Emergency Flashcards
Drugs that can cause hypoglycemia
Excess antidiabetic agents - insulin, glicazide
Excess paracetamo, apsirin, sulphonylureas
Treatment of hypoglycemia
1- conscious + can swallow
2- conscious+ cant swallow
3-unconscious
1- 200ml fruit juice oral oral glucose gel
2- 200ml 10% glucose IV or 1mg glucagon IM or SC
3- IV 75ml of 20% glucose or 1 mg glucagon IM or SC
When is glucagon ineffective in the treatment of hypoglycemia
Alcohol related hypoglycemia
Wallace rule of 9
Each full arm - 9 Head+ neck = 9 Ant leg = 9 Post leg = 9 Ant chest = 9 Post chest = 9 Ant abdomen = 9 Post abdomen = 9 Perineum = 1%
Superficial epidermal burn appearance
1st degree
Red + painful
Pale pink painful blistered skin after house fire
Type of burn?
Partial thickness (superficial dermal) 2nd degree
Non blanching erythema, reduced sensation at site of burn
Type of burn
Partial thickness, deep dermal
2nd degree
White/ brown/black burn
No blisters
Not painful
Type?
Full thickness
3rd degree
Immediate management burns
Thermal
Chemical
Electrical
ABC
Remove non adherent clothing
Thermal - remove them from source of heat, irrigate wound with cool water b/w 10-30 mins, cover with cling film (layered not wrapped)
Chemical - brush any powder off and then irrigate for 1 hour - do not attempt to neutralise
When to refer to secondary care in burn cases
All full thickness cases
Deep dermal > 5 % in adults, all deep dermal burns in children
Superficial dermal burns - face hands feet, perineum, genitalia, flexures or circumferential burns of abdomen , limbs or torso or neck
Any inhalation injury
Any electrical or chemical burn
Suspicion of non accident injury
Management of burns
ABC, referral criteria
Sup epiderm al analgesia, emollient
Sup dermal - cleanse wound, leave blister intact
= avoid topical creams and apply non adherent dressing - review 24 hrs
Management of severe burns
Stop burn process and resuscitate
Analgesia
IV fluids , insert catheter
= > 10% TBSA in children , >15% in adults
Echarotomies - in circumferential full thickness burns of torso or limbs
IV fluid calculation in burns
Parkland formula
TBSA% x Kg x 4 = ml
50% given in first 8 hrs
50% over best 16 hrs
Starting point of resuscitation in burns
Time of injury
Referrals for burns (burns unit)
> 5% children
10% adults
Give IV fluids if > 10, 15% adults
Burns of hands perineum face
RFs for paracetamol overdose
Liver enzyme inducing drugs - CRAP GPs
Malnourished patients - anorexia, bulimia, hepatitis C , cystic fibrosis, HIV
Patient who have not eaten for few days
Management
- investigations
- treatment
FBC UE LFT INR blood gas glucose
-Serum paracetamol @ >=4 hr post ingestion if >150mg/kg consumed or unknown amount (NOT post admission)
-Admit anyone with ingestion within 8 hrs >150mg/kg (>24 pills) or unknown amount
- if presents within 1 hr with >150mg/kg - activated charcoal
-N- acetyl cysteine = 5 situations
Liver transplant
When should n acetyl cysteine be given in paracetamol overdose (5)
- staggered overdose - all tablets were not taken within 1 hr
- doubt over paracetamol ingestion - regardless of plasma paracetamol concentration
- if plasma conc paracetamol (@ 4 hrs) is above appropriate line
- > 8hrs (late presentation) + ingested >150mg/kg or dose unknown
- jaundice or liver tenderness
Features of paracetamol poisoning
- 24 hrs
- 48 hrs
Initial - nausea , vomiting, pallor
24 0- hepatic enzymes rise
48- jaundice, enlarged liver
Hypoglycaemia, hypotension, encephalopathy, coagulopathy, coma can also occur
Liver transplant criteria in paracetamol overdose ?
Arterial ph <7.3, 24 hrs after ingestion Or all of the following : - PT > 100 s - creatinine > 300 umol/l - grade III or IV encephalopathy
Hepatic encephalopathy grading
1 - behavioural changes, mild confusion, slurred speech, disordered sleep
2- lethargy, moderate confusion
3- stupor, incoherent speech, sleeping but arousable
4- coma, unresponsive to pain
Aspiration of FB in child
Next step?
