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Urgent Care Book > Emergencies & Resuscitation > Flashcards

Emergencies & Resuscitation Flashcards

1
Q

What is anaphylaxis?

A

a severe, life threatening hypersensitivity reaction

that is characterised by either airway and/or breathing and/or circulation problems (likely when all 3 are present, but all are not needed for diagnosis)

with sudden onset and rapid progression

and is usually associated with skin and mucosal changes

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2
Q

What are possible triggers of anaphylaxis?

A
  • idiopathic
  • food (esp. nuts)
  • drugs (esp. penicillin)
  • venom, stings
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3
Q

Anaphylaxis is a clinical diagnosis. What kind of symptoms can anaphylaxis present with?

A

Airway - swelling, hoarse voice, stridor

Breathing - SOB, wheezing, cyanosis, SpO2 <94%

Circulation - pale, clammy skin. tachycardia, hypotension, reduced consciousness

Skin & mucosal changes - flushing, urticaria, angioedema - not always present

Possible GI symptoms - vomiting, abdominal pain, incontinence

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4
Q

What is the management of anaphylaxis?

A
  1. IMMEDIATELY give IM adrenaline with 1mg/ml concentration ASAP in outer middle third of the thigh
    - repeat this every 5 minutes until an adequate response is seen

For adults & children >12 = 500mcg IM
6-12 years = 300mcg IM
6months - 6yrs = 150mcg IM
<6 months = 100-150mcg IM

  1. Then if there’s any allergens, remove/stop them (e.g. bee sting, drug infusion) - do NOT try to make a patient vomit
  2. Give high flow oxygen and monitor oxygen saturations - should be between 94-98%
  3. Monitor HR and BP. If patient is hypotensive after 5 minutes, (or if not responding after initial IM dose) then give IV fluid challenge
    500-1000ml in adults
    10ml/kg in children

Use a non-glucose containing crystalloid (e.g. Hartmann’s or 0.9% NaCl)

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5
Q

What position would you put a patient with anaphylaxis in based on their symptoms?

A

If the patient has airway or breathing problems - semi-recumbent position will make breathing easier

If the patient has circulation problem - lying flat with leg elevation to manage BP

If patient is breathing normally but unconscious - in recovery position (on side)

If patient is pregnant - lie on their left side to prevent aortocaval compression

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6
Q

If the patient can laryngeal oedema, what other option can be used as an adjunct to IM adrenaline to manage this?

A

Consider nebulised adrenaline (5ml of 1mg/ml)

but only after IM treatment, NOT as an alternative

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7
Q

If the patient is wheezy, what other option can be used as an adjunct to IM adrenaline to manage this?

A

Consider oxygen-drive nebulised salbutamol (SABA) and ipratropium (bronchodilator)

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8
Q

If the patient has been successfully resuscitated but still has skin symptoms like urticaria, what can you give?

A

Antihistamines - preferably cetirizine

10-20mg for people 12+

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9
Q

Why should all patients that receive adrenaline for anaphylaxis be admitted?

A

Due to risk of a biphasic reaction

which is a life-threatening recurrence of symptoms after the initial presentation WITHOUT re-exposure to the trigger

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10
Q

What is refractory anaphylaxis?

A

Anaphylaxis requiring ongoing treatment due to persisting respiratory or cardiovascular symptoms

despite 2 appropriate doses of IM adrenaline

In worst case - low dose IV adrenaline infusions
1mg adrenaline in 100ml of 0.9% NaCl
may be given but only by qualified professionals (resus team should be called at this point)

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11
Q

What is the BLS protocol summarised?

A
  1. Safety - make sure you, the patient and bystanders are safe (e.g. not in middle of road traffic)
  2. Response - gently shake patients shoulders and ask loudly in the ear “are you alright”
    - if the patient responds, leave them in the position they are in but re-assess regularly
    - if they don’t respond, continue with the protocol
  3. Airway - head tilt & chin lift
  4. Breathing - assess for max 10seconds - listen with one ear to their face, and feel with hand on their stomach
    - if any problem, prepare to start CPR
  5. Start CPR
    - 30 chest compressions with your arms straight in the centre of the chest, 5-6cm depth at 100-120bpm
    - followed by 2 rescue breaths into mouth - do not take longer than 10 seconds to do this
    - continue, change person every 2 mins
    - only stop if you are exhausted or if you are certain the patient has recovered
  6. AED
    - attach electrodes to bare chest
    - minimise interruptions to CPR
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12
Q

What are the shockable and non-shockable rhythms?

