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Emergencies Flashcards

1
Q

Anaphylaxis Rx in <6 month old

A

Adrenaline 150mcg (0.15ml 1 in 1,000)

Hydrocortisone 25mg

Chlorphenamine 250mcg/kg

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2
Q

Anaphylaxis Rx in 6 months to 6 years old

A

Adrenaline 150mcg (0.15ml 1 in 1,000)

Hydrocortisone 50mg

Chlorphenamine 2.5mg

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3
Q

Anaphylaxis Rx in 6 to 12 years old

A

Adrenaline 300mcg (0.3ml 1 in 1,000)

Hydrocortisone 100mg

Chlorphenamine 5mg

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4
Q

Anaphylaxis Rx in >12 years old

A

Adrenaline 500mcg (0.5ml 1 in 1,000)

Hydrocortisone 200mg

Chlorphenamine 10mg

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5
Q

Management of Shock

A
  1. If ECG unrecordable, treat as cardiac arrest
  2. Raise foot of bed
  3. IV access + bolus (unless cardiogenic)
  4. Assessment
  5. Ix - lactate
  6. Monitoring catheter, arterial and CVP line
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6
Q

Mx Cardiogenic Shock

A

Rx Arrythymias/MI

Consider dobutamine

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7
Q

Mx Septic Shock

Abx for unknown cause, joint/soft tissue, C. diff, and abdominal source

A 
As for shock 
\+ IV Abx  
Unknown cause: mero + gent 
Joint + soft tissue: fluclox 
C diff: vanc and met 
Abdo: cef and met

Fluids, vasopressors

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8
Q

Mx Anaphylaxis

A
  1. Secure airway and give 100% O2
  2. Adrenaline 0.5mg 1:1000 IM (repeat every 5 min)
  3. Secure IV access and give fluid bolus
  4. Chlorphenamine 10mg IV + Hydrocortisone 200mg IV
  5. Salbutamol Nebs 5mg if wheeze
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9
Q

Mx SVT

A
  1. Patient compromised: sedate + DC 3x (100, 200, 360)
  2. If fails, amiodarone 300mg over 20-60 min
  3. Not compromised: Vagal manoeuvres
  4. Adenosine IV 6, 12, 12mg
  5. If fails, consider: VADA
    Verapamil
    Amiodarone
    Digoxin
    Atenolol
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10
Q

Mx Broad Complex Tachycardia

A
  1. O2 and IV access
  2. If adverse signs: sedate + DC, then amiodarone
    Adverse signs = shock, syncope, MI, HF
  3. If no adverse signs: correct electrolytes and assess rhythm
  4. Regular rhythm i.e. VT: amiodarone or lignocaine
  5. Irregular
    (AF with BBB treat as SVT,
    Pre-excited AF - fleic/amio, or TDP - MgSO4 3g IV)
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11
Q

Mx for STEMI

A
  1. Aspirin and Clopidogrel 300mg PO (then 75mg/d)
  2. Morphine and Metoclopramide 10mg IV
  3. Atenolol 5mg IV
  4. GTN 2 puffs or 1 tablet SL
  5. Primary PCI or thrombolysis

(Long term: BB, cardiac rehabilitation, statin, continue clopidogrel for 1 month, lifelong aspirin)

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12
Q

Mx for NSTEMI + Unstable Angina

A
  1. Aspirin and Clopidogrel 300mg PO
  2. Fondaparinux 2.5mg SC
  3. Morphine and metoclopramide 10mg IV
  4. GTN 2 puffs
  5. Atenolol 50mg/24hr PO

(Long term: BB, Statin, clopidogrel 1 year, lifelong aspirin)

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13
Q

Mx Severe Pulmonary Oedema

A
  1. Sit patient up + high flow oxygen
  2. Diamorphine 5mg + Metoclopramide 10mg IV
  3. Frusemide 40mg IV
  4. GTN 2 puffs
  5. Consider CPAP, increased frusemide, nitrate infusion and haemo-filtration
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14
Q

