Emergency Flashcards
Anaphylaxis Tx
0.5mg 1 in 1000 IM adrenaline
10mg Chlorphenamine IM/IV
200mg Hydrocortisone IM/IV
+/- 5mg nebulised salbutamol
Management of ?hypovolaemic shock
- Ix
- Tx
Ix:
- FBC (hb), U&Es, LFTs
- Cross match
- ABG (metabolic acidosis from hypoperfusion?)
- ECG
- FAST scan (assess for haemorrhage)
- CXR and AXR
Tx
- A + B (O2)
- Raise legs
- Fluid challenge (500ml 0.9% NaCl over 15 mins) –> give up to 2L then consider blood
- Aim: SBP >90, HR <100, UO >0.5ml/kg/hour
Stop bleeding
When is the major haemorrhage protocol indicated
30-40% blood loss
SBP <90
HR >110
? traumatic injury (e.g. splenic rupture or RTA)
What is given in the major haemorrhage protocol
4U RBC + 4U FFP
+ tranexamic acid
Give RBC and FFP in ratio 1:1 if bleeding does not stop.
Also platelets + cryoprecipitate
Cardiogenic shock
- definition
- Ix
Tissue hypoperfusion due to reduced CO due to damage to the heart.
Ix
- Cardiac markers (troponin, BNP)
- ECG
- Echo
- FBC, U&Es, LFTs, Ca2+
- ABG
- CXR (pneumothorax, pulmonary oedema, cardiomegaly)
Management of cardiogenic shock
If airway is compromised refer to senior.
Usually treated in CCU/ITU
- vasopressors
- cautious fluid resuscitation (risk of HF)
- hourly ECG or arterial line for CCM
- monitor UO (catheter)
- NIV
Treat underlying cause
- e.g. MI
When does septic shock need to be managed in critical care
- NEWS >7
- Lactate >4mmol/L
- Hypotension not responding to tx (vasopressors needed)
- Inotropes needed (hypotension refractory to vasopressors and MI has been ruled out)
What is present in septic shock
- Lactate >2mmol/L
- Vasopressors required to keep MAP >65mmHg
Management of sepsis
Elevate legs
Blood cultures (ideally from 2 sites) Urine output (monitor, ?catheter) Fluid challenge Antibiotics (within 1 hour) Lactate levels Oxygen (if hypoxic)
Ix in acute respiratory failure
Oxygen saturations
ABG (type 1 or type 2)
CXR (underlying pathology)
Management of acute respiratory failure
Oxygen. Aim for:
- 94-98% in type 1
- 88-92% in type 2
NIV if:
- kPa <8 despite 60% oxygen
- CO2 rising in type 2
- escalate and ? if need for intubation
Treat underlying cause
Ix if ? paracetamol overdose
- Paracetamol levels (4h post-ingestion)
- LFTs, prothrombin, INR
- Blood glucose
- U&Es, FBC
- ABG (metabolic acidosis)
- Toxicology screen (urine)
When to treat paracetamol overdose with NAC
> 150mg/kg ingested = NAC ASAP
4-8h since ingestion = if paracetamol levels above treatment line on nonogram
> 8 hours since ingestion = give NAC while awaiting paracetamol levels
> 15 hours since ingestion and >75mg/kg ingested
Staggered overdose
When is activated charcoal indicated in paracetamol overdose?
- dose?
<1h since ingestion
50mg PO
NAC regime
1st bag = 150mg/kg over 1 hour
2nd bag = 50mg/kg over 4 hours
3rd bag = 100mg/kg over 6 hours
Monitor for anaphylactoid reaction.
If occurs STOP + restart at slower rate when reaction has resolved.
when is liver transplant indicated in paracetamol overdose
pH <7.3 24 hours after overdose OR PT >100 OR Creatinine >300
When to escalate paracetamol overdose to senior
- Clinical signs of liver injury (RUQ pain, N+V, jaundice, asterixis, encephalopathy)
- AKI (Cr >300)
- pH <7.3
- hypoglycaemia
- deranged clotting
- lactate >3.5 on admission
when is 50mg activated charcoal indicated in salicylate overdose
<1h since ingestion
>125mg/kg ingested
Mild salicylate overdose
- plasma levels
- tx
<300mg/L
IV rehydration
K+ infusion if high K+ (aim for 4-4.5)
Moderate salicylate overdose
Severe salicylate overdose
- plasma levels
- tx
Moderate = 300-700mg/L Severe = >700mg/L
IV rehydration and replace K+ (aim for 4-4.5)
1.5L of 1.26% Sodium bicarbonate (urinary alkalisation, aim for pH 7.5-8)
CPAP/NIV
Benzodiazepines if seizures
Cooling if >39o
When is haemodialysis indicated in salicylate overdose
plasma salicylate level >900mg/L
plasma salicylate level >700mg/L + metabolic acidosis
coma
acute renal failure
pulmonary oedema
seizures
Ix if ?salicylate overdose
Serum salicylate levels
- 2h after ingestion then every 2 hours until peak.
ABG (mixed respiratory alkalosis and metabolic acidosis)
FBC, U&Es, LFTs, clotting, blood glucose (low)
ECG
Ix if ? TCA OD
ECG
- tachycardia
- PR prolongation
- QRS prolongation
ABG (metabolic acidosis)
Bloods + urinalysis for other drug screen
Tx for TCA OD
IV Sodium bicarbonate (if QRS widened)
Anti-arhythmic (not amiodarone)
IV fluids (correct hypotension)
BDZ if seizures
Ix if iron overdose
Serum iron levels
- immediately
+ after 4 hours (peak levels)
ABG (acidosis)
AXR
FBC, U&Es, LFTs, clotting
Initial Tx of iron OD
A-E + TOXBASE
IV fluid resuscitation
When is whole bowel irrigation indicated in iron overdose
<1h since OD
>60mg/kg ingested
When is medical treatment indicated in iron overdose
- what is it
15mg/kg/hour IV dexferoxamine
>90micromol/L 4-6h post ingestions systemic toxicity metabolic acidosis altered mental state
What tests are included in a confusion screen?
- Bloods
- Imaging
- other
Bloods:
- FBC
- B12, folate, ferritin
- U&Es
- CRP
- LFTs
- coagulation screen
- TFTs
- Ca2+
- Glucose + Hba1c
BP (lying and standing) ECG Visual/hearing test urinalysis medication review
CXR
CT/MRI head if ? injury
How to assess falls risk
Timed get up and go test
- patient asked to stand from sitting
- walk 3m
- turn 180 degrees
- walk back.
If >12s = falls risk
When is immediate evaluation needed of an elderly patient who has had a fall
Acute change in consciousness
? stroke
? seizure
? hypotension
Head trauma
Persistent pain and inability to weight bear
? fracture
when is medication indicated for delirium + what is it
Last resort if correcting precipitating factors has been unsucessful.
- 5mg Haloperidol (Avoid if parkinsons)
- 5mg lorazepam
titrate 2 hourly until response
do not use for >1 week.
