Emergency Flashcards
Dosing for single most important action in anaphylaxis?
(Adult)
Administer intramuscular injection of adrenaline 0.5mg (500micrograms) in an autoinjector to the outer mid thigh immediately
What is this?
(name the acute condition)
Patient has COPD
Right sided secondary spontaneous pneumothorax.
(secondary because the patient has an underlying lung condition)
Define Hypertensive Urgency vs Emergency?
- Urgency: BP >180/100mgHG
AND significant symptoms such as headache, dizziness or mild-moderate end organ damage.
- Emergency BP > 220/140 AND associated end organ damage
For hypertensive URGENCY what medications can you use to bring down the blood pressure?
Nifedipine IR 10mg, orally, stat
Catopril 12.5mg, orally, stat
Clonidine 100 Microg, orally, stat
Prazosin 2mg Orally, stat
What is the triad of serotonin syndrome?
Neuromuscular excitation (e.g. hyperreflexia, hypertonia)
Autonomic effects (e.g. hyperthermia, tachycardia, sweating, flushing)
Central nervous system effects (e.g. agitation, confusion)
What can you use to help treat a mild serotonergic toxidrome?
To help with agitation but if they are co-operative then..
diazepam 5 to 20 mg (child: 0.2 mg/kg up to 10 mg) orally; repeat after 30 minutes if required. Usually no more than 120 mg is required in 24 hours
What medication might cause the following signs and symptoms, and what needs to be done?
Progressive hyperthermia
muscle rigidity
Sustained clonus
Seizures
SSRI, Certain TCAs, combination with MOAs or opioids, lithium
Medical emergency, send to ED to prevent life threatening multi-organ failure
Start rapid cooling techniques
with rehydration –> Cold IV fluid therapy
For seizures–> midazolam/diazepam IV
For rigidity or clonus–> may need sedation
For a person with an eating disorder, what features on examination or investigations findings that would prompt an emergency admission?
- Heart rate <50 bpm
- systolic BP <80 mmHg or diastolic BP <40 mmHg
- Postural BP drop >10 mmHg
- ECG demonstrates any abnormalities, particularly prolonged QTc interval
- Temperature <35.5°C
- Weight <75% predicted ideal body weight (BMI <15)
- Electrolyte disturbance (eg. hypokalaemia)
What is your immediate management of this in the GP setting?
(7)
- Arrange urgent transfer to hospital in ambulance for management of STEMI
- Insert 2 x large bore cannula into ACF
- Give high flowOxygen in a non-breather mask if sats <94%
- Give chewable aspirin 300mg, orally stat
- GTN spray 400-800micrograms, every 5 minutes if needed
6.Administer Fentanyl 25mcg - 50mcg intravenously for pain relief
- Place in a monitored area of the clinic/monitor vital signs for signs of deterioration
What is the management for status epilepticus?
(6)
- Apply oxygen through a hudson mask to ensure sats ? 94%
- Obtain a fingerprick BGL
- Arrange transfer to nearest ED department for management of status epilepticus
- Continuing monitoring vital signs for signs of deterioration
- Insert 2 x large bore cannular into each ACF
- Administer one of
a. Midazolam 10mg IV, stat
b. if no IV access: midazolam 5-10mg buccally (or subcut if absolutely needed), Stat
List up to 9 features of dehydration in a child
Withdrawn or straight comatose
Rapid weak pulse
Sunken fontanelle
Very Sunken eyes
No tears
Dry MM
Decreased Skin Turgor with TENTING
No urine for several hours
Greater than 10% weight loss
What respiratory rates would make you worry in a child?
if between 6-12 months then RR>50
A chid over 12 months then RR> 40
Any age if RR > 60 ,thats a major warning sign.
Steps in anaphylaxis management in clinic on a 3 year old child?
(6)
Include any dosing
- Give 150 micrograms of adrenaline in autoinjector into the lateral thigh (doses for <1 year are not known, >5years or 20kg use 300microgam autoinjector)
- Insert 2 large bore cannula into the ACF
- Start fluid administration intravenously
- Call ambulence for immediate transfer to the emergency department to treat anaphylaxis
- Administer highest dose O2 until sats are between 94-98%
- Keep patient laying flat
What causes an Addisonian crisis ?