Mx Cardiogenic Shock

A
  1. IV access and monitor ECG
  2. Diamorphine 5mg + metoclopramide 10mg IV
  3. Correct arrhythmias, electrolyte disturbance and acid base abnormalities
  4. Assessment and monitoring
  5. Consider need for dobutamine
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15
Q

Tamponade: causes

A
  • Trauma
  • Lung cancer
  • Pericarditis
  • MI
  • Bacteria e.g. TB
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16
Q

Signs of Tamponade

A

Beck’s triad: low BP, raised JVP and muffled heart sounds

Kussmaul’s sign: raised JVP on inspiration

Pulsus paradoxus: (pulse fades on inspiration)

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17
Q

Ix for Tamponade

A

Echo: diagnostic
CXR: globular heart
ECG: ST changes, low voltage QRS

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18
Q

Mx for tamponade

A

ABCs

Pericardiocentesis (preferably under echo guidance)

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19
Q

Mx for Meningitis

A
  1. IV fluid and high flow oxygen
  2. Abx:
    Community: benpen 1.2g IM
    <50: cef 2g IV BD
    >50: cef + ampicillin 2g IV/4 hour
    Viral: aciclovir
  3. If not CI : LP
  4. Dexamethasone 0.15mg/kg IV QDS
  5. Monitor urine output, consider inotropes
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20
Q

Mx for Encephalitis

A
  1. Usually HSV 1
  2. Aciclovir STAT 10mg/kg/8h IVI over 1 hour for 14/7
  3. Supportive measures in HDU/ITU
  4. Phenytoin for seizures
21
Q

Mx for Cerebral Abscess

A
  1. Neurosurgical referral
  2. Abx e.g. ceftriaxone
  3. Treat raised ICP - dexamethasone
  4. (CT/MRI - ring-enhancing lesion)
22
Q

Mx for Status Epilepticus

A
  1. Secure airway + high flow oxygen + suction
  2. IV access + U+E, LFT, FBC, Glucose, Ca, AED levels, Tox screen
  3. Thiamine if alcohol, 100ml 20% if glucose
  4. Lorezapam 2-4mg IV, 2nd response within 2 min
  5. Phenytoin 18mg/kg IV or diazepam 100mg in 500ml 5% dex IVI
23
Q

Mx for Head Injury

A
  1. GCS, pupils
  2. Look for C spine tenderness, lacerations and signs of basal skull fracture on 2o survey
  3. Neurosurgical opinion if signs of raised ICP, CT evidence of intracranial bleed or significant skull fracture
  4. Neuro-obs half hourly until GCS 15
  5. Stay with someone for 48 hours and give advice card
24
Q

CT head guidelines: BANGS LOC

A 
Break: open, depressed or base of skull 
Amnesia >30 min retrograde
Neuro deficit or seizure 
GCS <13 at any time or <15 2 hours after injury 
Sickness: vomited > once

LOC or amnesia + any of:

  • Dangerous mechanism
  • Age >65
  • Coagulopathy (inc. warfarin)

@1 hour: BNGS
@8 hour: ALOC + warfarin

25
Q

Mx of raised ICP

A
  1. ABC
  2. Treat seizures and correct hypotension
  3. Elevate bed to 40 degrees
  4. Neuroprotective ventilation (PaO2>13, PCO2 4.5 - good sedation with NM blockade)
  5. Mannitol or hypertonic saline
26
Q

Cushing’s reflex

A

Raised BP, low HR and irregular breathing

27
Q

Tonsilar herniation (coning) syndrome

A

Displacement of cerebellar tonsils through foramen magnum

CNVI palsy, upping plantars, irregular breathing, apnoea

28
Q

Transtentorial/uncal herniation syndrome

A
  • Compression of ipsilateral inferomedial temporal lobe against free margin of tentorium cerebelli
  • Ipsilateral CNIII palsy (mydriasis then down and out), contralateral hemiparesis
29
Q

Subfalcine herniation syndrome

A
  • Displacement of cingulate gyrus (medial frontal lobe) under falx cerebri
  • Compression of ACA –> stroke
30
Q