Indirect laryngoscopes +- fibre optic examination of pharynx
If ^ not given and you see direct , pick that
Magills forecps
Where are they used?
Direct laryngoscopy
Treatment of opioid overdose
IV naloxone
- fast action , short duration
Can be repeated every 2-3 minutes if no response
Shorter half life than methadone
Features of opioid overdose (4)
Symmetrical Miosis
Respiratory depression
Bradycardia
Altered consciousness
= low RR BP HR and pinpoint pupils
NICE guidelines on head injury - Immediate CT (within 1 hr ) Adults (7)
- GCS <13
- GCS <15 @ 2hrs post injury
- Open/depressed skull frx
- Any sign if basal skull fracture
- post traumatic seizure
- Focal neurological deficit
- > 1 episode of vomiting
Signs of basal skull fracture (4)
Haemotympanum
Panda eyes
CSF leakages - ear nose
Battles sign
NICE guideline CT head - head injury
Within 8 hours
Adults (6)
Adult + Loss of consciousness or amnesia + RFs:
- > = 65 years old
- history of bleeding or clotting disorders/ on warfarin
- dangerous mechanism of injury
- > 30 mins of retrograde amnesia - can’t remember events before injury
What GCS is an indication for intubation
= 8
CT guidelines head injury - within 1 hr
Children (6)
Seizure GCS < 14 - initial assessment GCS <15 after 2 hrs of injury Basal skull fracture signs Tense fontanelle/open skull fracture/ depressed fracture Focal neuro deficit
CT head within 1 hr in children
According to RF in head injury (6)
Head injury + >/= 2 of the following - LOC >/= 5 mins Amnesia >/= 5 mins >/= 3 episodes vomiting FFH> 3 metres RTA high speed Abnormal drowsiness
If only 1 RF - observe for at least 4 hrs after injury
Management of anaphylaxis
ABC , high flow O2, lay patient flat
IM adrenaline - ant lateral aspect middle 1/3 thigh
Observe for 6-12 hrs after onset of symptoms
Serum tryptase - sometime taken to establish anaphylaxis
- remain elevated up to 12 hrs
If hypotensive - give IM adrenaline 1st then IV fluids
Doses of epinephrine/hydrocortisone/chlrophenamine <6 mo 6mo - 6 years 6-12 years Adults/ children > 12
<6 mo - 150mcg/ 25mg / 250mcg/kg
6-6 yrs - 150mcg / 50mg / 2.5mg
6-12 - 300 mcg / 100mg/ 5 mg
Adults - 500 mcg / 200mg / 10 mg
Adrenaline/ epinephrine
(MCG/1000= ml ) 1 in 1000
E.g 0.15 ml 1 in 1000
What causes tingling in panic attacks
Hypocalcemia
- caused by resp alkalosis due to CO2 washout
Management of panic attacks
Upcoming attack - beta blocker
During : Breathing excercise - paper bag
If severe and ongoing
- benzo
Long term - CBT , SSRIs
Diaphragmatic rupture
- dx
- features
Chest and abdominal pain , resp distress, diminished breath sounds
Usually left side affected
Dx - initial - CXR - unreliable (curt NGT in stomach is pathognomonic)
Thoracoabdominal CT - diagnostic
Confusion + ataxia + squint in
chronic alcoholics
Treatment
Chronic alcohol syndrome
Urgent IV thiamine
Vitamin B1
Confusion ataxia and squint
+ retrograde amnesia + confabulation
Dx?
Wernicke’s korsakoff syndrome
Aspirin overdose
Symptoms - earliest, clinically significant
Acid-base abnormality
Tinnitus , impaired hearing - early
Hyperventilation, nausea, vomiting, dehydration fever double vision
Feeling faint
Early - resp alkalosis
Late - metabolic acidosis
Excessive sedation, dry mouth, skin Tachycardia, dilated pupils ECG - prolonged QRS, QT, PR Suspected overdose? Treatment?
