Emergencies Flashcards
Anaphylaxis
Adult
ABCDE
Remove causitive agent
Lie flat, legs up
15L non rebreathe
0.5mg IM adrenaline (1:1000)
1 L IV fluid STAT
? Salbutamol/adrenaline Neb
After 2 doses IM
1mg adrenaline in 100ml
1ml/kg/hr then titrate
2-6h observation
Anaphylaxis
Child doses drugs
Adrenaline and IVF
Adrenaline:
>12 = 500mcg
6-12 = 300mcg
<6 = 150mcg
IVF = 20ml/kg
Choking
Adult
Effective cough
- encourage cough
Ineffective cough Conscious: - 5 back blows - 5 abdominal thrusts Unconscious - start CPR
Pre alert Adult Cardiac arrest
Actions
Check pulse (Trolley) Roll, Transfer
Start CPR and clock
Pads and rhythm check
Airway and capnography
IV access and VBG
2 minute cycle; time
Hx
Arrest time, CPR start time, PMH, QoL
Unresponsive patient
Unconscious patient
Stimulate: verbal/pain
Signs of life: Pulse check
Pads and BVM
ABCDE
Cardiac arrest
Drug doses
Adrenaline 1mg IV (1:10000)
Amiodarone 3rd and 5th shocks
- 300mg IV
- 150mg IV
Bradycardia
Signs of decompensation
Shock, syncope, angina, HF
Risk of asystole:
Mobitz II, CHB, ventricular pause >3s
Consider High ICP, hypoxia
Bradycardia
Treatment
Atropine 500mcg IV
Isporenaline 5mcg/min
Adrenaline 2-10mcg/min
Glycopyrronium 200-400mcg
Transcutaneous pacing
Stable Tachycardia
Dx
Narrow complex - irregular: AF - regular: SVT Broad complex - regular: VF ?SVT + BBB - irregular: AF + BBB
Other:
Polymorphic VT
WpW
WpW
Tx
Electrical cardioversion
Consider amiodarone
Do not give
Adenosine, beta/Ca blocker
(Block AV node)
Polymorphic VT
Torsades de pointes
Magnesium 2g IV (over 10 mins)
Do not give amiodarone
Prolongs QT
Fast AF
Tx
Stable Rhythm control? Rate control: Bisoprolol 5-10mg IVF bolus Digoxin 500mcg Amiodarone 300mg (30-60min)
SVT
Treatment
- Modified valsava
- Adenosine (?WpW?asthma)
6,12,18mg - Sync shock
VT
Treatment
Unstable
Sync shock
Stable
Amiodarone 300mg (20-30mins)
Then 900mg over 24h
Unstable tachycardia
Treatment
Sync shock (x3)
- Sedation
- 100,150,200
Amiodarone 300mg (20min) - repeat shocks
Adenosine
Contraindications
WpW
Asthma
Adenosine
Consent
Flushing and chest pain
Massive PE
Dx
Hypoxia, tachycardia Hypotension Signs of Right HF - raised JVP - TWI (V1-4 +/- inferior leads) - S1Q3T3 - right axis deviation - dominant R wave V1
Neutropaenic sepsis
Suspect in these groups…
- Any unwell haematology patient (regardless of treatment or not)
- Any unwell oncology patient within 6 weeks of systemic anti cancer Tx
STEMI
Dx
ST elevation in 2 contiguous leads >2mm chest leads >1mm limb leads ST depression V1-2 \+\-Wellens syndrome (Biphasic TW or deep inversion V1-3)
STEMI
Tx
MONA
Aspirin 300mg
Ticagrelor 180mg PO
?GTN 1-10mg/hr
HHS
(Hyperosmolar hyperglycaemic)
Dx
BG>30
Serum Osmolality>320
Treat as per DKA if:
pH <7.3
HCO3< 15
Ketones >3(b) or 2(u)
Meningitis/ meningococcal sepsis
Tx
Blood cultures Dex 10mg IV Ceftriaxone 2g IV BD \+\- Amoxicillin (Low immune, EtOH, DM, pregnant)
Rhesus negative woman
Sensitising event
- Complete and incomplete miscarriage after 12 weeks
- Threatened miscarriage with heavy or recurrent bleeding
Primary pneumothorax
Dx and Tx
Breathless +/- rim of air >2cm at level of hilum
Tx
Aspirate 16-18G canula
>2.5L aspirated or unsuccessful
-> intercostal drain
Secondary pneumothorax
Dx and Tx
Any of:
>50yrs, smoker, underlying lung disease
With:
Breathless +/- Tim of air >2cm (hilum)
Tx
Intercostal drain
Neutropaenic sepsis
Tx
Tazocin 4.5g QDS
+
Gentamicin 3-5mg/kg
If
Penicillin allergy
Or myeloma
See protocol
Encephalitis
Tx
Aciclovir 10mg/kg IV TDS
Upper GI/ Variceal bleeds
Abx
<64yr
Ceftriaxone 1g IV OD
>65
Ciprofloxacin 400mg IV BD
Penicillin allergy = cipro
Gentamicin dose
<65
5mg/kg
>65
3mg/kg
eGFR 10-30
2-3mg/kg
eGFR 5-10
2mg/kg
Metastatic spinal cord compression
Suspect if…
Bone mets +
Back pain, worse on lying or moving, prevents sleep
New nerve root pain
(Do not wait for weakness or sensory level)
Ix and Tx!