Adrenal Crisis (more formal name) is caused when somebody has addison’s disease or primary adrenal insufficiency. Usually precipitated by acute stress or sudden cessation of glucocorticoids.
There is not enough glucocorticoids to go around.
How do you immediately treat Adrenal Crisis?
Give immediate glucocorticoid
Nb: if no previous diagnosis of Addison’s disease, take bloods to measure plasma cortisol, adrenocorticotrophic hormone (ACTH) and renin concentrations but
do not wait for lab results
- hydrocortisone 100 mg intravenously, initially, then 50 mg intravenously, every 6 hours until stable and tolerating oral intake.
if no IV access/hard to obtain then
- prednis(ol)one 40 mg orally.
In this general condition, what factors would make you seek urgent attention for the patient?
(5)
This is AF on the ECG with a slow ventricular response
This ECG itself (slow V response) is not an indication for Emergency management. But the following are
- Rest angina (obviously)
- AF with rapid ventricular response
- Syncope or presyncope
- Clinical signs of heart failure
- Hypotension (haemodynamically unstable- which could happen with a slow response like this)
What is the NEXUS criteria for neck pain?
(5)
Following trauma, cervical spine injury cannot be excluded if any of these criteria are present:
midline cervical tenderness
altered mental status
focal neurologic deficit
evidence of drug or alcohol intoxication,
presence of other injury considered painful enough to distract from neck pain.
For low risk, alert and stable trauma patients, what would exam finding with necessitate imaging?
As per Canadian C spine rules
not able to ROTATE neck 45 degrees
using a CT for trauma
What are signs and symptoms of a potential PE?
(8)
New onset worsening SOB
RR > 20
Chest pain, can be pleuretic or restrosternal (like angina)
HR > 100
Haemoptysis
Syncope
sBP < 90
Crepitations
What steps do you take if suspecting a PE based on symptoms and risk factors?
two different risk categories?
- Do a wells score for everyone
- A. high risk on wells score proceed directly to CTPA and treatment
B. Interderminant or low risk, do a D Dimer
If D-Dimer is positive then proceed to CTPA, if negative, no further investigation
What medication do you use to treat a PE? and for how long
Apixaban 5mg, orally, 12 hourly
If caused by a provoking factor then 3 months of treatment, if off course the provoking factor is now removed.
If NO provoking factor than longer than 3 months. No exact guidance on when to stop.
What are features of a severe asthma exacerbation?
unable to complete a sentence
Increased WOB (accessory muscles- tracheal tug, intercostal recession, excessive abdominal breathing, chest wall recession in children)
Obvious respiratory distress
Sats <94% RA (if below 90% then it’s life threatening)
Treatment of severe Asthma exacerbation in a GP setting/ED?
Adults vs Children
Anyone over 6 years old
Salbutamol 12 actuations of 100micrograms pMDI via spacer repeated as needed
PLUS
ipratropium 21 micrograms, 8 puffs, repeated as needed
PLUS
within an hour
dexamethasone 0.6mg/kg up to 16mg given orally followed by a single dose the next day
OR prednisolone 1mg/kg- up to 50mg, oral, daily for 5-10 days
Anyone < 6 years old
Salbutamol is 6 puffs every 20 minutes if needed
and Ipratropium is 4 puffs every 20 minutes if needed
Plus prednisolone or dexamethasone
Note if oral medication isn’t tolerated then use hydrocortisone 4 milligrams per kg up to 100 mg intravenous 6 hourly for 24 hours. Then switch to an oral steroid if tolerating it. If not then continue IV therapy but reduced to 12 hourly
What are aspects of a secondary assessment in asthma that will determine severity?
Conscious level. alert, alert, reduced consciousness
Ability to speak: full, incomplete, not
Skin colour/cyanosis
Mobility: walking, tripoding, collapsed
Respiratory distress: non, some, severe
HR: normal, tachy, up to arrhythmia or arrest
Sats >94, 90-94, <90
ABG: not needed, yes needed, definitely needed –> corresponding to sat level above
Which parameters would indicate a patient with CAP needs ICU?
