Emergencies & Resuscitation Flashcards
What is anaphylaxis?
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
What are possible triggers of anaphylaxis?
- idiopathic
- food (esp. nuts)
- drugs (esp. penicillin)
- venom, stings
Anaphylaxis is a clinical diagnosis. What kind of symptoms can anaphylaxis present with?
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
What is the management of anaphylaxis?
- 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
- Then if there’s any allergens, remove/stop them (e.g. bee sting, drug infusion) - do NOT try to make a patient vomit
- Give high flow oxygen and monitor oxygen saturations - should be between 94-98%
- 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)
What position would you put a patient with anaphylaxis in based on their symptoms?
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
If the patient can laryngeal oedema, what other option can be used as an adjunct to IM adrenaline to manage this?
Consider nebulised adrenaline (5ml of 1mg/ml)
but only after IM treatment, NOT as an alternative
If the patient is wheezy, what other option can be used as an adjunct to IM adrenaline to manage this?
Consider oxygen-drive nebulised salbutamol (SABA) and ipratropium (bronchodilator)
If the patient has been successfully resuscitated but still has skin symptoms like urticaria, what can you give?
Antihistamines - preferably cetirizine
10-20mg for people 12+
Why should all patients that receive adrenaline for anaphylaxis be admitted?
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
What is refractory anaphylaxis?
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)
What is the BLS protocol summarised?
- Safety - make sure you, the patient and bystanders are safe (e.g. not in middle of road traffic)
- 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 - Airway - head tilt & chin lift
- 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 - 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 - AED
- attach electrodes to bare chest
- minimise interruptions to CPR
What are the shockable and non-shockable rhythms?
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
What is the ALS protocol summarised?
- CPR - 30 shocks : 2 rescue breaths
- Attach defibrillator/monitor and assess the rhythm
- If it is a shockable rhythm, give 1 single shock
- Immediately resume with 2 minute cycle of CPR
- 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 - 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 - After 3 shocks have been administered, give amiodarone 300mg IV/IO
- after 5 shocks, give an additional 150mg
- lidocaine can be an alternative
What are the 4H and 4T reversible causes of cardiac arrest or PEA?
4Hs:
- Hypoxia
- Hypovolaemia
- Hypo/Hyperkalaemia
- Hypo/Hyperthermia
4Ts:
- Thrombosis (coronary or pulmonary)
- Tension pneumothorax
- Tamponade (cardiac)
- Toxic/therapeutic disturbances
How would you manage a choking patient?
- encourage patient to cough
- 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 - 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 - continue alternating 5 back blows & 5 abdominal thrusts
- Start CPR if patient becomes unresponsive
Who are the 4 main groups at risk of opioid toxicity?
- Opioid addicts
- Chronic users after a period of abstinence - they lose their tolerance for it and may incorrectly judge what dose they need
- Long-term users who have become acutely unwell so increase their dose
- Palliative care patients
What are features of opioid toxicity?
- Respiratory rate <12 breaths/min
- Miosis (excessive constriction of pupils)
- Circumstantial evidence of opioid abuse - patches, track marks
- CNS depression
- Relative bradycardia
Management of opioid abuse
- 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 - 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
What is a seizure?
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
What is status epilepticus?
A continuous seizure for 30 minutes or longer
OR recurrent seizures lasting 30mins or longer without regaining consciousness
What are potential causes of status epilepticus in patients with known epilepsy?
- poor anti-epileptic drug control
- reduced drug absorption
- sleep deprivation
- infection
