Emergencies Flashcards
What to do in Airway?
Check patency - airway maneuvers, suction
Sats - 15L O2 NRM;
aim for 88-92% in COPD –> titrate using 24-28% venturi mask if T2RF
Protect C-spine if necessary
What to do in Breathing?
RR
Examine the chest –> look, palpate, percuss + auscultate for signs or resp distress [symmetrical chest expansion? tracheal deviation?]
Squeeze calves to look for DVT!
What to do in Circulation?
HR - ?arrhythmias
BP
CRT
Auscultate the heart + ECG
UO + Catheter
2xLarge bore cannulae [send blood for FBC, U+Es, LFT, cross match, clotting, G+S]
Fluids - 500ml bolus of normal saline (+rpt)
What to do in Disability?
AVPU --> if abnorm --> GCS Pupils (PEARL) Glucose Temp \+/- abdo/neuro examinations
What to do in Exposure?
Expose patient
Look for bleeding, rash, trauma etc
What to do after ABCDE?
Continue monitoring Full colateral hx R/v notes/charts R/v lab/radiolog results ?escalate care --> HDU/ICU Document + handover
What to do before ABCDE assessment?
SBAR handover Check notes, drug chart, vital signs, ecg, bm Quickly eyeball pt ?critically ill Brief hx including relevant PMH If help needed, get help early --> 2222
Signs to assess for in a patient with acute breathlessness?
wheeze stridor crepitations chest clear other
DDx of acute breathlessness + wheeze
ashtma
copd
HF
anaphylaxis
DDx of acute breathlessness + stridor
foreign body tumour epiglottitis anaphylaxis trauma (laryngeal fracture)
DDx of acute breathlessness + crepitations
HF
pneumonia
bronchiectasis
fibrosis
DDx of acute breathlessness + clear chest
PE hyperventilation metabolic acidosis eg DKA anaemia drugs (aspirin OD) shock PCP
Breathlessness +
Hyper-resonant to percussion?
Stony dull to percussion
pneumothorax
pleural effusion
Life threatening causes of chest pain? (3 categories)
CARDIAC [acute MI, ACS, aortic dissection]
RESP [tension pneumothorax, PE]
GI [oesophageal rupture]
what is coma?
unrousable unresponsiveness
how to quantify coma?
when do you need to intubate?
GCS
intubate when <8
Causes of coma? (2 categories)
METABOLIC [drugs, poisoning, hypoglycaemia, hypoxia, hypercapnia, septicaemia, hypothermia, hepatic/uraemic encephalopathy]
NEUROLOGICAL [trauma, infection, tumour, vascular, epilepsy]
Scoring for best motor response?
6 - obeys commands 5 - localise to pain 4 - withdraw to pain 3 - flex to pain 2 - extends to pain 1 - no response
scoring for best verbal response?
5 - oriented 4 - confused 3 - inappropriate speech 2 - sounds 1 - none
scoring for eye opening?
4 - spontaneous
3 - to speech
2 - to pain
1 - none
How to cause pain in assessing GCS?
fingernail bed pressure
supraorbital pressure
sternal pressure
What is shock?
circulatory failure –> inadequate organ perfusion
SBP < 90 / MAP <65
Calculate MAP?
MAP = CO x SVR
So shock results from a drop in CO or a loss of SVR or both..
Causes of shock? (CATEGORISE) 2
INADEQUATE CARDIAC OUTPUT
hypovolaemia –> bleeding / fluid loss
pump failure –> cardiogenic shock, 2dary cause
LOSS OF SVR sepsis --> vasodilation anaphylaxis neurogenic endocrine failure other
Management for septic shock?
ABCDE (primarily ‘C’)
2xLarge bore cannulae, check ECG, signs of ischaemia
Septic shock –> BCs, abx in 1h (Tazocin + gentamicin + vancomycin) fluid bolus, ? refer to ICU
Management of anaphylactic shock?
including 3drugs and doses
Type 1 - IgE mediated hypersensitivity
A/B - secure airway; 100% O2; ?intubate if obstruction
Remove the cause, raise feet
C - ADRENALINE IM 0.5mg (rpt every 5mins as needed)
IV access ->
CHLORPHENAMINE 10mg IV
HYDROCORTISONE 200mg IV
IV fluids, 500ml boluses, up to 2L
Further management of anaphylactic shock..?
Admit + monitor ECG Measure mast cell tryptase 1-6h Continue chlorphenamine Education about epipen Skin prick tests to find allergens
How does sepsis cause shock?