(Respiratory failure 3)
(Organ failure 5)
Signs of respiratory insufficiency:
-RR>30Br/m
-O2 <90% RA, PaO2 <60mmHg
-Multilobar or rapid progression of infiltrate on CXR
Signs of organ failure:
-Hypotension <90mmHg
-Acute onset confusion
-Poor peripheral perfusion
-Acute oliguria, elevated creatinine or uraemia
-Blood lactate 2mmol/L
What are some causes of Acute Pulmonary Oedema?
(8)
Not all causes are due to Chronic Cardiac Failure, though that is one. Non compliance with CCF medications.
Could be
MI/ACS
Arrhythmia
Valve dysfunction
Endocarditis
Drugs: NSAIDS, CCB
AKI or failure
PE
1 Definitive management and 3 other cornerstones of management for APO?
- Frusemide 20-80mg, IV given stat and repeated after 20 minutes if needed
- GTN Spray or Infusion 400micrograms, given SL, every 5 minutes, goal to maintain sBP>100mmHg
(DO NOT USE if a PDE5i has been used in the last 48 hours). - Oxygen in a reservoir mask
10-15L in a hudson mask and reservoir bag.
And if GTN and Frusemide aren’t working then
4. CPAP
In APO, apart from Frusemide, Oxygen, CPAP and GTN sprays, what other management steps might you start?
(4)
*Morphine for anxiety 1-2mg, IV.
(also reduces respiratory work)
Enoxaparin 40 (or 20)mg subcut
Spironolactone 25-50mg, oral, stat, in a volume overloaded patient not responding to frusemide.
*Make sure to sit patient in an upright posture
*=more important
What are the parameters that define severe croup?
Persistent stridor at rest
Increasing fatigue
Markedly increased RR
Markedly decreased AE
Tachycardia
Emergency or community (whilst awaiting T/F) medical management of severe croup ?
(2)
Adrenaline 1:1000 (1mg/1ml) solution 5ml inhalation via nebuliser. Repeated after 30 minutes
PLUS EITHER of
prednisolone 2mg/kg up to (50mg), orally, stat then 1-2mg/kg (max 50mg) 24 hours later
OR
dexamethasone 0.6mg/kg (up to 12mg), orally, stat or IV or IM if child is vomiting. once only.
In a presentation of severe croup, consider discharge once there is no
______ at ______. And plan a follow up in __ ____.
stridor at rest
24 hours
What symptoms differentiate a stroke from a SAH?
Usually the stroke has deficits (neurological) without a headache and the SAH has a sudden onset harsh headache without focal neurological deficits.
Also full loss of consciousness is not likely to be a stroke
What is the ABCD2 score?
It’s the scoring system used to help determine stroke risk in those with a TIA
Age > 60 +1
BP - hypertensive (140/90) +1
Clinical. If unilateral weakness +2, if speech impaired without weakness +1, if other symptoms =0
Duration of symptoms: <10 minutes =0, 10-59 min = +1, >60min = +2
Diabetes +1
Scores
0-3 low risk
4-5 moderate risk
6 and over, high risk
What is the immediate management steps for a stroke?
- Keep monitored
- Urgent Hospital management for
A. CT scan
B. thrombolysis with alteplase (within 3 hours) - Aspirin 300mg to be commenced within 48 hours. Don’t do this prior to the CT.
- Placed on a stroke specific ward
What should be done in a patient who has stroke symptoms for over 24 hours?
Urgent referral to tertiary hospital with specialist stroke services.
If they had a symptoms within 3 hours then urgent referral to centre that offers thrombolysis.
A 10 year old boy was climbing a tree in his backyard during summer and was bitten by a black spider about 2 hours ago. He described it as “really big,” and he’s currently having abdominal pains. What is the management from here?
Treat any big black spider and a funnel web spider (this is the most dangerous type)
- apply a pressure bandage around the bite site
- Apply the pressure bandage along the whole limb
- Immobilise the limb and patient
- Arrange transport to the nearest hospital with anti-venom
(5. antivenom needs to be administered in a critical care or resus area with readily available adrenalin and resuscitation equipment)
What are the directions of applying a pressure bandage to a spider bite?
apply a 15cm pressure bandage around the bite site then wrap distally and proximally around the whole limb.
For the pressure bandage to work the limb and patient need to be completely immobilised.