TCA
IV fluid bolus 250ml NS
IV sodium bicarbonate 50-100ml 8.4% slowly - corrects ECG changes
Aim for pH 7.5-7.55
Organophosphate overdose
Features
Increased saliva ,tear production, diarrhoea Vomiting Small constructed pupils Sweating Muscle tremors Confusion
Plummer Vinson syndrome
Triad -
Treatment
Dysphagia
Glossitis
IDA
Treatment - iron supplementation, dilation of webs
Boerhaave syndrome
Severe vomiting - oesophageal rupture
Management of Mallory Weiss tear
If vitally stable and hemodynamically stable =
- discharge with advice or repeat FBC or observe vitals for fear of deterioration
Discharge low risk blatchford score patients
Severe - resuscitation ( high flow O2, IV fluids, IV blood)
Blatchford score : low risk
SBP >/= 110 Urea < 6.5 Hb >/= 13 males or >/= 12 females Pulse < 100 Absence of melena , liver disease, HF, syncope
Admission and early endoscopy for GI bleed + calculation of Rockall score if :
SBP <100 and pulse >/= 100 - hemo disturbance
Continued bleeding
Age >/= 60, all patients over 70 should be admitted
Liver disease, HF , known varices
Class 1 hemorrhage can shock
<750 ml blood loss / <15% Pulse < 100 Normal BP RR 14-20 UO >30 ml Normal sx
Class II hemorrhagic shock
750-1500 ml blood loss (15-30%) Pulse 100 199 Normal BP RR 20-30 UO. 20-30 ml Anxious
Class III hemorhhagic shock
1500-2000 ml blood loss / 30-40% Pulse 120-139 Decreased BP RR 30-40 UO 5-15ml Confused
Class IV hemorhhagic shock
>2000 ml blood loss / >40% Pulse > 140 Decreased BP UO < 5 ml Lethargic
CO poisoning
Causes
Features
Investigation of choice
Cause - car exhaust, fires, faulty gas heaters, paints
Paint = methylene chloride (dichloromethane) from paint fume
IOC - carboxyhaemoglobin levels
Features- severe dizziness, headache (tension), malaise, vomiting
If severe - pink skin and mucosa, fever, hyperventilation, arrhythmia, coma
Management of CO poisoning
ABC
100% oxygen via tight fitting mask - if conscious
If unconscious / SBP <100 - intubate + ventilate IPPV 100% O2
Management of upper GI bleed due to varices
- Initial step - IV fluids
2- terlipressin - 2mg IV repeat every 4-6 hrs + prophylactic antibiotics
- cipro or cephalosporin
3- endoscopy -
Oesophageal - band ligation
Gastric -N butyl 2 cyanoacrylate inj - Transjugular intrahepatic portsystemic shunt (TIPS) - if bleeding not controlled with above measures
Avoid PPI unless known peptic ulcer pt
INR prolonged - Vitamin K
Liver disease + haematemesis + raised INR = FFP
Active bleeding + Plt < 50000 - transfusion of platelet s
Pelvic fracture with urinary retention
Next step
Suprapubic catheter
- why?
= post urethral tear usually associated with pelvic frx
When should you suspect urethral injury in pelvic frx
How do you manage it?
perineal bruising, blood at external meatu s
PR = abnormal high rising prostate or inability to palpate prostate
Refer to urology - suprapubic cath +- retrograde/ascending urethrogram imaging to assess injury
Management of flail chest
Avoid over hydration and fluid overload
1-Vitally stable + normal vitals + normal sats
= analgesia
- paracetamol/NSAIDs/opiates/intercostal block*/thoracic epidural up to T4
2- vitally unstable
= ABC / high flow O2 and analgesia
3-drowsy, laboured breathing, worsening RR
- intubate (double lumen ETT)
Hereditary angioedema
Cause?