Systemic Inflammatory response syndrome (SIRS)
cytokine cascade, free-radical production and release of vasoactive mediators.
Management of ACS? (STEMI)
Aspirin 300mg PO Morphine 5-10mg IV (+anti-emetic) GTN Oxygen (if <95%) Restore coronary perfusion --> PCI within 120mins; if PCI not available fibrinolysis Anticoagulation
Management of ACS? (NSTEMI)
Aspirin 300mg PO Morphine 5-10mg IV (+anti-emetic) GTN Oxygen (if <90% or breathless) Beta-blocker Fondaparinux IV nitrate if pain continues
Mx of severe pulmonary oedema?
If does not improve
Sit upright O2 Investigate Diamorphine 1.25-5mg IV Furosemide 40-80mg IV GTN
If no improvement –> further dose of furosemide +/- CPAP, nitrates (if systolic >100)
Causes of severe pulmonary oedema?
LVF
ARDS
Fluid overload
Neurogenic
Mx of cardiogenic shock?
O2
Diamorphine 1.25-5mg (for pain + anxiety)
Correct arrhythmias, electrolyte disturbance
Find any reversible causes (e.g. MI, PE)
?filling pressure –> under filled give plasma expander
–> over filled give inotropes
Causes of cardiogenic shock?
MI Arrhythmia PE tension pneumothorax cardiac tamponade myocarditis endocarditis aortic dissection
Define broad complex tachycardia? (2 things)
Rate > 100bpm
QRS > 120ms (>3 small squares)
DDx of broad complex tachycardia?
VT
TdP
Mx of broad complex tachy?
O2
Correct electrolytes
If regular –> amiodarone
If irregular –> TdP give Mg
+/- DC shock
Define narrow complex tachycardia?
Rate > 100bpm
QRS < 120ms (<3 small squares)
DDx of narrow complex tachycardia?
Sinus tachy Atrial tachyarrhythmias (AF, AFlut, junctional)
Mx of narrow complex tachy?
O2 continuous ECG trace Vagal manoeuvres Adenosine \+/- cardioversion [DC / amiodarone]
Acute severe asthma - how to assess severity?
LIFE THREATENING = 33,92,CHEST PEFR < 33% O2 < 92% Cyanosis Hypotension Exhaustion Silent chest Tachycardia
Mx of severe asthma attack?
OSHITMS + escalate to ICU O2 Salbutamol neb 5mg Hydrocortisone IV 100mg Ipratropium 0.5mg add to neb Theophylline MgSO4 2g IV
AECOPD?
common medical emergency
viral or bacterial infection
Mx of AECOPD?
Neb bronchodilators --> salbutamol + ipratropium Controlled O2 therapy (monitor rpt ABGs) Steroids --> IV hydrocortison 200mg Abx --> amoxicilline/doxy/clarithro \+/- aminophylline \+/- NIPPV / intubation
When to suspect PE?
sudden collapse 1-2weeks post surgery
RFs for PE
malignancy surgery immobility COCP prev VTE
Mx of large PE
O2 if hypoxic
Morphine 5-10mg IV (+anti-emetic)
If peri-arrest consider thrombolysis (50mg alteplase)
Otherwise, IV heparin/LMWH
If systolic <90 –> ICU input; colloid infusion, +/- dobutamine, adrenaline
If systolic >90 –> warfarin loading.
Causes of acute upper GI bleed
PUD Gastroduodenal erosions Oesophagitis Mallory-Weiss Varices Malignancy
Mx of upper GI bleed
Protect airway, NBM, 2xLarge-bore cannulae
Bloods [FBC, U+E, LFT, clotting screen, crossmatch]
IV crystalloid
Blood transfusion
Correct any clotting abnormalities
Urgent endoscopy for diagnosis +/- control bleeding
pre-hospital mx of meningitis
IM benzylpenicillin
Hospital mx of meningitis (no signs of septicaemia)
ABC: IV fluids
Cefotaxime 2g (+ ampicillin if >55yo)
Dexamethasone 4-10mg/6h IV
Hospital mx of meningococcal septicaemia
ABC: IV fluids
Cefotaxime 2g (+ampicillin if >55yo)
ICU –> intubation, ionotropes, aim for MAP>70
Careful monitoring
Mx of viral encephalitis
Aciclovir 10mg/kg/8h IV for 14d
+ supportive treatment
+phenytoin if seizures
Sx of encephalitis
Prodrome of raised, temp, rash, lymphadenopathy, cold sores etc +: odd behaviour reduced consciousness focal neuro seizure
Define status epilepticus
seizures > 30min
rpt seizures without intervening consciousness
Mx of status epilepticus
A- maintain airway, lay in recovery position, insert airway +/- intubate
B - O2 100% + suction as required
1 - lorazepam 01.mg/kg
2 - rpt lorazepam if no response in 10mins
3 - phenytoin
4 - GA
what other drugs (non-anti-epileptics) could be useful in treating the cause of status epilepticus?