What are features of DKA (diabetic ketoacidosis)?
Apart from the obvious hyperglycemia
(3)
- polyuria
- polydipsia
- tachypnoea
Others
4. deep sighing respiration
5. breath smelling like acetone
6. Nausea and vomiting
7. abdominal pain
8. Confusion
9. drowsiness
What is the criteria for DKA diagnosis?
There is no specific criteria
typically..
pH is 7.3 or less
serum bicarb <15mmol/L
positive ketones in urine
BGL is usually > 14 (but can be less if on an SGLT2i)
use the clinical presentation + in room findings to decide.
DKA needs to be managed in hospital by an emergency team, what aspects of management should be addressed?
dosing not needed.
(4)
1 Aggressive fluid replacement
- Correction of hyperglycemia and ketone production with insulin
- Correction for potassium disturbance
- Thorough investigation and management of concurrent infection or other precipitating conditions (MI, CVA, VTE)
What is the main difference in treating adult vs. children in DKA?
Do not use the same protocol
Avoid giving excess fluid if intravenous rehydration is started for a child or adolescent with DKA. Excess fluid replacement can cause significant harm.
What is HHS? what is is characterised by?
Hyperosmolar Hyperglycemic Syndrome?
- severe hyperglycemia
- little or no ketoacidosis
- Dehydration
- Altered Mental state
HHS like DKA requires specialist management in E.D.
One aspect is fluid resuscitation, over what time course should this be done?
How do you correct the hyperglycemia in HSS?
Replace approximately 50% of estimated fluid loss within the first 12 hours and the remainder in the following 12 to 36 hours
Unlike in DKA, insulin is not needed to correct the hyperglycemia, fluid resuscitation and time should be enough.
However still monitor potassium and correct if needed
What are patients with HHS at high risk of developing?
(1-2)
There is high risk of developing arterial and venous thrombosis so use prophylactic anticoagulation
If working in the ED and suspecting bowel obstruction what investigations should you order?
(6)
Imaging. Preferrably CT, but abdominal XRAY has been the standard- though is more useful for identifying perforation than obstruction itself
FBC (anaemia might suggest malignancy)
EUC
Serum lactate - ischemia
PT
Group and Save
These should happen pretty much simultaneously with starting treatment.
What is the mainstay of treatment in LBO?
(4)
- Nasogastric tube if severe distention and vomiting
- Volume resuscitation
- Timely surgical consult
- Initiation of preoperative antibiotics.
In a patient with ______(a) _______, their BMI is under ___(b)__ due to a fear of gaining weight. You can use the __(c)____ questionnaire to help determine the patient’s risk of actually having an eating disorder.
When consulting the patient, assessing them for _______ (d) _______, dehydration and ___(e)_______ ________( especially ___f____) is vital and can be lifesaving.
a. anorexia nervosa
b. 18
c SCOFF
d. Comorbid conditions
e. dehydration and metabolic disturbances
f. hypokalemia
List at least 5 acute/emergency complications of the extensive list of complications from anorexia nervosa?
Acute Pancreatitis
Hypokalemia
Mallory-Weis tear (not always an emergency, but needs an emergency evaluation)
Arrhythmias
Suicide
What is the most serious complication-syndrome that can arise when treating anorexia nervosa
Refeeding syndrome
During starvation, intracellular electrolytes become depleted from fat and protein catabolism.
Upon refeeding insulin secretion stimulates intracellular glucose and electrolyte uptake
leading to:
- Derangement of serum electrolytes (PO4, Mg, K)
- Vitamin deficiencies (Thiamine, B12, folate)
- Sodium and fluid retention
RFS can be life-threatening leading to complications such as cardiac failure, arrhythmia,
delirium and seizures.
What are the four main drug induced dermatological emergencies ?
What is the management of them?
Steven Johnson Syndrome -SJS
Acute generalised exanthematic pustolosis (AGEP)
Toxic Epidermal Necrolysis (TEN)
Drug rash with eosinophilia and systemic symptoms (DRESS)
Management:
Transfer all suspected cases to the nearest emergency department, if suspecting TEN then arrange transfer to nearest hospital with a burns unit.
What medications are implicated in causing this?