Inheritance pattern
Autosomal dominant
Low plasma levels of C1 esterase inhibitor (C1-INH) protein - during attack
Low C2 C4
Serum C4 - most reliable , screening tool
Hereditary angioedema
- symptoms
Recurrent episodes of facial and tongue swelling
Family history
Attacks may be proceeded by painful macular rash
Occasionally presents as abdominal pain - viscera oedema
Urticaria not really a feature
Hereditary angioedema
- management
= acute , prophylaxis
Acute
- IV C1 inhibitor concentrate
^ FFP if not available
Prophylaxis
- anabolic steroid Danazol may help
When does heroin withdrawal begin & peak
12 hours after last dose - starts
Peak - 24-48hrs
When does benzodiazepine withdrawal begin
1-4 days - begins
Peaks @ 2 weeks
Cocaine
- withdrawal starts
- peaks at
- within hours of last dose
Peaks in few days
Alcohol withdrawal sx
- 6-12 hours
- incidence of seizure
- delirium tremens
Sx - tremors sweating tachycardia anxiety
Seizure - 36. Hrs is peak incidence
Peak incidence of delirium - 48-72 hrs
= coarse tremor , confusion, delusions, auditory and visual hallucinations, fever, tachycardia
Management of acute alcohol
1 - Chlordiazepoxide (benzodiazepine)
2- if seizure use - lorazepam or diazepam
3- vitamin B1 - IV pabrinex
Drug for alcohol abstinence
Disulfiram
Drug to reduce craving for alcohol withdrawal
Acamprosate
Metabolic disturbance in ecstasy overdose
Metabolic acidosis
- increased venous lactic acid
Sx of ecstasy overdose
Tachycardia tachypnea
Thirst
Agitation confusion
Hyperthermia, spots of colours (flashing)
Uncontrolled body movements, muscle rigidity
Treatment of ecstasy
Supportive : ABC + treat metabolic acidosis
IV diazepam or lorazepam - for agitation
Dantrolene for hyperthermia
LSD overdose
Sx
Delusions and hallucinations Mydriasis Flushing sweating TremorsHyperreflexiaDiarrhoea Paraesthesia Smells colours sees sounds Sees colours when eyes are closed
Thoracic aortic rupture Clinical features CXR changes Site injured commonly Dx
Contained hematoma = persistent hypotension
CXR - wide mediastinum, trachea/oesphagus to the right
Dx - CT aortogram
Proximal descending aorta
Femur frx management
Stable (SBP >100 ) - Thomas splint first, then IV fluid ABCDE
- align frx to reduce further blood loss
Not stable ABCDEs (ATLS)
Burn injury + evidence of airways obstruction
What do you do?
Cal senior ED/ anaesthetist
Urgent tracheal intubation
CPR ratio
Adults - 30:2
Paeds
- layman 30:2
- professional 15:2
Splenic trauma
Management
FAST US - Iofchoice or CT scan- subcapsular hematoma
Stable - observation
Unstable + free peritoneal fluid - emergency laparotomy
Urticaria
Treatment
Oral antihistamine
IM adrenaline - if in anaphylactic shock
Unilateral dilation of pupil
Suspect
Space occupying lesion
Bilaterally constructed pupils
Suspect
Opiate overdose - heroin morphine
CVA affecting brainstem
Bilaterally dilated pupils
TCA overdose
Cocaine overdose
Side effects of benzodiazepines
Respiratory distress - apnea Hypotension Anterograde amnesia Sedation Cognitive impairment
Mild vs severe airway obstruction
Treatment
Mild - able to speak , cough, breathe
Severe - wheezy breath, silent coughs
Mild - encourage them to cough
Severe - 5 back blows if unsuccessful - 5 Heimlichs or for kids < 1 yr - 5 chest thrusts
If unconscious - call ambulance , start cpr
Aspirin and paracetamol cause what metabolic disturbance
Metabolic acidosis
Aspirin/as;icy late - early = resp alkalosis
Late = met acidosis
ACEi and NSAIDS
Metabolic alkalosis
Acid base disturbance caused by benzodiazepines
Respiratory acidosis
MAIIAD
Metabolic acidosis drugs Metformin Aspirin Isoniazid Iron Alcohol Digoxin
Causes of metabolic acidosis
MAIIAD
Diarrhoea
Renal insufficiency
Addisons
Metabolic alkalosis causes
ACEi, NSAIDs Diuretic Vomiting Hypovolemia, HypOkalemia 2ry hypoparathyroidism
Respiratory acidosis causes
Any cause of airway obstruction
Benzos, organophosphates
COPD
Pneumothorax, haemothorax, ascites
Respiratory alkalosis causes