Mx of Acute Severe Asthma

A
  1. Sit up + high flow O2
  2. Salbutamol neb 5mg + ipratropium (0.5mg)
  3. Hydrocortisone 100mg IV or pred 50mg PO
  4. Life threatening: inform ITU, MgSO4 2g IVI over 20min, neb salbutamol every 15 min
  5. Continue pred 50mg for 5 days
31
Q

Assessment of life threatening asthma

A
  • PEFR <33%
  • SpO2 <92 or PCO2 >4.6
  • Cyanosis
  • Hypotension
  • Exhaustion
  • Silent chest
  • Arrythmia
32
Q

Mx of acute exacerbation of COPD

A
  1. Sit up and controlled O2 therapy (aim for PaO2>8)
  2. Salbutamol 5mg and Ipratropium 0.5mg nebs
  3. Hydrocortisone 200mg IV + Prednisolone 40mg PO
  4. Abx if evidence of infection (Doxy 200mg STAT)
  5. Repeat neb and consider aminophylline IV and NIV if no response
33
Q

Mx of PE

A
  1. Sit up and O2
  2. Morphine + metoclopramide if distressed
  3. Consider thrombolysis (alteplase 50mg bolus STAT) if massive PE
  4. Interim LMWH or fondaparinux
  5. Confirmed PE: TEDS, continue LMWH until INR>2, continue for:
    3 months if remedial cause
    6 months if no identifiable cause
    Indefinitely if on-going cause
34
Q

Mx of Pneumothorax

A
  1. Tension: resuscitate and large bore cannula into 2nd ICS mid-clavicular line
  2. 3 sided wet dressing if sucking wound (traumatic)
  3. All PTX: definitive Mx is insertion of chest drain
  4. Primary PTX (no underlying lung disease): discharge if no SOB and <2cm
  5. Secondary PTX: admit for 24 hours if aspiration successful, insert ICD if SOB and >50yrs and >2cm
35
Q

Mx of Upper GI Bleed

A
  1. Resuscitate: head down, oxygen, 2xcannulae
  2. Bloods: FBC, U+E, LFTs, clouting, XM 6u, ABG, glucose
  3. Variceal: terlipressin IV, prophylactic cipro
  4. Maintenance and correct coagulopathy
  5. Urgent endoscopy: adrenaline/ laser coagulation/ endoclips/ variceal banding
36
Q

Mx of Acute Renal Failure

A
  1. Pulmonary oedema: sit up and high flow oxygen
  2. Assess fluid status: CV, tissues, and end-organ
  3. Rx life threatening Cx: hyperkalaemia, pulmonary oedema, consider need for rapid dialysis
  4. Rx shock or dehydration
  5. Look for evidence of post-renal causes
37
Q

Mx of DKA

A
  1. Fluids: 0.9% NS until SBP>90, then 1L over next 2, 2, 4, 4, and 6 hours
    Add 10% dextrose 1L/8h when glucose <14mM
  2. Start K replacement with 2nd bag (40mM/L)
  3. Insulin: 0.1u/kg/h Actrapid (6u if no weight, max 15u)
  4. Monitoring: hourly capillary glucose and ketones, VBG at 60 mins then every 2 hours, U+E 4 hourly
  5. Resolution: Ketones <0.3mM + venous pH >7.3. Transfer to sliding scale if not eating. Return to C insulin when eating and drinking.
38
Q

Mx of HONKC

A
  1. Diagnosed via marked dehydration and glucose >35mM (symptomatic >60), no acidosis and osmolality >340
  2. Rehydrate with 0.9% NS over 48 hours (may need 9L)
  3. Wait 1 hour before starting insulin (may not be needed) and start slow to avoid rapid change in osmolality
  4. Look for precipitant e.g. MI, infection, bowel infarct
  5. LMWH as risk of DVT and stroke
39
Q

Mx of Hypoglycaemia

A
  1. Symptoms: autonomic and neuroglycopaenic
  2. Alert and orientated: oral carbohydrate
  3. Drowsy but swallow intact : buccal carb e.g. glucogel
  4. unconscious or poor swallow: IV dextrose 100ml 20%
  5. No IV access or refractory: 1mg glucagon IM/SC - beware rebound hypoglycaemia after 20mins
40
Q