5As
This is Toxic Epidermal Necrolysis
Infact SJS and TEN are just variants of the same condition. Both include sheet like skin and mucosal loss.
Medications include
40% of the time Antibiotics: penicillins, cephalosporins, Co-trimoxazole
Anticonvulsants- lamotrigine, carbamazepine, phenytoin, phenobarbitone
Acetominophin; paracetamol and
Aspirin/NSAIDs
Allopurinol
What is the clinical course in developing SJS/TEN?
- Before the rash there is usually a flu like prodrome (fever of 39+, conjunctivitis, rhinorhoea, cough, aches and pains)
- Rash Usually develops
1 week after starting an antibiotic
or 1-2 weeks after antiepileptic
up to 1 month for other drugs
Then there is a rapid abrupt initiation of red skin rash, that for some reason doesn’t affect the scalp, soles or palms.
The lesions can be either
Macules
Purpura
Diffuse erythema
Targetoid (like in erythema multiforme)
Blisters
- The blisters then merge to form sheets of skin detachment, exposing red, oozing dermis. The Nikolsky sign is positive in areas of skin redness. This means that blisters and erosions appear when the skin is rubbed gently.
What are 4 signs of sepsis or impending septic shock?
Tachypnoea (RR >22)
Hypotension (sBP < 90mmHg)
Altered consciousness
Blood Lactate >2mmol/L
What are some life threatening features, when presented with a probably sepsis, indicated organ failure?
(5)
Poor peripheral perfusion
Mottled skin
Acute oligouria or raised serum creatinine
Raised billirubin
Low platelet count
If hospital management is likely to be delayed by over an hour for sepsis, what antibiotic can you start?
ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously or intramuscularly given immediately
Use ceftriaxone even if there is mild-moderate reaction/hypersensitivity as treating sepsis is more important. However don’t make things worse if the person is known to have a SEVERE reaction to ceftriaxone.
In the management of Sepsis in the ED, what steps are important to take?
- Measure blood lactate
- Obtain blood samples for culture
- Collect other samples as soon as possible, but not if it will delay treatment
- Administer broad spectrum antibiotics
- Begin rapid administration of IV fluids to manage hypotension or a blood lactate concentration more than 2 mmol/L
- Give a vasporessor IF NEEDED to maintain a MABP of 60mmHg
What is the defining factor between non severe and severe hypoglycaemia and what is the treatment for non severe hypoglycemia?
If the patient is conscious and able to self administer oral treatment, it is non severe. If not able to treat themselves, even if not unconscious, then it is severe. This can be because patient has altered mental status because of the hypo or is generally incapable.
Non severe
Basically needs to eat/drink glucose.
< 5 years old AND under 25kg then 5grams of glucose
6 years and older or > 25kg then 10grams of glucose
for an adult then 15grams
It takes about 10-15 minutes for the glucose to arise. When it does rise to normal then longer acting carbohydrate should be consumed to prevent recurrence.
If BGL < 4.4 or if child is vomiting and cannot eat/drink then you can give a minidose of glucagon approx 10micrograms per year of age up to 150micrograms or 15 years old (then everyone gets 150micrograms)
How do you treat severe hypoglycemia?
First
Glucagon
less than 25 kg: 0.5 mg subcutaneously or intramuscularly
25 kg or more: 1 mg subcutaneously or intramuscularly.
If the patient hadn’t eaten and has run out of glucose stores in the liver, then the patient will need IV glucose. In a 10% glucose solution over 20 minutes. Once glucose concentration >4mmol/L then can start a regular 5% glucose with NaCl 0.9% solution.
remember to warn of the implications for driving.
When is acute mania an emergency?
Acute mania is an emergency with severe symptoms: no insight and risk taking behaviour likely to cause harm to themselves or others (physical, financial, reputation destroying behaviours).
What medications would you use to treat acute severe mania?
MAniA
Antipsychotic (quetiapine or olanzapine)
+
Mood stabliser (lithium or valproate)
+
Anxiolytic like a benzo
What is the paediatric dose of adrenaline for management of anaphylaxis?
150microgram dose for children weighing 7.5-20kg (about 1-5 year olds)
Apart from adrenalin when managing anaphylaxis what else should you do?
