Emergency Flashcards
Paracetamol Poisoning
what may toxic dose lead to
- severe hepatocellular necrosis
- renal rubular necorsis
Paracetamol Poisoning
presentation
- early feature: N+V
- hepatic necrosis: R subcostal pain + N+V after 24h
Paracetamol Poisoning
what is the max body weight to use when calculating the total dose of paracetamol ingested
110kg
Paracetamol Poisoning
mnx within 1h
activated charcoal
Paracetamol Poisoning
mnx up to 24h
acetylcysteine (most effective given within 8h)
Paracetamol Poisoning
what is an acute overdose
ingestion of a potentially toxic dose of paracetamol in 1 hour or less.
Paracetamol Poisoning
when to refer pts to hospital if >6y
- self-harm
- symptomatic
- ≥75mg/kg in <1h
or time uncertain but dose is ≥75mg/kg
Paracetamol Poisoning
when to refer pts to hospital if <6y
- symptomatic
- ≥150mg/kg in <1h
or time uncertain but dose is ≥150mg/kg
Paracetamol Poisoning
when can plasma-paracetamol concentration be measured from time of ingestion
from 4hr
Paracetamol Poisoning
when should acetylcysteine be commenced
- plasma-paracetamol concentration falls above the treatment line on the paracetamol treatment graph
- present within 8 hours of ingestion of more than 150 mg/kg of paracetamol if there is going to be a delay of 8 hours or more in obtaining the paracetamol concentration after the overdose
- present 8–24 hours after ingestion of an acute overdose of more than 150 mg/kg of paracetamol even if the plasma-paracetamol concentration is not yet available
- present >24h after ingestion of an overdose if they are clearly jaundiced or have hepatic tenderness, high ALT, INR>1.3 or paracetamol conc is detectable
Paracetamol Poisoning
what is therapeutic excess
the ingestion of a potentially toxic dose of paracetamol with intent to treat pain or fever and without self-harm intent during its clinical use
Paracetamol Poisoning
therapeutic excess: when should pts be referred to hospital
- symptomatic
- > licensed dose + ≥75 mg/kg in any 24-hour period
- > licensed dose but <5 mg/kg/24 hours on each of the preceding 2 or more days.
Paracetamol Poisoning
what is a staggered overdose
ingestion of a potentially toxic dose of paracetamol over more than 1 hour, with the possible intention of causing self-harm
Paracetamol Poisoning
staggered overdose: when should pts be referred to hospital
all pts and treat with acetylcysteine without delay
Paracetamol Poisoning
what is the standard 21-hour regimen for acetlcysteine
acetylcysteine is given in a total dose that is divided into 3 consecutive intravenous infusions over a total of 21 hours
pt presents with fever, headache, altered mental status, personality change, focal neurological deficits and convulsions. What could it be
encephalitis
mnx of encephalitis
Aciclovir covers for HSV-1 and HSV-2.
Cefotaxime is a 3rd generation cephalosporin and covers for most causes of bacterial meningitis
Digoxin poisoning
presentation
- hyperkalaemia
- Yellow-green colour disturbance
- Dizziness, N + V
- Palpitations (due to arrhythmias)
- Bradycardia typically without hypotension
- Visual haloes
- Confusion
Digoxin poisoning
mnx
- Immediate digoxin level
- IV fluids
- Correct electrolyte abnormalities
- Continuous cardiac monitoring
- Give digibind if:
- Level >15ng/ml after 6 hours of last dose
- Level >10ng/ml within 6 hours of last dose
- Symptomatic
Digoxin poisoning
ECG signs
reserve tick ST depression
with first degree heart block
resus in paeds
5 rescue breaths then 15 chest compressions
then
2 rescue breaths: 15 chest compressions
mnx of choking child if conscious and coughing
encouraging them to cough may help dislodge the obstruction
mnx of choking child if conscious but unable to cough
alternate between giving 5 back blows and 5 chest (infant)/abdominal (child) thrusts
mnx of choking child if unconscious
5 rescue breaths should be given before immediately starting CPR.
when should the Heimlich manoeuvre be performed in a choking child
if back slaps fail and only if the child is large enough (as it can cause significant damage to intra-abdominal organs in a small child).