Metastatic spinal cord compression
Tx
16mg dexamethasone IV
With ranitidine
MRI whole spine
General principle
Unstable
Vs
Stable
Tachycardia
Unstable
- sync DC shock
- sedation ?conscious
Stable
- 300mg Amiodarone IV over 20-30mins
- unless TdP - IV MgSO4 2g (10min)
Upper GI bleed (severe)
Tx
2222 major haemorrhage
2 large bore IV canula
Blood if Hb<10 or significant ongoing bleeding
Vit K 10mg IV
Terlipressin 2mg IV
Tazocin 4.5g
GBS score
?endoscopy
Reverse clotting?
Traumatic cardiac arrest
Pre-alert -> prepare
Trauma team Call Consultant Prioritise HOT H: - Pelvic splint/ tourniquets - IO kit - Blood - Level 1 infuser O: - Intubation/ Capnography T: - Chest drain kit
Traumatic cardiac arrest
Algorithm
Trauma to chest/epigastrium?
- bilateral finger thoracostomy
- penetrating wound <10min down time -> clamshell
HOT +/- CPR Hypovolaemia - pelvic binder/ tourniquets - IV/IO blood Oxygen - I+V Tension PNX - bilat thoracostomy
Stroke
NIHSS IV access, VBG ECG monitor Blood sugar Immediate CT head
?Thrombolyse
ECG
Swallow screen
Aspirin 300mg
Severe HTN
Dx
Consistent BP of either
220/120
ABG (for hypoxia)
Normal bicarb and high CO2
Dx and Tx
Acute T2RF
Requires ventilation
?naloxone
ABG (for hypoxia)
High bicarb, high CO2, low pH
Dx and Tx
Decompensated chronic T2RF
Life threatening
Requires help ventilating
?naloxone
CPAP starting pressure
5-8cm H2O
BiPAP starting pressures
and increases
IPAP and EPAP
10 and 5 cm H2O
If hypercapnic
- increase IPAP by 2
If Hypoxic
- increase IPAP and EPAP by 2
Max 25/15
Max BiPAP
25/15 cm H2O
IPAP/EPAP
Suspected raised ICP
Tx
30deg head up
sBP>100
sBP>120 in isolated HI
Analgesia
Normothermia
PaCO2 4-4.5
100ml of 5% saline over 10min
Aim Na 150-155
Hypoglycaemia
Dx and Tx
<4mmol/L
(<3 neuro signs)
Give fruit juice or glucogel
1mg glucagon IM
50ml 50%, 100ml 20%, 200ml 10%
Maintenance
10% glucose 100ml/h
Severe hyponatraemia
Dx and Tx
Na<120 and Sx
- seizure, low GCS, headache
Tx 1.8% hypertonic saline 150ml over 15min Repeat VBG after 20min Consider repeat bolus
If rapid over correction use IV dextrose
Signs and Tx Addisons crisis
Hypotension \+/- Hyperkalaemia Hyponatraemia Hypoglycaemia
Tx
IV hydrocortisone 100mg
Midazolam conscious sedation
Dose
Initial
2mg under 60
1mg over 60
Boluses: (minimum 2 min)
1mg under 60
0.5mg over 60
Max 7.5mg
NIHSS
1ABC: LOC, Qs, command 2 Best gaze 3 visual fields 4 facial palsy 5AB Power arms 6AB Power legs 7 limb ataxia 8 sensory 9 language 10 dysarthria 11 inattention
Thrombolysis
BP control
Either >185/110
Intravenous nitrate
Or
Labetolol
Thrombectomy
Inclusion criteria
CT angiogram: major vessel occlusion (M1,M2,basilar) And NIHSS>6
Available even if had thrombolysis
Pre-alert adult cardiac arrest
Team
MET; 2222 - adult arrest
5+scribe
- CPR
- Airway: capnography
- Pads; defib, time
- IV access, VBG
- Drugs: 1L saline STAT, adrenaline
Gloucester 2nd line
Anti epileptic
Phenytoin 20mg/kg (max 2g)
Keppra 20-30mg/kg
Contra indication to thrombolysis
Stroke
Warfarin/DOAC/TxLMWH Recent CVA (3m) Seizure at stroke onset Previous intracranial haemorrhage Recent intervention Pregnancy GCS<8 NIHSS>25 BP>185/110 Plt<100 BG>22