(4)
- Monitor HR, bp, RR and O2Sat
- Give oxygen and or airway support if needed
- Obtain IV access. Consider larger bore cannula if hypotensive
- Administer normal saline rapidly 20ml/kg if hypotensive.
What analgesia would you use acutely to treat cardiac suspected chest pain?
Fentanyl 25-50micrograms IV, repeated 5-10 minutes if needed
While Morphine makes up the “MONA” approach to treatment, it can reduce the amount of anti-platelet agents absorbed
What dose of Aspirin and GTN do you give in acute chest pain?
Aspirin 300mg chewable aspirin. Chewed or dissolved.
GTN spray 400-800micrograms, sublingual, every 5 minutes if needed. max 3 doses
What dose of Aspirin and GTN do you give in acute chest pain?
Aspirin 300mg chewable aspirin. Chewed or dissolved.
GTN spray 400-800micrograms, sublingual, every 5 minutes if needed. max 3 doses
OR GTN tablet 300-600mg, sublingual, every 5 minutes if needed for pain, max 3 doses
When is oxygen needed/should be applied during a suspected ACS event?
if sats <94%
What are sore throat conditions that NEED hospitalisation?
Acute epiglottitis
Retropharyngeal abscess
SEVERE EBV infection
SEVERE croup
Peritonsillar abscess and peritonsillar cellulitis
Pharyngeal diphtheria
What are findings with HHS?
(hyperosomolar hypergylcaemic syndrome)
(4)
Dehydration
Altered mental State
Severe hyperglycaemia
No or little ketoacidosis
What is the usual cause for HHS?
Related to medications
omitting or forgetting glucose lowering medication
Starting medication or drugs that cause hyperglycemia
discontinuing antihyperglycemics
What is the mainstay of treatment for Hyperosmolar Hyperglycemic Syndrome?
Fluid resuscitation
but this shouldn’t be done too aggressively
The aim of treatment should be to replace approximately 50% of estimated fluid loss within the first 12 hours and the remainder in the following 12 to 36 hours
Also need anticoagulants, and they are in a prothrombotic state
Potassium can be monitored, but isn’t as much of an issue. There is NO acidosis (DKA), so there shouldn’t be large intracellular shifts.
When doing CPR, when do you administer adrenalin and how much?
If rhythm is shockable then give after the 2nd shock
If the rhythm is not shockable then give after the first cycle/AED rhythm check.
Give 1mg of Adrenalin
In a shockable rhythm what other medication should be administered, and when?
Amiodarone 300mg IV after the third shock
What are the 4 T’s and 4H’s for cardiac arrest?
Toxins
Tamponade
Tension Pneumothorax
Thrombus
Hypovolemia
Hypoxia
Hyper/hypokalemia or other metabolic
Hypothermia/hyperthermia
What are treatment options for this?
This is an SVT, fast rhythm, no visible P waves, but regular.
Try Vagal manoevres
Can give Adenosine STAT (fast push)
How do you immediately treat a tension pneumothorax?
needle decompression using a 16 gauge needle into the second intercostal space, midclavicular line.
What needs to be done immediately after a needle decompression for a tension pneumothorax?
Insert an underwater chest tube and drain.
Why?
the needle decompression causes a simple pneumothorax, and the lung could collapse so needs a way to stay open
What is beck’s triad and what is it potentially an indicator of?
Neck vein distention
Hypotension
Muffled heart sounds
It is not super reliable , but can indicate cardiac tamponade. Best use an U/S.
what does this show?
NSTEMI
sinus tachycardia with right bundle branch block and inferolateral ST depressions and T wave inversions.
When suspecting a ACS event, what treatments should be initiated?
Analgesia with opioids
GTN
Oxygen if sats <94%
Aspiring 300mg (chewable preferrably)
Arrange t/f to tertiary centre
What are the main treatment steps in hypothermia?
Drying and insulation (e.g. removing wet clothes and insulating patient)
Fluid resuscitation (usually because they are hypovolemic). Can heat the fluid to about 40-42dC.
Active rewarming if between 28 to 32dC. via hot air enclosures.
If <28dC, needs CORE rewarming; inhalation, IV infusion, Lavage.
What are ECG changes expected with Hyperkalemia?