A

Shockable:
- ventricular fibrillation
- pulseless ventricular tachycardia

Non-shockable
- PEA (pulseless electrical activity) - there is electrical activity in the heart but it is not generating a heartbeat
- Asystole - no electricity or movement in heart

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13
Q

What is the ALS protocol summarised?

A
  1. CPR - 30 shocks : 2 rescue breaths
  2. Attach defibrillator/monitor and assess the rhythm
  3. If it is a shockable rhythm, give 1 single shock
  4. Immediately resume with 2 minute cycle of CPR
  5. If an advanced airway is required, rescuers with a high tracheal intubation success rate should use tracheal intubation
    - use waveform capnography to confirm tracheal tube position
    - give the highest feasible inspired oxygen
    - ventilate the lungs and continue chest compressions
  6. Attempt IV access for drug delivery - IO if IV is unsuccessful or not feasible
    - give 1mg IV/IO adrenaline ASAP for non-shockable rhythms
    - give 1mg IV/IO after the 3rd shock for patients with a shockable rhythm
    - repeat this every 3-5 mins
  7. After 3 shocks have been administered, give amiodarone 300mg IV/IO
    - after 5 shocks, give an additional 150mg
    - lidocaine can be an alternative
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14
Q

What are the 4H and 4T reversible causes of cardiac arrest or PEA?

A

4Hs:
- Hypoxia
- Hypovolaemia
- Hypo/Hyperkalaemia
- Hypo/Hyperthermia

4Ts:
- Thrombosis (coronary or pulmonary)
- Tension pneumothorax
- Tamponade (cardiac)
- Toxic/therapeutic disturbances

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15
Q

How would you manage a choking patient?

A
  1. encourage patient to cough
  2. give 5 back blows
    - stand to the side and slightly behind
    - support chest with 1 hand and lean patient forward
    - with the heel of the other hand, give a sharp blow between the shoulder blades
  3. If this isn’t working, give up to 5 abdominal thrusts
    - stand behind patient and put both arms around upper part of abdomen
    - lean patient forward
    - clean your first and place between the umbilicus and ribcage
    - grasp this with your other hand and pull sharply inwards and upwards
  4. continue alternating 5 back blows & 5 abdominal thrusts
  5. Start CPR if patient becomes unresponsive
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16
Q

Who are the 4 main groups at risk of opioid toxicity?

A
  1. Opioid addicts
  2. Chronic users after a period of abstinence - they lose their tolerance for it and may incorrectly judge what dose they need
  3. Long-term users who have become acutely unwell so increase their dose
  4. Palliative care patients
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17
Q

What are features of opioid toxicity?

A
  1. Respiratory rate <12 breaths/min
  2. Miosis (excessive constriction of pupils)
  3. Circumstantial evidence of opioid abuse - patches, track marks
  4. CNS depression
  5. Relative bradycardia
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18
Q

Management of opioid abuse

A
  1. Follow A-E approach
    - maintain airways through chin lift/head tilt or jaw thrust
    - simple airway adjuncts if necessary - oro or nasopharyngeal airway
    - for breathing - bag valve mask and supplemental oxygen
  2. Naloxone administration - should be tailed according to severity of presentation
    - typically give 400mcg IM naloxone while you establish IV access
    - after this IV infusion of naloxone
    - naloxone duration is 30-90mins, so repeated doses may be needed
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19
Q

What is a seizure?

A

Transient occurrence of signs and symptoms due to abnormal electrical activity in the brain

They can manifest as loss of consciousness, motor function or sensation

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20
Q

What is status epilepticus?

A

A continuous seizure for 30 minutes or longer

OR recurrent seizures lasting 30mins or longer without regaining consciousness

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21
Q

What are potential causes of status epilepticus in patients with known epilepsy?

A
  • poor anti-epileptic drug control
  • reduced drug absorption
  • sleep deprivation
  • infection
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22
Q

What are potential causes of seizures in patients that do not have epilepsy?

A
  • ischaemic stroke
  • hypoxaemia
  • traumatic brain injury
  • CNS infection
  • alcohol withdrawal
  • metabolic disturbances
  • hypo/hyperglycaemia
  • hyponatraemia
  • hypercalcaemia
  • hypomagnesemia
23
Q

What investigations would you carry out in patients that do not have a diagnosis of epilepsy but are having seizures?

