Emergencies Flashcards
metabolic causes of coma?
Drugs e.g. CO poisoning, alcohol, tricyclics Hyper/hyperglycaemia Hypoxia Septicaemia Myoxedema/Addisonian crisis Hepatic/uraemic encephalopathy
neurological causes of coma?
Trauma
Infection- meningitis, encephalitis, malaria
Tumour
Vascular- stroke, SAH/SDH, hypertensive encephalopathy
Epilepsy
immediate mx of coma?
ABC
Check BG- give 50ml 20% glucose IV stat if needed
IV thiamine if suggestion of wernicke’s encephalopathy
IV naloxone for opiate intoxication
Ix of coma?
ABG FBC, U&E, LFT, ESR, CRP Ethanol Toxic screen Drug levels Blood cultures Urine culture CXR CT head
signs of shock?
low GCS/agitation pallor cool peripheries tachycardia slow capp refill tachypnoea oliguria lactate reduced BP
2 physiological causes of shock?
MAP = CO x SVR
reduced CO or reduced SVR
causes of inadequate CO?
- hypovolaemia- bleeding or fluid loss
2. pump failure- cardiogenic shock, PE, tension pneumothorax, cardiac tamponade
causes of peripheral circulatory failure?
- sepsis
- anaphylactic
- neurogenic e.g. spinal cord injury
- endocrine failure
- drugs e.g. antihypertensives
signs and symptoms of anaphylaxis?
- itching, sweating, D&V, erythema, urticaria, oedema
- wheeze, laryngeal obstruction, cyanosis
- tachycardia, hypotension
mx of anaphylaxis?
- secure airway
- give 15L O2 non-rebreathe mask
- remove the cause
- adrenaline IM 0.5mg (0.5mL of 1:1000)
- secure IV access
- chloramphenamine 10mg IV and hydrocortisone 200mg IV
- IV saline
- if wheeze, treat for asthma
tests on admission if suspected STEMI?
12 lead ECG, U&E, troponin, glucose, cholesterol. FBC. CXR
initial treatment of STEMI?
Aspirin 300mg PO
Morphine 5-10mg IV with metoclopramide 10mg IV
O2 if sats <95%
GTN spray
when should PCI be performed?
within 120 mins of admission
if not possible fibrinolysis should performed and if unsuccessful, transfer for rescue PCI or angiography
main choice of agent for thrombolysis?
tissue plasminogen activator e.g. alteplase or tenecteplase
what med needs to be given in primary PCI?
IV anticoagulant e.g. bivalirubin
contraindications to thrombolysis?
prev intracranial haemorrhages ischaemic stroke <6 months cerebral malignancy recent major trauma or surgery (<3 weeks) GI bleeding (<1 month) known bleeding disorder aortic dissection `
ECG criteria for thrombolysis?
ST elevation
LBBB
Posterior changes e.g. deep ST depression and tall R waves in leads V1 to V3
complications to STEMI?
recurrent ischaemia stroke pericarditis cardiogenic shock HF
brief history questions in NSTEMI?
prev angina
relief with nitrates/rest
hx of cv diseaase
RFs for IHD
brief examination in NSTEMI?
pulse BP JVP cardiac murmurs signs of HF peripheral pulses scars from prev cardiac surgery
acute management of NTEMI?
O2
morphine and metoclopramide
GTN spray
aspirin and second antiplatelet agent e.g. clopidogrel, ticagrelor
oral beta blocker if hypertensive
anticoagulant e.g fondaparinux (factor Xa inhibitor) or LMWH
causes of severe pulmonary oedema?
- cardiovascular e.g. ususally left vetricular failure, valvular heart disease, arrhythmias, malignant hypertension
- ARDS caused by trauma, malaria, drugs
- Fluid overload
- Neurogenic e.g. head injury
differential diagnosis of pulmonary oedema?
asthma/ COPD
pneumonia
symptoms of pulmonary oedema?
dyspnoea
orthopnoea
pink, frothy sputum
signs of pulmonary oedema?
distressed pale sweaty tachycardia pulsus alternans high JVP fine lung crackles gallop rhythm wheeze
Ix of pulmonary oedema?
CXR- cardiomegaly, shadowing, small effusions at costophrenic angles, fluid in the ling fissures, kerley B lines ECG- signs of MI Bloods- U&E, troponin, ABG ECHO plasma BNP
mx of acute heart failure?
- sit the patient upright
- O2
- IV access and monitor ECG
- diamorphine 1.25-5mg IV slowly
- Furosemide 40-80mg IV
- GTN spray
- if systolic BP >100 start a isosorbide dinitrate infusion
- if systolic BP <100 treat as cardiogenic shock
LOON
long term mx of heart failure?
daily weight repeat CXR change to oral furosemide can add thiazide ACEi if LVEF <40% consider beta-blocker and spironolactone
what is cardiogenic shock?
a state of inadequate tissue perfusion primarily due to cardiac dysfunction
causes of cardiogenic shock?
MI arrhythmias PE tension pneumothorax cardiac tamponade myocarditis; myocardial depression (drugs, hypoxia) valve destruction (endocarditis) aortic dissection
mx of cardiogenic shock?
O2 Diamorphine 1.25-5mg IV investigations and close monitoring correct arrhythmias, U&E abnormalities or acid-base disturbance look and treat reversible causes
what is cardiac tamponade?
pericardial fluid collects -> intrapericardial pressure rises -> heart cannot fill -> pumping stops
what 4 things to check in CXR if you think it’s normal?
apices (TB or sarcoid)
diaphragm (perforation)
bones (fractures)
behind the heart (shadowing)
what can be seen on a CXR in pulmonary fibrosis?
reticulonodular opacities
causes of cardiac tamponade?
trauma lung/breast cancer pericarditis MI bacteria e.g. TB
signs of cardiac tamponade?
falling BP
rising JVP
muffled heart sounds (beck’s triad)
kussmaul’s sign (JVP rising on inspiration)
pulsus paradoxus (pulse fades on inspiration)
diagnosis of cardiac tamponade?
CXR- globular heart, left heart border convex or straight, right costophrenic angle <90 degrees
ECG- electrical altercans
what is broad complex tachycardia?
rate >100bpm and QRS complex >120ms (>3 small squares)
principles of mx of broad complex tachycardia?
- if in doubt, treat as VT
- identify the underlying cause
differentials of broad complex tachycardia?
- VT including torsade de pointes
- SVT with aberrant conduction e.g. AF, atrial flutter with bundle branch block
- pre-excited tachycardia e.g. AF, atrial flutter, AVRT
what are adverse signs of broad complex tachycardia?
systolic BP <90
chest pain/ischaemia on ECG
heart failure
heart rate >150bpm