Widening QRS
first increased PR interval then absence of p waves
Peaked T waves (early on)
Treatment for moderate to severe hyperkalemia? (6.0 + mmol/L)
Give IV insulin and glucose
Calcium Gluconate 10mg over 10 minutes IV
Can try inhaled beta2 agonist at a high dose as an adjunct (don’t use in MI)
Consider haemodialysis if treatments are ineffective
What are ECG changes with hypokalemia?
Flattening T waves
ST segment sagging
U wave elevation
What is severe hypokalemia and what is the treatment?
usually below 3.0mmol/L and with symptoms
IV replacement of potassium. 40mmol. but slowly at 10mmol per hour.
Signs and symptoms you might expect with hypertensive emergency?
Symptoms you may expect
SOB
Chest pain
Stroke symptoms: numbness or weakness, difficulty speaking
Severe headache
Visual changes
Signs
Pulmonary creps
Retinal hemorrhages
Peripheral swelling (hands and feet)
What factors may increase the risk of complications in someone with hypertensive urgency, that may warrant a visit to the E.D rather than community work up?
- Extreme BP elevation not due to missed meds
- coagulopathy
- Anticoagulant or antiplatelet therapy
- Pregnancy
- kidney impairment
- recent or imminent fibrinolysis
- aortic dissection suspected
- Recent vascular procedure
- suspicious of an aneurysm
In a patient with suspected sepsis, what are features of life threatening organ dysfunction?
(4+4)
- Impaired consciousness
- RR >22
- sBP <90mmHg
- Blood lactate >2mmol/L
Note that HR and Fever are not on here
Other features include
- poorly perfused and mottled skin
- Acute oliguria
- Low platelet count
- Elevated serum bilirubin from baseline
If hospital management for sepsis is likely to be delayed by over an hour, what steps can you initiate in the community?
Dosing for antibiotic
(6 +1)
Start resuscitation ABC
Determine Advanced care plan for appropriate situations
Keep in a monitored area
Take blood for cultures. Take other cultures/samples ASAP but not to delay Abx administration.
Start fluid administration if hypotensive or raised lactate
Start antibiotic ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously or intramuscularly
If patient cannot maintain their BP with fluid administration or just after, consider giving a vasopressor
What is the qSOFA score and what does it compromise of?
used when suspected sepsis and shock.
It stands for
quick sequential organ failure assessment
If 2 or more of:
RR > 22
BP > 100mmHG
Altered mentation
Then proceed to further investigation for sepsis.
With an acute/active seizure what are the first 3 things to consider doing?
- Placing in the left lateral position
- Protect the airway
- Remove dangerous objects
(Can also start a timer)
After initially ensuring the safety of the patient, what 5 further steps can you take to manage an acute seizure?
Take finger prick BGL
Maintain Oxygen saturation above 94%, can use a hudson mask to provide oxygen
Keep in a monitored area
Insert 2 x large bore cannula if able
Take bloods if able
What is the first line agent to give during status epilepticus?
What is status epilepticus?
Definition:
A seizure > 5 minutes
Or no recovery between seizure attacks
Treatment
Administration of a benzo (midazolam)
With IV accss
Midazolam 10 mg (child: 0.15 to 0.2 mg/kg up to 10 mg) intravenously, over at least 2 minutes
Without IV access
First line: midazolam 10mg (adult or child > 40kg), given Intramuscularly, immediately
(Child dose child: 0.15 to 0.2 mg/kg up to 10 mg)
Second line: midazolam 5 to 10 mg (child: 0.2 to 0.3 mg/kg up to 10 mg) buccally or intranasally
Advice to give regarding seizures in a child e.g. febrile seizures
(8)
It is important to stay calm
Ensure child is in a safe position, on a soft surface, lying on his side or back
Remove any objects from around the child to ensure his safety
Time how long the convulsion lasts for
Watch or video carefully the movements that take place during the convulsion so you can inform medical staff later
Do not try to restrain him
Do not put anything in his mouth
Do not put him in a bath to lower his temperature
What is the definition of a minor burn?
superficial in depth (eg painful, moist, brisk capillary return)
less than 10% total body surface area in adults and less than 5% total body surface area in children.