A
  • 12 lead ECG
  • blood tests - inflammatory markers, blood glucose, biochemistry
  • chest X-ray
  • brain imaging
  • lumbar puncture
  • urine and serum toxicology
24
Q

Management of repetitive/prolonged seizures?

A
  1. Airways - open airways, consider nasopharyngeal airway if necessary
  2. FiO2 100% high flow Oxygen
  3. Protect patient from any injuries - cushion their head, remove any harmful objects nearby
  4. Gain IV access and consider benzodiazepines
    - the preferred drug is IV Lorazepam 4mg, repeat after 5 minutes
  5. If IV access is unavailable, 10mg Midazolam
  6. If patient has a known epilepsy diagnosis, escalate their usual anti-epileptic drug therapy
  7. Escalate to neurology reg or consultant
25
What are the 3 options for medical management for status epilepticus?
1. IV Levetiracetam up to 60mg/kg over maximum 4500mg over minimum 10mins 2. IV Phenytoin 20mg/kg maximum 2g over 40mins requires cardiac monitoring 3. IV Valproate up to 40mg/kg maximum 3000mg over 5 mins
26
What are febrile seizures?
Occur in childhood after 1 month of age, up to 6 years with a peak at 18 months associated with a febrile illness NOT caused by CNS infection and no previous seizures
27
What are the 3 types of febrile seizures?
1. Simple - generalised tonic-clonic, lasts less than 15 mins, only one in 24hr period 2. Complex - can be focal; or prolonged (more than 15 mins) or multiple (more than 1 in 24hrs) 3. Febrile status epilepticus - seizure lasts more than 30 mins; or recurrent seizures without full recovery of consciousness
28
What are red flag symptoms that indicate that the febrile seizures are due to a CNS infection?
- irritability, decreased feeding and lethargy - bulging fontanelle, neck stiffness, photophobia - incomplete vaccinations - prolonged post-ictal phase (the phase after the seizure ends and patient returns to normal)
29
Management of febrile seizures
1. open airway if necessary 2. protect child from injury - cushioning 3. put in recovery position when seizure has stopped 4. 1st line is buccal midazolam 300mcg/kg 5. second doses of benzodiazepines are only given if the seizure is ongoing after 10mins
30
What is the definition of sepsis?
A life threatening organ dysfunction occurs due to a dysregulated host response to infection (basically immune system over reacts) it is a time critical emergency
31
Risk factors for sepsis
- age <1 and >75 - frailty - immunocompromised - indwelling lines and catheters - IV drug use - recent surgery or invasive procedure in last 6 weeks - pregnant women, women who gave birth, has a miscarriage or termination in the last 6 weeks
32
What are non specific and specific symptoms of sepsis?
Non-specific symptoms include: - fever - lethargy - confusion - myalgia Specific symptoms are based on the infective source, this can include: - respiratory - dyspnoea, productive cough - urinary - dysuria, cloudy/foul smelling urine, urinary frequency or urgency - GI - diarrhoea, abdominal pain - skin - erythema, swelling - CNS - neck stiffness, photophobia, confusion
33
NICE recommends using red flag and amber flag criteria to manage patients with potential sepsis. What are the red flag criteria?
1. Behaviour: alteration in mental state/ confusion 2. Heart rate >130bpm 3. Resp rate >25bpm; or patient now requires oxygen to maintain saturations 4. Systolic BP <90mmgHg 5. Urine output - not passed urine in 18hrs; or <0.5ml/kg output in catheterised patients 6. Skin - mottled OR cyanosis OR non-blanching rash
34
NICE recommends using red flag and amber flag criteria to manage patients with potential sepsis. What are the amber flag criteria?
1. Behaviour: alteration in mental state/ confusion 2. Heart rate 91-130bpm 3. Resp rate 21-25bpm 4. Systolic BP 91-100mmgHg 5. Urine output - not passed urine in 12-18hrs; or 0.5 -1ml/kg output in catheterised patients 6. Temperature <36
35
What is the sepsis 6 bundle?
In any patients with suspected sepsis, the sepsis 6 bundle should be started ASAP can remember it with BUFALO 1. Blood cultures - check blood glucose, FBC, U&Es, CRP 2. Urine output - ensure fluid balance chart is complete hourly; may require catheter 3. Fluids - if the patient is hypotensive or lactate is >2mmol/L, give 500ml IV crystalloid stat and assess 4. Antibiotics - according to trust protocol 5. Lactate - take serial measurements, especially if >2mmol/L or if NEWS is increasing. Escalate if it rises above 4. 6. Oxygen - keep saturation at 94-98% but at 88-92 in pt is at risk of CO2 retention ALSO, always ensure you have escalated to a reg or consultant