Any cause of hyperventilation - high RR Pulm embolism Salicylate, aspirin (early poisoning) Mechanical ventilation - rapid ventilation Panic attack
Mixed acidosis seen in
Treatment
Cardiac arrest
Low pH, high pCo2, low HCO3
= accumulation of CO2 , kidneys not perfused due to low cardiac output
Increase ventilation
Pulmonary embolism vs panic attack
Respiratory alkalosis
PE - low PaO2
PA - normal PaO2
qSOFA
Heightened risk of mortality if score = or > 2
RR > 22/min
Altered mental state
SBP <100
Red flag sepsis criteria
Unresponsive/ responds to voice or pain SBP = 90 or >40 mm drop from normal HR > 130 RR >/= 25 /min UO /= 2 mmol/l
Sepsis 6
Started if any red flags seen Admit patient Give 3 1.High flow oxygen 2. IV fluids - 500ml bolus over <15mins 3. IV broad spectrum ABx Take 3 1.blood culture 2. FBC UE clothing’s lactate 3. UO hourly
TCA overdose immediate management
ECG - widened QRS, PR,QT, broad complex tachy
Iv fluid NS bolus. + sodium bicarbonate 8.4% slow IV injection
Indications for adrenaline
SOB Stridor Hoarseness Wheeze Shock Swelling tongue face cheek
Hypovolemic shock - physiology
Early -
Loss of blood - stretches the receptors in the atria > the baroreceptors in the aorta activated > vasomotor centre stimulates efferent output > catecholamine release > increased sympathetic activity
= vasoconstriction,arteriolar constriction and tachycardia to maintain blood
Late
Decreased GFR - aldosterone & ADH activated - salt and water reabsorption - activation of thirst centr e - maintain volume
Toxic shock syndrome
Diagnostic criteria
S.aureus
- fever>38.9
- SBP <90
- diffuse erythematous rash
- desquamation of rash - palms soles
- involvement of 3 or more organ systems
= renal failure, hepatitis , thrombocytopenia , CNS, mucous membrane erythema , GI sx
- high WBC plts <100,000
Absent left psoas shadow on abdominal X ray
FAST US = free peritoneal fluids
Splenic rupture
Diagnostic imaging for splenic rupture and treatment
CT abdomen
Urgent surgery
Treatment of costochondritis
Self limiting
Mild analgesics and NSAIDs
Liver disease + haematemesis + high INR
Treatment
Most appropriate initial step
FFP
Initial - IV fluid
Investigation of choice in acute renal trauma
Abdomen CT.
Orbital blowout frx
- commonest bones affected
- manifestations
Maxilla (orbital floor), ethmoid (medial wall)
Diplopia on upward gaze - impingement of superior rectus muscle
ACS treatment
ST elevation - MONA then PCI (preferred) or alteplase
NSTEMI - Normal ECG + high troop in - LMWH (Fonda) + aspirin
ECG + troponin normal . Pt stable- discharge with cardi review
Cardiac tamponade
Becks triad
Hypotension
Muffled heart sounds
High JVP
CXR in cardiac tamponade
Enlarged globular heart
Diagnostic imaging of cardiac tamponade
Echo
Cardiac tamponade management
Urgent periocardiocentesis
Oxygenation and ventilation
1-2 L of IV fluid NS
Basal skull / temporal bone fracture (Petrous part)
Features
Battle sign - mastoid ecchymosis CSF rhinorrhoea Peri-orbital ecchymosis - raccoon eyes Hearing loss Heamotympanum Facial n palsy
Initial management of DKA
IV fluids - NS
IV infusion insulin(.1/kg/hr) + ABG
Dx of DKA
pH < 7.3 , ketonemia ++, glucose >11 , bicarbonate <15
Beta blocker poisoning
Management
Hypotension bradycardia dizziness
Management - supportive
IV fluids for hypotension if SBP <90
Symptomatic bradycardia- atropine
Most appropriate test to determine asthma exacerbation
PEFR
Moderate = 50-75% best or predicted
Acute severe - 33-50%
Life threatening <33%
Severe Hyperkalemia management
Calcium gluconate/chloride/carbonate
Insulin
Bedside Blood glucose normal -
10 units IV with 50- ml of 50% dextrose over 10-15 mins
Glucose >11.1 (high)
Iv insulin 10 units with 50 ml .9% NaCl over 10-15 mins
Insulin = act rapid - soluble short acting insulin used in hyperK
Inhaled FB
Investigation
CXR +- bronchoscopy
Haemothorax management
O2
2 large venous cannula - send blood fro cross match
Chest drain
Surgery - rarely
