose infusion of 300ml/hr for 15 min (so 75ml). Check glucose in 10 min and repeat if necessary. Unable to cannulate- give 1mg IM glucagon.
After response- give long-acting carb e.g. 2 biscuits, sandwich, do not omit insulin if due. Check CBG in 30-60 min
Salicylate poisoning - features
Vomiting, dehydration, hyperventilation, tinnitus, vertigo, sweating. Rarely decreased GCS, seizures, hypotension, heart block, pulmonary oedeoma, hyperthermia. Resp alkalosis due to stimulation of resp centres and then metabolic acidosis
Salicylate poisoning- management
Correct dehydration. Cardiac monitoring. Give activated charcoal if <1hr since ingestion, consider even if later- 1g/kg (max 50g). .
Bloods- U+Es, glucose, LFTs, INR, paracetamol and salicylate levels, fbc, ABG. Monitor U+Es, glucose, salicylate levels, serum pH.
Urine- urine pH. monitor urine output.
Correct acidosis- if plasma salicylate level>500mg/L (3.6mmol/L) or severe acidosis-alkalanise urine with IV sodium bicarb 1.5L 1.26% over 3hr. Beware of hypokalaemia.
Dialysis if salicylate level is >700mg/L, if AKI, heat failure, pulmonary oedema, cerebral oedema, seizures etc. Contact nephrology early
Paracetamol poisoning- fatal dose?
150mg/kg or 12g in adults
Paracetamol poisoning-management
If present early- activated charcoal 1g/kg (max 50g)
Bloods- glucose, INR, U+Es, LFTs, FBC, ABG, blood paracetamol levels 4h post ingestion.
Plot nomogram- give NAC if above line. Give NAC anyway if don’t know when ingestion was, dose uncertain, very large dose, staggered/modified release dosing and then do levels and stop if below line/continue if above. Repeat levels 4hr later if staggered dosing.
Give NAC IV with 5% dextrose. Look at BNF for dose. SE: rash-give chlorampenamine. Only stop if anaphylaxis. methionine is alternative to NAC.
King’s college criteria for referral.
Anaphylaxis
Airway, oxygen,
C= raise feet.
Adrenaline 1:000 0.5l (0.5mg) IM- may need to repeat every 5 min. 10mg chloramphenamine IV, 200mg hydrocortisone IV. IV fluids. Consider ITU, asthma treatment.
Bloods- mast cell tryptase 1-6h afterwards. May need chloramphenamine infusion.