Mx Thyroid Storm

A
  1. Fluid resuscitation + NGT
  2. Propranolol PO/IV
  3. Carbimazol then Lugol’s iodine 4h later to inhibit thyroid
  4. Hydrocortisone
  5. Rx cause e.g. infection, MI, trauma
41
Q

Mx of Myxoedema Coma

A
  1. Bloods: TFTs, FBC, U+E, glucose, cortisol
  2. Correct any hypoglycaemia
  3. T3/T4 slow IV (may ppt. MI)
  4. Hydrocortisone 100mg IV
  5. Rx hypothermia and heart failure
42
Q

Mx Addisonian Crisis

A
  1. Bloods: cortisol, ACTH, U+E
  2. Check CBG
  3. Hydrocortisone 100mg IV 6 hourly
  4. IV 0.9% NS
  5. Septic screen/ Rx cause e.g. infection, trauma
43
Q

Mx Hypertensive crisis (Phaeochromocytoma)

A
  1. Alpha blocker e.g. phentolamine 5mg IV
  2. Then beta blocker e.g. labetalol 50mg IV - repeat until safe BP
  3. Phenoxybenzamine 10mg/d PO when BP controlled
  4. May now give BB to control tachycardia/ arrhythmias
  5. Elective surgery after 4-6 weeks to allow full alpha-blockade
44
Q

Mx Burns

A
  1. Airway: examine for respiratory burns e.g. soot, burnt nasal hairs, hoarse voice, consider flexible laryngoscopy and early intubation with dexamethasone
  2. Breathing: high flow oxygen, look for signs of CO poisoning, ABG gives COHb level
  3. Circulation: fluid losses may be huge, 2x large bore, bloods, start 2L warmed hartmann’s immediately
  4. Parkland Formula to guide replacement in first 24 hours: 4x weight (kg) x %burn = mL Hartmann’s in 24 hours
  5. Analgesia, dress partial thickness burns (cadaveric skin, synthetic or cream and sterile film), manage full thickness with tangenital excision debridement and split-thickness skin grafts
45
Q

Wallace rule of 9s

A

%BSA burn

Head and neck 9% 
Arms 9% each 
Torso 18% front and back 
Legs 18% each 
Perineum 1% 
Palm 1%
46
Q

Mx Hypothermia

A
  1. Moderate hypothermia shows J waves on ECG between QRS and T
  2. Cardiac monitor, warm IVI 0.9% NS and urinary catheter. Consider Abx for pneumonia prevention
  3. Slowly rewarm (risk of shock) at 0.5 degrees an hour:
    Passive external e.g. blankets
    Active external e.g. warm water or air
    Active internal: mediastinal lavage only in severe (<28)
  4. Complications: arrythmias (VT to VF), pneumonia, coagulopathy, acute renal failure
  5. Shivering stops below 32.2
47
Q

Adult ALS

A
  1. Look, listen feel –> call for help 2222
  2. CPR 30: 2, secure airway, give oxygen, attach defib
  3. Shockable (VF/pulseless VT): 1 shock, CPR 2 mins, adrenaline 1mg + amiodarone 300mg after 3rd shock, repeat adrenaline every other cycle
  4. Non-shockable (PEA/Asystole): resume CPR for 2 mins, adrenaline 1mg IV, repeat adrenaline every other cycle
  5. Reversible causes:
    Hypoxia, hypovolaemia, hypo/hyperkalaemia, hypothermia
    Thrombosis, tamponade, toxins, tension PTX
48
Q

Mx Bradycardia

A
  1. Treat if: adverse features or risk of asystole
    Adverse: shock, syncope, myocardial ischaemia, heart failure
    Asystole: recent asystole, mobitz II, complete block or ventricular pause >3 secs
  2. Atropine 500mcg IV repeat to maximum of 3mg
  3. Isoprenaline, adrenaline or transcutaneous pacing
  4. Consider: amionphylline, dopamine, glucagon (if BB or CCB overdose)
  5. Seek expert help and arrange transvenous pacing

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