36
What are investigations that can be carried out to determine a cause for sepsis?
1. FBC - assess for neutrophilia or neutropenia (neutropenic sepsis is a medical emergency) 2. Urea and electrolytes - assess renal function 3. Liver function tests - assess for liver dysfunction 4. Blood cultures - plus cultures from invasive lines if present 5. Urine culture - to identify UTI 6. Viral swabs - including COVID-19 7. Sputum culture - if productive cough is present 8. Stool culture - if diarrhoea is present 9. Lumbar puncture - if suspecting meningitis 10. Chest X-ray: to assess for pneumonia 11. Ultrasound / CT abdomen: if suspecting intra-abdominal infection 12. Echocardiography: if suspecting endocarditis
37
What are possible complications of sepsis?
- Shock - ARDS - Acute/chronic renal injury - Acute liver failure - Multi-organ failure - Death
38
What is neutropenic sepsis?
Defined as a temperature > 38 with (or without) any symptoms/signs of suspected sepsis and a neutrophil count of < 0.5 x10^9/L
39
Common causes of neutropenic sepsis?
Most commonly in patients on anticancer or immunomodulatory treatment Can be due to: - infection - HIV, TB, EBV - haematology pathology - aplastic anaemia, leukaemia - drugs - carbimazole - B12 or folate deficiency
40
Management of neutropenic sepsis
- refer immediately to oncology or haematology - 1st line = monotherapy with Piperacillin & Tazobactam 4.5g IV QDS - if a patient is allergic to penicillin, then give Ciprofloxacin 400mg IV BD and Vancomycin 1g IV BD - give IV fluids - for high risk patients give Filgastrim 300mcg sc
41
What is meningitis?
Inflammation of the meninges, the membranes covering the brain and spinal cord (dura mater, arachnoid and pia mater) Viral meningitis is more common, but bacterial has a higher mortality - all cases should be treated as bacterial until proven otherwise
42
What is meningococcal disease?
This refers to - meningococcal meningitis - meningococcal septicaemia - or a combination of both
43
Risk factors of meningitis?
- age < 5years - winter season - immunocompromise - smoking - overcrowding
44
What are the most common bacterial causative agents of meningitis?
- streptococcus pneumoniae - Neisseria meningitidis - haemophilus influenzae
45
What are the most common viral causative agents of meningitis?
- enteroviruses like coxsackie - herpes zoster - influenza
46
What is the classical triad of features seen in meningitis?
1. fever 2. neck stiffness 3. altered mental state but this is not always present, esp. in children
47
What are some common, non-specific signs of meningitis?
- fever - nausea and vomiting - lethargy - headache - irritability - muscle or joint pain - respiratory symptoms - SOB
48
What are some specific signs of meningitis?
- bulging fontanelle - photophobia - high pitched cry - stiff neck - back rigidity - non blanching rash - mottled skin - cold hands/feet with reduced capillary refill - leg pain from ischaemia - altered mental state - shock - tachycardia, hypotension, poor urine output) - neurological symptoms - seizures, paresis
49
What are Kernig's and Brudzinski's signs?
These can indicate meningeal irritation but should not be relied on for diagnosis Kernig's = pain and resistance on knee extension with hips fully flexed Brudzinski's = knees and hips flex on bending the head forward
50
What are potential differential diagnosed of meningitis?
- influenza or other viral illness - sepsis - encephalitis - brain or CNS malignancy
51
What is the gold standard investigation for diagnosing bacterial meningitis?
Lumbar puncture - if possible perform within 1hr of arriving at hospital before antibiotics - but if it is delayed then start antibiotics - do not perform is patient is showing signs of shock or seizures
52
Management of meningitis
Should always be treated as bacterial unless proved otherwise - if not in a hospital setting, give IM or IV benzylpenicillin and urgently transfer to hospital - in hospital, for children 3 months and older give IV Ceftriaxone - in children under 3 months, give IV Cefotaxime + Amoxicillin - once a specific causative agent has been identified, adjust treatment accordingly
53
What are possible complications of meningitis?
- sepsis, septic shock - seizures - death - permanent neurological complications - hearing loss, visual disturbances, cognitive disturbances
54

Urgent Care Book (11 decks)

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