EMERGENCIES- all topics Flashcards
What is adrenaline?
This is a sympathomimetic agent with both alpha and beta adrenergic stimulating properties
What is adrenaline used for and what are the doses?
anaphylaxis: 0.5mg 1:1,000 IM
cardiac arrest: 1mg every 3-5 minutes as required, a 1 in 10,000 solution is recommended
What should alcoholic patients be offered, nutrition wise?
SIGN recommends alcoholic patients should receive oral thiamine if their ‘diet may be deficient’
What are the drugs used for alcohol withdrawal?
Benzodiazepines are used for acute withdrawal
Disulfram promotes abstinence
alcohol intake causes severe reaction due to inhibition of acetaldehyde dehydrogenase. Patients should be aware that even small amounts of alcohol (e.g. In perfumes, foods, mouthwashes) can produce severe symptoms. Contraindications include ischaemic heart disease and psychosis
acamprosate: reduces craving, known to be a weak antagonist of NMDA receptors, improves abstinence in placebo controlled trials
When is allopurinol used and what is it’s mechanism of action?
Allopurinol is used in the prevention of gout. It works by inhibiting xanthine oxidase.
Initiating allopurinol prophylaxis
it has traditionally been taught that urate-lowering therapy (ULT) should not be started until 2 weeks after an acute attack, as starting too early may precipitate a further attack. The evidence base to support this however looks weak
What can be used when starting a patient on allopurinol?
Colchicine cover should be considered
What are the risks of allopurinol?
The most significant adverse effects are dermatological and patients should be warned to stop allopurinol immediately if they develop a rash:
severe cutaneous adverse reaction (SCAR)
drug reaction with eosinophilia and systemic symptoms (DRESS)
Stevens-Johnson syndrome
Certain ethnic groups such as the Chinese, Korean and Thai people seem to be at an increased risk of these dermatological reactions.
Patients at a high risk of severe cutaneous adverse reaction should be screened for the HLA-B *5801 allele.
What are alpha blockers used in?
Give examples of alpha blockers
They are used in the management of BPH and hypertensiom
Doxasozin and tamsulosin
Side effects…
- postural hypotension
- drowsiness
- dyspnoea
- cough
Caution should be exercised in patients who are having cataract surgery due to the risk of intra operative floppy iris syndrome
What are the adverse reactions with Amiodarone?
Adverse effects of amiodarone use thyroid dysfunction: both hypothyroidism and hyper-thyroidism corneal deposits pulmonary fibrosis/pneumonitis liver fibrosis/hepatitis peripheral neuropathy, myopathy photosensitivity 'slate-grey' appearance thrombophlebitis and injection site reactions bradycardia lengths QT interval
Important drug interactions of amiodarone include:
decreased metabolism of warfarin, therefore increased INR
increased digoxin levels
How does aspirin work?
It works by blocking the action of both cyclooxygenase 1 and 2 (cyclooxygenase is responsible for prostaglandin, prostacyclin and rhromboxane synthesis)
When is clopidogrel used?
First line for ischaemic heart disease
Can be used in ischaemic stroke and TIAS, however….
NICE now recommend clopidogrel first-line following an ischaemic stroke and for peripheral arterial disease. For TIAs the situation is more complex. Recent Royal College of Physician (RCP) guidelines support the use of clopidogrel in TIAs. However the older NICE guidelines still recommend aspirin + dipyridamole - a position the RCP state is ‘illogical’
What does aspirin potentiate?
Oral hypoglycaemics
Warfarin
Steroids
Who shouldn’t aspirin be used in?
Shouldn’t be used in children under 16 due to the risk of Reye’s, an exception is kawasaki where the benefits outweigh the risk
What are the features of a beta blocker overdose?
bradycardia
hypotension
heart failure
syncope
You can use atropine for this
What is hyrdrocortisone, when is it used, what dose do you use?
It is a corticosteroid- it has equal glucocorticoid and mineralcorticoid activity
It is used in anaphylaxis and in severe acute asthma
Asthma= (can be used IV if patients can’t tolerate oral prednisolone- 100mg every 6 hours until conversion to oral pred is possible
Anaphylaxis= 100-300mg administered as sodium succinate
What is the management of anaphylaxis in adult?
