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Phase 4 > Emergencies > Flashcards

Emergencies Flashcards

1
Q

What is the definition of a major haemorrhage?

A

50% blood loss within 3 hours

> 150mls per minute

Full circulatory volume lost in 24 hours

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2
Q

What should the management be during a major haemorrhage?

A
  1. Assess if this is a major haemorrhage
    - put out major haemorrhage protocol
  2. Restore circulating volume
    - IV access
    - Fluids - warm if possible
  3. Stop bleeding
  4. Send samples
    - emergency cross match
    - FBC
    - Clotting studies
    - ROTEM
    - U&;Es
    - ABGs
  5. Give blood products
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3
Q

What is made available following a major haemorrhage protocol?

A

6 units of RBCs

- O negative will be provided until a 2nd cross matched sample is received

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4
Q

If there is trauma, obstetric or risk of DIC what should also be requested upon the major haemorrhage protocol?

A

FFP

Platelets may also need to be requested

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5
Q

How long does a group specific, cross match take?

- where can O neg blood be found?

A

Group and save: 25 mins
Cross match: 60 mins

O Neg can be found in:

  • Blood bank
  • Satellite fridges
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6
Q

What haemoglobin should be aimed for in Major haemorrhage?

A

Hb> 80g/L

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7
Q

How much time for products do you need to leave during a major haemorrhage?

A

20mins thawing time for FFP
25 mins for group specific RBCs
60 mins for crossmatch
Transport time

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8
Q

What drug can be given during a major haemorrhage to help control bleeding?

A

Tranexamic acid

IV infusion - slowly initially.

then transfusion over 24 hours

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9
Q

What is the ideal blood product use for DIC?

A

Cryoprecipitate - contains fibrinogen

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10
Q

What are the different types of shock?

A 
Cardiogenic shock 
Hypovolemic shock 
Septic shock 
Neurogenic shock 
Anaphylactic
Obstructive
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11
Q

What are the classifications of shock?

A 
Type I:
<750ml 
15% 
<100bpm 
BP normal 
slight anxious 
Type II: 
750-1500ml 
15-30% 
100-120bpm 
BP normal 
Mildly anxious 
Type III: 
1500-2000
30-40% 
120-140
BP lowered 
Anxious confused 
Type IV: 
>2000
>140 
BP lowered 
RR>35 
Confused lethargic
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12
Q

How do you manage a haemorrhage causing shock?

A
  1. Assess if this is a major haemorrhage
    - put out major haemorrhage protocol
  2. Restore circulating volume
    - IV access
    - Fluids - warm if possible
  3. Stop bleeding
    - active haemorrhage control
    - direct compression
    - pelvic binder
  4. Send samples
    - emergency cross match**
    - FBC
    - Clotting studies
    - ROTEM (assesses haemostasis in patients)
    - U&Es
    - ABGs
  5. Give blood products
    - give O neg blood initially then move to group specific when able
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13
Q

How much and how quickly should a fluid bolus be given in an emergency situation?

A

500ml saline over 15 mins

or

250ml in heart failure over 15mins

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14
Q

List some causes of cardiogenic shock:

A

M.I

Mitral regurgitation

Subarachnoid inducing catecholamine release causing cardiogenic stunning

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15
Q

Name some causes of obstructive shock

A

P.E

Cardiac tamponade

Tension Pneumothorax

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16
Q

List some causes of neurogenic shock, and explain the underlying pathological mechanisms:

A

High cervical cord trauma

Major brainstem or spinal injury

Guillain Barre syndrome

Loss of vasomotor control induces mass peripheral dilation.
Also damage to sympathetic nerves system can induce severe bradycardia

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17
Q

What are some clinical features of septic shock?

A

Warm peripheries
Bounding pulse
Large pulse pressure (120/ 50)

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18
Q

What are some clinical features of Anaphylactic shock?

A 
Wheeze 
Stridor 
Angioedema - especially facial and laryngeal 
Itch 
Urticaria 
Bounding pulse
warm peripheries 
Large pulse pressure
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19
Q

What are some mimics of anaphylaxis?

A

Carcinoid syndrome
Pheochromocytoma
Angioedema
Mastocytosis

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20
Q

What should be measured to confirm anaphylactic reaction and when?

A

Tryptase

1 - 6 hours following onset

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21
Q

What is the management of hemorrhagic shock following from initial ABC (i.e. fluids and oxygen is already on)?

A

Stop bleeding

  • pelvic binders
  • Leg splints

Contact Haematology

Give blood and FFP (1:1 ratio)

  • O Neg
  • specific blood

Platelets (keep >100) - platelets

Fibrinogen (>1) - cryoprecipitate

Tranexamic acid

22
Q

Following ABCDE if someone is in cardiogenic shock, how are you going to treat them?

A

Diamorphine
- reduce pain and anxiety

Correct arrhythmias and U&E abnormalities

Optimise filling pressures:
Underfilled:
- Plasma expanders

Underfilled:

  • Inotropic support - dobutamine
  • Nitrates
23
Q

Name some complications of shock:

A

Hypoperfusion to vital organs which may cause irreversible damage.

  • Brain - coma
  • Kidneys
  • Ischemic Hepatitis
  • Myocardial ischemia
24
Q

What clinical signs may you see with cardiogenic shock?

