Emergencies Flashcards
What essentially happens in DKA
Not enough insulin and high blood glucose so body runs out of insulin
What are the signs and symptoms of DKA?
- acetone smell breath
- dehydration, polydipsia, polyuria
- abdo pain, vomiting
- Kussmaul resp
- shock, coma, death
- drowsiness
What are the diagnostic criteria for DKA?
- BM >11.1mmol/L
- Blood ketones >3mmol/L or urine ketones on dipstick
- Venous ph <7.3
- Bicarbonate <15mmol/L
What are the signs of clinical dehydration?
unwell irritable and lethargic decreased UO Sunken eyes dry mucous membranes reduced skin turgor tachycardia and tachypnoea
What is the first step in treatment of DKA?
ABC
fluid resuscitation w 0.9% saline
Why do you need to be careful with fluids in resuscitation for DKA?
Too much puts at risk of cerebral oedema
What is the second step in treatment of DKA?
Rapidly confirm diagnosis, then formal Ix
what are the next steps of treatment of DKA once fluid resuscitation has occurred?
- Assess dehydration, work out volume of fluid to be replaced and give at constant rate for 1st 48hr
- give IV insulin 1hr after IV fluids
- reduce insulin when glucose <14mmol/l
- stop insulin when ketone <1.00mmol/l change to subcut
How is fluid replacement worked out in DKA?
MAINTENANCE + DEHYDRATION DEFICIT - FLUID GIVEN IN RESUSCITATION
What shouldn’t be given as part of treatment of DKA and why?
bicarbonates as they increase risk of cerebral oedema
Explain the different fluids that are given in DKA and when
- 9% saline + 20mmol KCl/500ml when BM 14mmol/l
0. 45% saline + 20mmol KCl/500ml + 5%glucose after 12 hr if plasma Na stable
When does cerebral oedema usually occur following treatment of DKA?
4-12 hrs
What are the most common precipitating factors of DKA?
Infection
Missed insulin doses
MI
What is the mortality of meningitis?
5-10%
what are the causes of meningitis n neonates -3m?
GBS
E.coli
Listeria monocytogenes
What are the causes of meningitis in 1m-6y?
neisseria meningitidis
strep. pneumoniae
h. influenzae
what are the causes of meningitis in >6yr
N. meningitidis
s. pneumoniae
What are the general signs/sx of meningitis?
fever headache lethargy/drowsiness poor feeding/vomiting irritability
What are neurological signs of meningitis?
hypotonia
LoC
seizures
shock
What are characteristic signs of meningitis?
non-blanching rash
photophobia
neck stiffness
Brudzinski’s/Kernig’s sign
What sign of meningitis is seen in infants?
bulging fontanelle
Give the ix for meningitis
FBC, U&Es, LFTs Blood, throat, urine, stool cultures LP!!! Blood glucose/gas for acidosis Coag screen CRP
What imaging can be used in meningitis ix?
CT/MRI
EEG
Explain the pathophysiology behind meningitis
Infection of meninges usually follows bacteraemia
Host response causes damage - release of inflammatory mediators and leucocytes w endothelial damage
Subsequent cerebral oedema, ICP + cerebral blood flow
What is the management of meningitis with non-blanching rash or meningococcal septicaemia/ in the community?
parenteral benzylpenicillin IV or IM <1yr - 300mg 1-9yrs - 600mg >10yrs - 1200mg dexamethasone to reduce risk of long term complications
what feature is suggestive of meningococcal infection?
non-blanching rash
Which meningitis is LP contraindicated in and why?
MENINGococcal septicaemia as coning of the cerebellar tonsils may follow
What is management of meningitis without a non-blanching rash in the community?
benzylpenicillin
cefotaxime
chloramphenicol
What are early signs of septic shock?
pale/mottled skin cold hands and feet prolonged ccap refill tachycardia tachypnoea
Who should be notified in cases of meningitis?
Public Health Authority
What should be given to close contacts for prophylaxis of meningitis?
rifampicin/ciprofloxacin - eradicates nasal carriage for meningococcal meningitis and H. inflenzae
When is LP contraindicated in meningitis?
- cardiorespiratory instability
- focal neurological signs
- signs of raised ICP
- coagulopathy
- thrombocytopenia
- local infection at site of LP
what are cerebral complications of meningitis?
Hearing loss Local vasculitis Local cerebral infarction Subdural effusion (h. influenzae) Hydrocephalus Cerebral abscess
What are ix for meningococcal septicaemia?
Blood cultures and PCR
What is rx of meningitis in >3m in secondary care?
IV ceftriaxone
What is rx of meningitis in <3m in secondary care?
IV cefotaxime + amoxicillin or ampicillin
What changes would you expect in the CSF in meningitis?
appearance - turbid
predominant cell - polymorphs
glucose level - <2/3 of blood
Protein increased mean approx 300mg/dL
What changes would you expect in the CSF of tubercular meningitis?
appearance - fibrin web
predominant cell - mononuclear 10-350/mm^3
Glucose level - <2/3 of blood
Protein increase
what are the complications of meningitis ?
secondary abscesses subdural effusion hydrocephalus ataxic paralysis deafness lowered IQ epilepsy
What is the cause of toxic shock syndrome?
toxin producing staph. aureus and group a strep
What are the features of toxic shock syndrome
fever >39 hypotension D&V renal and liver impairment clotting abnormalities and thrombocytopenia altered consciousness
What are skin changes in toxic shock syndrome?
diffuse red macular rash
desquamation of palms and soles after 1-2 weeks
What is the management of TSS?
Intensive care - manage shock
debridement
ABx - 3rd gen cephalosporin + clindamycin
IVIG to neutralise toxins
What is a complication of TSS?
Panton-Valentine leucocidin toxin can lead to necrotising fasciitis due to causing recurrent infection
What is necrotising fasciitis?
severe subcut infectie down to the muscle
What are the causes of necrotising fasciitis?
staph aureus and group a strep
What are the main features of necrotising fasciitis?
severe pain
systemically unwell
what is the rx of necrotising fasciitis
§abs
surgical intervention and debridement of necrotic tissue
+/- IVIg
What is the route of administration of adrenaline in anaphylaxis?
IM
What is the dose of adrenaline/hydrocortisone/chlorphenamine IM in <6m old in anaphylaxis?
0.15ml
25mg
250micrograms/kg
What is the dose of adrenaline/hydrocortisone/chlorphenamine IM in 6m-6yr in anaphylaxis?
0.15ml
50mg
2.5mg
What is the dose of adrenaline/hydrocortisone/chlorphenamine IM in 6-12yr in anaphylaxis?
0.3ml
100mg
5mg
What is the dose of adrenaline/hydrocortisone/chlorphenamine IM in adolescent/adults in anaphylaxis?
0.5ml
200mg
10mg
What can be given as well as adrenaline in anaphylaxis?
hydrocortisone
If there is no improvement after the initial dose of adrenaline, what is the next step in management of anaphylaxis?
repeat adrenaline dose after 5 mins (repeat every 5 mins if necessary)
high flow O2
crystalloid
remove the trigger
What is the best site of IM injection of adrenaline in anaphylaxis?
anterolateral aspect of the middle third of the thigh
What are common causes of anaphylaxis?
food
drugs
venom
What should be given if bronchospasm is a feature of anaphylaxis?
salbutamol
What are dd of anaphylaxis?
asthma
septic shock
breath holding
panic attack
How can you confirm a diagnosis of anaphylaxis?
serum tryptase levels
remain elevated for up to 12hrs in acute episode of anaphylaxis