what are the reversible causes of cardiac arrest
4H's and 4T's hypoxia hypokalaemia/hyperkalaemia hypothermia/hyperthermia hypovolaemia
tension pneumothorax
tamponade
thrombosis
toxins
in patients with poor renal function, what should happen to the dose of furosemide
increased so that an increased concentration reaches the glomerulus and tubules to achieve the desired effect
CO poisoning
presentation of carbon monoxide poisoning
Confusion
Nausea and vomiting
Cherry red skin
Tachycardia
CO poisoning
why is pulse oximetry 100% if they have CO poisoning
because it only measures saturation of non-affected haemoglobin molecules
CO poisoning
diagnostic inx
VBG/ABG: A carboxyhaemoglobin concentration >20%
CO poisoning
mnx
- 100% oxygen via face mask - helps unbind CO from the haemoglobin molecule
- Hyperbaric oxygen
what is the most important adverse effect of tricyclic overdose
- QRS prolongation
- PR and QT interval prolongation
- can easily progress to heart blocks and ventricular arrhythmias
what murmur is associated with aortic dissection
aortic regurg
what other features apart from tearing chest pain is aortic dissection associated with
- paraparesis (carotid or spinal artery involvement)
- anuria and loin pain (renal artery involvement)
- abdo pain (mesenteric artery involvement)
- acute limb ischaemia (subclavian or femoral artery involvement)
Management of acute spinal cord compression if metastatic aetiology is suspected
- dexamethasone 16mg PO asap (to reduce tumour size and therefore relieve pressure)
- urgent whole spine MRI
Management of Ethylene Glycol Poisoning (anti-freeze)
- Gastric lavage or NG aspiration if <1 hour since ingestion
- Fomepizole (competitive inhibitor of alcohol dehydrogenase) - prevents metabolism of ethylene glycol into toxic metabolites.
- ethanol if Fomepizole is unavailable.
- Haemofiltration can be used in severe cases
which abx can cause prolongation of the QT interval, which can lead to polymorphic VT aka torsades de points
Clarithromycin
blood glucose level is 1.7 mmol/L (4-7 mmol/L). IV access is obtained. what do you give
100ml of 20% glucose IV
when to consider PCI for a STEMI
within 12 hours of symptom onset and within 2 hours of medical contact
STEMI
Patients who present within 12 hours of symptom onset but after 2 hours of medical contact can be offered?
thrombolysis
STEMI
If patients present more than 12 hours of symptom onset
pharmacotherapy provided they are stable
Contraindications to thrombolysis in MI
AGAINST
Aortic Dissection GI bleed Allergic reaction Iatrogenic: recent surgery Neuro: recent stroke (within 3m), malignancy Severe HTN (>200/120) Trauma, including recent CPR
when should mast cell tryptase samples be taken after an anaphylaxis reaction
during, 4h and 12h post reaction.
what will the ABG show in salicylate poisoning (e.g. aspirin poisoning)
respiratory alkalosis early on then resp acidosis
why is there respiratory alkalosis then resp acidosis in salicylate poisoning (aspirin)
activation of respiratory centres in the brain
then wasting of bicarbonate ions due to the ingested acid load - this is often mixed with the respiratory alkalosis
mnx of aspirin overdose
- Activated charcoal if ingestion <1 hours ago
2. IV fluid, sodium bicarbonate and potassium chloride
Cushing’s triad for raised ICP
- increased BP
- bradycardia
- irregular breathing
stepwise mnx of suspected choking
- encourage pt to cough
- 5 back blows followed by 5 abdo thrusts repeated
- unconscious: CPR
Criteria for performing a CT head scan within 8 hours following head injury
- Age 65 years or older.
- Any hx of bleeding or clotting disorders.
- Dangerous mechanism of injury
- > 30 min retrograde amnesia of events immediately before the head injury
Criteria for performing a CT head scan within 1 hour of head injury (7)
- GCS <13 on initial assessment in A&E
- GCS <15 at 2h after the injury on assessment in A&E
- Suspected open or depressed skull fracture.
- Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).