Open fracture
Tx
- IV Abx ASAP
(?co amoxiclav) - Tetanus cover
- Analgesia and splint
Orthopaedics ASAP
Wound >1cm -> trauma centre
Renal colic aged over 50
Exclude AAA
- exam, USS, CT
Trauma 5 sec round
Pulse
Airway
External haemorrhage
Hypothermic arrest
Changes to ALS
3shocks then No shocks until over 30C
No drugs until over 30C
Then double drug times between 30-35deg
Near drowning
Observe for
4-6h
To ensure no Resp distress
Loss of surfactant and atelectasis
Diving emergencies
Types and Time period
Barotrauma v decompression illness
Any symptom within 48h
= dive related until proven otherwise
Chest pain and syncope
Rule out
PE
Dissection
Tension PNX
ACS
Chest drain insertion depth
8-16cm
At least 4cm past last hole
Estimate position of chest drain
Mid axillary line
At level of nipple
Or breast crease
Opiate OD
Or any unknown hypoventillation
100-400mcg IV
400mcg IM
IV infusion (mcg/hr) 60% resus dose that provided adequate ventilation for 15 mins
IV drugs for raised ICP
Mannitol 500ml, 20%
Hypertonic saline 150ml, 3%
Or
100ml of 5%
Consider AAA USS in
Old Back pain - can cause compressive neuropathy Renal colic Diverticula disease
GI bleed with AAA or AAA repair is
Aorto enteric fistula until proven otherwise
Causes of acute mesenteric ischaemia
Embolism
SMA thrombosis
Mesenteric venous thrombosis
Non occlusive ischaemia (low flow state eg HF)
High lactate in mesenteric ischaemia
Late sign
High suspicion of pancreatitis but lipase/ amylase negative
Refer and CT scan
Bleeding
Fibrinogen <1.5
Give
Cryoprecipitate: 2 pools
Bleeding
INR >1.5
Give
FFP 2-4units
OOHCA
Decisions
Urgent cardiac catheter? Resus in best interests? Signs of cardiac cause? - STEMI, cardiogenic shock, recurrent VF/VT Significant HI? CTH+N Other cause: CTPA/Aortogram
OOHCA
A to E
A: ?RSI, CO2 B: ?ventillator, A/E, Sats C: Defib, HR, BP (?bilat), ECG, Echo, ART line D: BG, Pupils, ?GCS E: ?HI
Tx OOHCA
Likely ACS as cause
A to E
Aspirin 300mg PR
(Do not need CT head prior)
Emergency PCI
Causes of obstetric haemorrhage
Antepartum:
Placenta praevia, abruption
Postpartum
Tone, trauma, tissue, thrombin
Antidote
Dabigatran
Praxbind
Antidote
Rivaroxiban and apixaban
Andexanet Alfa
Ondexxya
OOHCA
Decisions
Urgent cardiac catheter? Resus in best interests? Signs of cardiac cause? - STEMI, cardiogenic shock, recurrent VF/VT Significant HI? CTH+N Other cause: CTPA/Aortogram
OOHCA
A to E
A: CO2 B: A/E, Sats C: Defib, HR, BP (?bilat), ECG, Echo, ART line D: BG, Pupils, ?GCS E: ?HI
Tx OOHCA
Likely ACS as cause
A to E
Aspirin 300mg PR
(Do not need CT head prior)
Emergency PCI
Causes of obstetric haemorrhage
Antepartum:
Placenta praevia, abruption
Postpartum
Tone, trauma, tissue, thrombin
Aims in major haemorrhage care
Hb>10 Fibrinogen > 1.5 Severe trauma 1:1 RBC:FFP INR< 1.5 TXA 1g 10min, 8h infusion Platelet > 75
Intra lipid dose
1.5ml/kg 20% over 1 min
(Up to 2x)
Start infusion
15ml/kg/h
Tx hypoglycaemia
<4mmol
Fruit juice
Hypostop
150ml 10% Dec
Or 100ml/hr
1mg IM glucagon