Remove trigger if possible Call for help early ABCDE assessment Administer oxygen and Lie patient flat and raise legs Administer adrenaline (Adult dose is 500 micrograms IM) Administer chlorphenamine and hydrocortisone IV fluid challenge if hypotensiv
When skills and equipment are available:
Manage airway
Attach patient to monitoring
Consider Intensive Care referral
What is the dose of chlorphenamine for adult allergic reactions?
10mg, repeated as necessary, max 4 doses per day
How do you manage anaphylaxis in children?
Remove trigger if possible Call for help Lie patient flat and lift their legs A —> E assessment Administer adrenaline
The management of a STEMI can be remembered as MMONAC, what does this stand for?
Morphine Metoclopramide Oxygen ( if sats <94%) Nitrates (GTN) Aspirin 300 mg Clopidogrel 300mg (although similar drugs are now being used as alternatives- ticagelor)
What is the acute management of ischaemic stroke?
A- E Airway protection (in impaired consciousness) and aspiration precautions (swallowing problems) are very important
How does alteplase work?
It is a tissue plasminogen activator
When should you start aspirin following a stroke?
If hyper acute treatment are not offered then aspirin 300mg should be started immediately once daily for two weeks
If hyper acute treatments are offered then aspirin is usually started 24 hours after the treatment following a repeat CT head that excludes any new haemorrhage stroke
What is the chronic management of an ischaemic stroke?
Can be remembered by HALTTS
H= Hypertension= studies show there is no benefit in lowering the blood pressure acutely (may impair cerebral perfusion) unless there is malignant hypertension, however antihypertensives should be initiated 2 weeks post stroke
A= Anti platelet therapy- patients should be administered clopidogrel 75mg OD for long term anti platelet therapy
HOWEVER IF THEY HAD A STROKE DUE TO AF YOU GIVE AN ANTICOAGULANT INSTEAD- DOAC (RIVAROXABAN/APIXABAN) OR WARFARIN 2 WEEKS AFTER THE STROKE
LIPID LOWERING THERAPY- ATORVASTATIN 20-90MG ONCE NIGHTLY
Tobacco- offer smoking cessation support
Sugar- screen for diabetes and manage appropriately
Surgery- Patients with ipsilateral carotid artery stenosis more than 50% should be referred for carotid endarterectomy
What is a PE?
Sudden blockage of a major blood vessel of the lung, usually by a clot
What are the risk factors for PE?
Can be remembered as A EMBOLISM…
A= Age Ex= previous DVT/PE M= MALIGNANCY- CANCER CARE B= BABY (PREGNANCY)- OBSTRETICS O= Oestrogen (OCT/HRT) L= Large (obesity) I= immune conditions/ inherited thrombophilias- antiphospholipid/ factor V Leiden M= MOBILITY (OPIC)
What are the ECG findings in a PE?
The most common in SINUS TACHYCARDIA
Other features- right heart strain (RBBB, right axis deviation, T wave inversion, ST segment changes)
S1Q3T3 (S wave in lead 1, Q and T wave inversion in lead 2)
How do you investigate a pregnant woman with a PE?
- don’t do D dimers
- Do a CXR, ECG, V/Q perfusion scan or CTPA (CTPA in preference to V/Q when clinical suspicion of PE and CXR is abnormal)
- complex duplex ultrasound if they are suspected of having a DVT
You also need to take some bloods before commencing pregnant women on anticoagulation
- FBC
- U and ES
- Coagulation screen
- Liver function tests
How do you manage a a pregnancy woman with DVT/PE?
LMWH if strong clinical suspicion you shouldn’t wait for IX to come back
The LMWH dose should be based on the booking clinic/ early pregnancy weight
Enoxaparin should be given for the duration of the pregnancy
Warfarin should not be given- it has a teratogenic effect although its use preclude breast feeding
Approaching delivery of the baby discuss with the obstretic team and consider the following…
1) substitute with unfractionated heparin, as this can be reversed readily
2) 6 hours before delivery you want to stop or reduce the heparin dose
What are massive PEs?
PEs which are significant enough to cause circulatory collapse
How do you investigate a PE normally?
Wells score
If it is low then D dimer
If high then CTPA
ECG
What is the usual treatment of a PE?
LMWH followed by an oral anticoag treatment (rivoroxaban, dabigatran)