Thiamine (if alcoholism)
Glucose
Dexamethasone (for vasculitis/cerebral oedema)
Head injury:
How to diagnose rising ICP?
Cause of rising ICP?
What to do?
Unequal pupils
EDH
Urgent involve neurosurgery
Signs of basal skull fracture?
CSF rhinorrhoea/otorrhoea
Battle’s sign
Panda eyes
Blood behind the ear drum
Indications for CT head?
GCS < 13 at any time GCS=13/14 at 2h post-injury Focal neuro deficit Suspected skull fracture Post-traumatic seizure Vomiting > once LoC + [age>65, coagulopathy, dangerous mechanism, anterograde amnesia]
Indications for ventilation post head injury
GCS =< 8
PaO2 <9kPa on air / <13kPa in o2
Resp irregularity
Mx of head injury
ABC O2 Treat blood loss Assess GCS Involve neurosurgery
Mx of raised ICP
ABC Correct hypotension Brief examination (any clues to cause) Mannitol Dexamethasone (for reducing oedema around tumours) Fluid restriction Close monitoring If focal cause --> urgent neurosurgery (craniotomy/Burr)
signs of raised ICP
Cushing’s triad!
- Hypertension
- Low heart rate
- Low resp rate
Pres of DKA
gradual drowsiness --> coma vomiting dehydration abdo pain polyuria/dipsia ketotic breath Kussmaul breathing
Triggers for DKA
4 Is Infection (UTI, pancreatitis) Infarction (MI) Iatrogenic (surgery, chemo, antipsychotics) Insulin (missed dose)
Diagnosis of DKA
Acidaemia (pH < 7.3)
Hyperglycaemia
Ketonaemia
Mx of DKA
A - patent airway
B - O2 if desat
C - 2xLarge-bore cannulae; if SBP<90 give 500mL saline –> if no response - 2nd + ICU advise. If responds (SBP>90 after 1st bolus –> start fluids)
Fluids -> insulin 50U to 50ml 0.9% saline - infusion at 0.1U/kg/h.
–> until ketones<0.3mmol/L, pH>7.3 and bicarb>18mmol/L
+/- K+ replacement
When glucose < 14mmol/L start 10% glucose @ 125mL/h alongside insulin
Pres of paracetamol OD
late signs
initially asympto
vomiting +/- RUQ pain
later –> jaundice + encephalopathy
what dose of paracetamol can be fatal?
150mg/kg
12g in adults
mx of paracetamol OD:
<4h?
<10h?
>10h?
Activated charcoal in first 4h
N-acetylcysteine (use treatment line)
N-acetylcysteine
How to give N-AC?
IVI 150mg/kg in 5% dextrose
F/U of paracetamol OD?
INR, U+E, LFT on day after
If continued deterioration –> liver transplant
AKI mx
Urgent ABG to check K+ / ECG for signs
1) treat hyperkalaemia - Calcium gluconate; actrapid + glucose
2) Fluid input/output monitoring
3) Fluid challenge if dehydrated until SBP>100
4) If vol overload consider dialysis
Causes of AKI
Pre-renal [hypotension, sepsis, cardiac dysfunct]
Renal [drugs, GN, vasculitis]
Post-renal [obstruction]
Principles of AKI treatment
Treat hyperkalaemia Treat hypotension/sepsis [pre-renal] Catheterise [post-renal] Treat pulm oedema w/ diuretics Contact renal team if no UO Urgent USS to r/o supra-bladder obstruction ?ICU requirement
When would someone need urgent dialysis in AKI?
Unresponsive hyperkalaemia
Unresponsive pulm oedema
Uraemic complications (pericarditis, encephalopathy)
Severe metabolic acidosis
How to gauge severity of pancreatitis?
Glasgow criteria PaO2<8kPa Age>55 Neutrophilia (WBC>15x10) Calcium<2 Renal (Urea>16) Albumin<32 Sugar (Glucose>10)
3 or more positive in first 48h suggests severe pancreatitis -> transfer to HDU/ITU