When should you refer a burn to a specialist centre?
burns greater than 10% total body surface area in adults
burns greater than 5% total body surface area in children
full thickness burns greater than 5% total body surface area
burns to the face, hands, feet, genitals, perineum, major joints and circumferential limb or chest
burns with inhalation injury
electrical burns
chemical burns
burns in patients with pre-existing illness
burns associated with major trauma
burns at the extremes of age—young children and the elderly
burns in women who are pregnant
intentional burns (assault and self-inflicted).
What is the wallace rule of 9 regarding burns?
Determines the surface area of the burn and hence need for specialist management.
Applies to > 10 years old
In descending order of deep, these are the burn categories
Epidermal burn
Superficial dermal burn
Mid dermal burn
Deep dermal burn
Full thickness burn
Which can be managed without consideration of a burns specialist?
Epidermal burns
and superficial dermal burns can be managed in a GP setting
What is this? Why?
and how can it be treated?
This is an epidermal burn
Because the epidermis is damaged but intact, appears pink/red and painful.
Example: sunburn
management Cool showers or compress to manage warmth and pain. Ensure adequate hydration and moisturise skin.
If pain is significant use a hydrogel to soothe and provide analgesia. A secondary dressing is generally not needed.
What type of burn is this?
Can it be managed in a GP setting?
Superficial dermal burn
Yes it can
What is the recommended treatment for a superficial dermal burn?
Can be managed in GP setting
Provide first aid and analgesia.
Ensure adequate hydration.
Deroof blisters and debride as required.
Advice Significant exudate is often produced in the first 72 hours.
Appropriate dressings include a silicone foam dressing and, if contaminated, silver-based dressings (eg Acticoat or AquacelAg)
-If there is minimal exudate, use a moisture retention dressing (eg a clear acrylic dressing)
First aid management of thermal burns?
(6)
If on fire: stop drop and roll
Remove clothing NOT stuck to the burn
Remove all jewellery and watches
Run under cold water for 20 minutes *useful for up to 3 hours after the burn
DO NOT try to induce hypothermia
DO NOT use ice
Cover the burn with cling wrap but not wrapped circumferentially
Fluid resus dose in major burns?
Adults: 0.5 – 1.0 ml/kg/hr
Children <30kgs: 1ml/kg/hr
First aid points for chemical burns
(5)
Remove contaminated clothing from patient
Powdered agents should be brushed from the skin whilst protecting care giver
Areas of contact should be irrigated with copious amounts of cool running water
Avoid washing chemical over unaffected skin
If an eye is affected always ensure the unaffected eye is uppermost when irrigating to avoid contamination
For a non contaminated burn, what dressings can be used when
- Absorption is the goal
- Balance of dry/wet conditions is ok
- When area is dry
For a CONTAMINATED burn, what dressings can be used when
- Absorption is the goal
- Balance of dry/wet conditions is ok
- When area is dry
When inspecting a epidermal burn, does the percentage of burned surface area need to be assessed the same way as other burns?
no
Epidermal burns are NOT included in the assessment of % total body surface area burnt.
What analgesia can be given for severe burns?
Apart from IV access, analgesia and fluid resuscitation, what else should you consider in your management of a severe burn?
- Preventing heat loss. cover the burn. cover the patient with warm blankets or bear huggers. remove wet dressigns
- Tetanus status and booster
- Measuring urine output
- Elevate the burnt area
- Make sure to manage or monitor the airway
How do you treat sustained VT?
(2 scenarios)
One:
Unstable VT- DC cardioversion
Two:
Stable VT- can consider DC cardioversion at some stage,
other options medical
amiodarone intravenous infusion
or
lidocaine infusion
What is paraphimosis and how can you attempt to treat it without surgical intervention?
It is when the foreskin is left in a retracted position and becomes oedematous, then tight and cannot be reduced over the glans
Steps
Give oral analgesia and reassurance
Wrap a firm compression bandage (ideally 1 inch, for example Coban, pictured) over the oedematous area, starting at penile tip
Leave bandage for 10-15 minutes (use a timer)
Remove bandage and attempt to reduce foreskin over the glans. If unsuccessful, repeat bandage for further 15 minutes and re-attempt
If manual reduction fails, obtain urgent surgical consult