A 
Low BP/ High diastolic 
Weak pulse 
Raised JVP 
Low GCS 
Oliguria
Cool peripheries
25
Q

What is the management of anaphylaxis ?

A

Secure Airway
- intubation may be needed

Remove cause

IM adrenaline - 0.5mg - 1:1000ml 
- repeat every 5 mins if needed 
\+ 
IV chlorpheniramine 
\+ 
IV steroids

IV saline

still hypotensive:
- ICU 
- IV Adrenaline 
\+ 
- IV aminophylline
26
Q

What are the generalised stages of shock?

A

Initial

Compensating

Progressive/ Decompensating

Refractory/ irreversible

27
Q

List some signs of hypovolemic shock?

A

altered mental status

Cool clammy skin
Mottled skin

weak, thready pulse
tachycardia

thirsty/ dry/ low JVP

Pupil dilation

28
Q

In E of the ABCDE, what are you looking for in shock?

A

Signs of blood loss:

  • injury sites
  • penetrations
  • bruising across the flanks / abdomen
  • High riding prostate

Signs of infection:
- Rash

29
Q

When should someone be admitted following a head injury?

A 
<15 GCS 
Focal neurological symptoms 
Vomiting 
Amnesia 
Alcohol ingestion 
Coagulopathy 
Suspected cranial fracture
30
Q

What are the signs of a basal skull fracture?

A 
Panda eyes 
Hemotympanum
Otorrhoea - CSF from ears
Rhinorrhoea - CSF from nose 
Battle's sign - bruising on mastoid
31
Q

What is a LBBB in keeping with in the setting of an M.I?

A

Large anterior M.I

32
Q

What are the rhythms that cause arrest?

A

PULSELESS VT

VF

Pulseless electrical activity

Asystole

33
Q

How are you going to monitor a patient with shock?

A 
Mental status 
Vitals - HR, BP, RR, Stats 
Cap Refill 
Urine output 
ECG 
Skin colour and temperature
CVP - if in place
34
Q

What immediate investigations do you want when someone is in shock?

A 
Bloods: 
- FBC 
- U&amp;Es 
- ABG 
- Coagulation studies 
- LFTs 
- Glucose 
\+/- 
CRP 
\+/- 
Blood cultures

Orifices:
- Urine output
+/-
urinalysis

X-rays:
- Ultrasound of heart (if cardiosuspected)
+/-
CXR

ECG

Special tests:

  • tryptase
  • D-dimer
35
Q

How are you going to monitor someone following shock?

A 
Mental status 
Urine output 
Vitals - HR, STATS, BP 
Skin Colour 
Cap Refill 
CVP 
ECG
36
Q

What makes up the trauma triad?

A

Hypothermia

Coagulopathy

Acidosis

37
Q

If you are at bedside with a patient who has collapsed, what bedside investigation should you always do?

A

BM’s

38
Q

In addition to atropine, what additionally inputs can be done into severe bradycardia?

A

external pacing
Adrenaline
Temporary pacing wire

39
Q

What important medication must be given when there is stridor and oxygen sats falling?

A

Nebulised Epinephrine
+
Contact anesthetists

40
Q

List actions you would take during a AAA?

A

Major haemorrhage protocol
Give O negative blood
Senior help/ Vascular surgery

41
Q

What bedside tests can be done to confirm an AAA?

A

Ultrasound

FAST scan

**CT confirms whether it has rupture

42
Q

Give some differentials for stridor:

A

Inspiratory:

  • Epiglottitis
  • Glandular fever
  • Laryngitis
  • Croup

Expiratory:
- Tracheal compression

43
Q

If a person goes into cardiac arrest following a P.E and is treated with thrombolysis - how long should CRP be continued for?

A

90 minutes.

thrombolytic drug needs time to work

44
Q

If someone presents with a collapse - what is a very important aspect of the systemic enquiry history you want to ask about?

A

Melena or G.I bleed.

they be volume depleted leading to low BP

45
Q

What signs may you see during a P.E?

A

Tachypnea
Pleuritic chest pain
Hemoptysis
Syncope

Right ventricular heave
Loud 2nd heart sound
Splitting of heart sound
Increased JVP

46
Q

Management of a P.E?

A 
Oxygen 
Fluids 
LMWH 
or 
Thrombolysis
47
Q

Immediate management of NSTEMI:

A 
Beta blockers 
Aspirin 
Ticagrelor
Morphine 
Anticoagulation - LMWH 
Nitrates 
\+/- 
Oxygen (<94%)

GRACE Score
>10% = PCI or CABG

Follow up they will need:

  • Echocardiogram
  • Stress ECG
  • Angiogram
48
Q

During an upper G.I bleed, when should O- blood be given?

A

If they patient is severely unstable or Hb <7

49
Q

When in an upper G.I bleed is terlipressin and antibiotics given?

A

If high suspicion of varices i.e. liver failure.

given before scope

50
Q

What are the initial symptoms of anaphylaxis?

A

Tingling
Warmth
Itchiness
Mild oedema

followed by:

  • urticaria
  • generalised flush
  • wheeze
  • bronchospasm
  • hypotension
51
Q

What biochemical directly correlates with the severity of an anaphylactic reaction?

A

Serum Platelet Activating Factor

Phase 4 (49 decks)

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