Retest in 10min
Refer to diabetes team
AF Sync DC cardioversion
Clexane 1.5mg/kg
200J sync DC shock
AP pad placement
Haloperidol contraindications
Long QT
PD or LBD
IV can cause arrhythmia
Restraint considerations
Lack capacity Possibility of harm (self/others) Last resort; de-escalate, oral meds Least restrictive Proportionate to likelihood of harm
Red flag sepsis
Unwell and source of infection \+ Reduced GCS sBP<90 HR>130 RR>25 O2 requirement Rash/mottled Anuric Lactate>2 Recent chemo
Place Major trauma call
Anatomy reasons
A: ?airway concerns B; ?PNX ?Flail C: ?pelvic # ?crush injury torso ?2 or more long bone # ?Proximal limb amputation ?burns >20% ?penetrating injury torso/abdomen D: ?spine injury + neurology
Place Major trauma call
Physiology concerns
<75 RR<10 or >30 O2 >4L HR<50 or >120 sBP<90 GCS<13
> 75
sBP<100
GCS<14
Major trauma call
consider other teams
Cardiothoracics ENT Maxfacs Obstetrics Paeds
Septic arthritis
Features
Short Hx (under 2 weeks)
Decreased ROM (all directions)
+- fever
RF other chronic ds or recent injury
TXA in head injuries
Give if under 3hours from injury
CRASH 3
Amniotic fluid embolism
Symptoms
Anaphylactoid type syndrome - acute hypoxia - haemodynamic collapse - DIC Treatment is supportive - O2 - fibrinogen and TXA
Amniotic fluid embolism
Diagnosis
Maternal collapse with no clear cause and any of;
C Arrest
Arrhythmia
Coagulopathy
SOB
Seizure
Premonitory sx; restlessness, agitation, numbness
Shoulder dystocia
Dx and Tx
After delivery of head if baby does not deliver on next contraction
Tx
McRoberts and suprapubic pressure
Alteplase dose
CA
- 50mg (1 vial) push
Massive
- 10mg over 1-2min
- 1.5mg/kg (max 90mg) over 2h
Chemical burn antidote
Diphoterine
Fast flow cupboards
Stop and summarise
X yo with X (PC) A to E or H&Ts Main issues are 1)2)3) Plan is; immediate, 10mins, 30mins Any other thoughts
Hyperthermia ddx
Heat stroke >40C
Heat exhaustion <40C
Malignant hyperthermia; sux/anaesthetic
Neuroleptic malignant syndrome
ABD
Serotonin syndrome; clonus
Sympathomimetic syndrome
Collapsed neonate
Sepsis
Cardiac
Metabolic - send ammonia on ice
NIA
Thyroid storm Dx
Burch Wartofsky score
Temperature
CNS effects
Gastrointestinal
HR
HF
AF
Precipitating event
Lab Dx; low TSH, high T3/4
Thyroid storm Tx
Cooling
Abx
IVF
Propranolol 1mg every 5min until HR<100
Propylthyrouracil
Hydrocortisone 100mg
?lugols solution
Collapsed patient request items
Can I get some pads and a BVM
After treatment hypoglycaemia recheck BG at x minutes
15 minutes
Age for surgical cricothyroidotomies
Under 12 needle cricothyroidotomy or tracheostomy
Rule of 9s
All 9% except back and legs (18% each)
Aortic dissection BP management
Aim sBP 100-120
Labetalol infusion
SCAPE
Sympathetic crashing acute pulmonary oedema
Aka
Hypertensive pulmonary oedema
Tx GTN infusion and CPAP
HF vs sepsis ix and signs
JVP, oedema, murmur
Ultrasound - b lines?, plethoric iVC, cardiac motility
CXR
HF vs sepsis ix and signs
JVP, oedema, murmur
Ultrasound - b lines?, plethoric iVC, cardiac motility
CXR
NIHSS LOC questions
Month and age