- Post-traumatic seizure
- Focal neurological deficit
- > 1 episode of vomiting
which drugs can cause serotonin syndrome
SSRI
MAOI antidepressants
ecstasy
amphetamines
which score predicts the 6-week risk of major adverse cardiac event
the HEART score
mnx if HEART score 0-3
discharged
mnx if HEART score 4-6
admit
mnx if HEART score ≥7
50-65% risk of adverse cardiac event
in a patient with a suspected cervical spine injury but an airway is needed to be managed, what is the best option
jaw thrust
but if a life-threatening airway obstruction, head tilt should be performed incrementally until the airway opens (patent airway takes priority over potential cervical spine injury).
initial trx if alcoholic has an acutely altered mental status and is agitated
IV diazepam
what type of shock may patients with cardiac tamponade have
tamponade prevents heart from filling adequately, causing an obstructive shock
signs of opiate overdose
- constricted pupils
- Drowsiness
- Confusion
- Decreased respiratory rate
- Decreased heart rate
signs of opiate withdrawal
- Sweating
- clammy/cold
- pallor
- N+V
- diarrhoea
- abdo pain
- tachycardia
GCS response is different in each hand. how are they scored
on their best response
how is lactic acidosis initially managed
a fluid bolus
mnx for hypotension during surgery (after fentanyl, fluid bolus doesn’t work)
Metaraminol is an alpha agonist
causes of type I resp failure
Decreased atmospheric pressure Ventilation-perfusion mismatch Shunt Pneumonia ARDS Pulmonary embolism
causes of type II resp failure
COPD Brain stem disease/lesion Bronchitis Motor neuron disease Deformity e.g. ankylosing spondylitis, kyphoscoliosis
soot in nasal cavity and hoarse voice. What mnx?
signs of smoke inhalation
Early intubation as the rapidly developing swelling and oedema may quickly lead to total airway obstruction and a difficult or failed intubation.
Local anaesthetic toxicity pathophysiology
blockade of sodium channels
signs + symptoms of local anaesthetic toxicity
Numbness or tingling around the mouth Restlessness/agitation Tinnitus Shivering Vertigo/dizziness Subtle tremors of the face and extremities Hypertension Tachycardia Decreased consciousness Respiratory depression Hypotension Apnoea Seizures Sinus bradycardia Ventricular arrhythmias Asystole
mnx of local anaesthetic toxicity
- Stop administration of local anaesthetic!
- ABCDE inc ECG
- Lipid emulsion (20% intralipid) 1mL/kg every 3 minutes up to a dose of 3mL\kg
- Initiate lipid emulsion infusion at a rate of 0.25mL\kg\min
- Maximum total dose = 8mL\kg
what may ECG show in TCA (amitriptyline) overdose
QT interval prolongation which can precipitate a cardiac arrythmia
1st line for TCA (amitriptyline) overdose
IV bicarbonate
why does bicarb work for TCA overdose
Alkalisation favours the neutral form of the drug thus reducing the amount of active cyclic antidepressants
what does bogginess of skull on palpation suggest
a depressed skull fracture. This is a ‘high’ risk factor for intracranial haematoma.
well-recognised side effect of epidural anaesthesia
hypotension due to local anaesthesia of sympathetic nerves
what is malignant hyperthermia
a life-threatening syndrome triggered by inhalation anaesthetics or suxamethonium
most common cause of malignant hypothermia
autosomal dominant mutation in the ryanodine receptor 1
presentation of malignant hyperthermia
typically present at the induction of general anaesthesia with:
- increased body temp
- muscle rigidity
- metabolic acidosis
- tachycardia
- increased exhaled CO2
mnx of malignant hyperthermia
- stopping triggering agent
- administer IV dantrolene (a ryanodine receptor antagonist)
- restore normothermia
name 3 other conditions which presents like paracetamol overdose
- Acute hepatitis
- alcoholic liver disease
- steroid induced ALF
complications of paracetamol overdose
- liver failure
- encephalopathy
- hypoglycaemia
- CKD
what formula can be used to calculate the amount of fluids required (mnx of burns)
Parkland formula:
4 x weight (kg) x %burn = ml fluid required in the first 24 hours
what is the most accurate method of assessing the extent of the burn
Lund and Browder chart
what is Wallace’s Rule of Nines to assess the extent of the burn
- head + neck = 9%
- each arm = 9%
- each anterior part of leg = 9%
- each posterior part of leg = 9%
- anterior chest = 9%
- posterior chest = 9%
- anterior abdomen = 9%
- posterior abdomen = 9%
4 mechanisms to sustain a burn
- thermal
- electrical
- chemical
- Non-accidental injury
pt given painkillers. Hour later, he is seizing. What was given to him
tramadol (lowers seizure threshold)
what medication can be used to temporarily raise a pt’s BP
Fludrocortisone
which medication is CI’d when taking viagra (Sildenafil)
nitrates
what strong painkiller to give if got renal disease
tramadol or oxycodone
initial mnx for superior vena cava obstruction
dexamethasone
