emergency Flashcards
antidote for benzo OD
supportive
flumazenil (has high seizure risk)
features benzo OD
low GCS
resp depression
hypothermia
antidote for opioid OD
naloxone
repeated doses may be needed
tricyclic antidepressant OD
IV bicarbonate - reduces risk of seizure + arrhythmias
lithium OD
volume resus
haemodialysis
sodium bicarbonate
warfarin OD antidote
VK
heparin OD antidote
protamine sulphate
beta blocker OD
bradycardic - give atropine
in resistant cases can use glucagon
Ethylene glycol OD (in antifreeze)
fomepizole
ethanol
methanol poisoning
fomepizole
ethanol
haemodialysis
Organophosphate insecticides OD
atropine
digoxin OD
Digoxin-specific antibody fragments
iron OD
Desferrioxamine, a chelating agent
lead OD
Dimercaprol, calcium edetate
CO poisoning
100% oxygen
hyperbaric oxygen
cyanine poisoning
Hydroxocobalamin; also combination of amyl nitrite, sodium nitrite, and sodium thiosulfate
Organophosphate insecticide poisoning
D: defaecation & diaphoresis.
U: urinary incontinence.
M: miosis (pupil constriction).
B: bradycardia
E: emesis.
L: lacrimation.
S: salivation.
presentation of salicylate poisoning (aspirin OD)
hyperventilation (centrally stimulates respiration)
tinnitus
lethargy
sweating, pyrexia*
nausea/vomiting
hyperglycaemia and hypoglycaemia
seizures
coma
what does salicylate poisoning cause
a mixed respiratory alkalosis and metabolic acidosis.
Early stimulation of the respiratory centre leads to a respiratory alkalosis whilst later the direct acid effects of salicylates (combined with acute renal failure) may lead to an acidosis (w raised anion gap)
tx salicylate poisoning
general (ABC, charcoal)
urinary alkalinization with IV sodium bicarbonate - enhances elimination of aspirin in the urine
haemodialysis
what is neutropenic sepsis
a neutrophil count of < 0.5 * 10^9 in a px who is having anticancer treatment and has one of the following:
- temp > 38ºC or
- other signs or symptoms consistent with clinically significant sepsis
commonly occurs 7-14 days after chemo
RFs assoc w neutropenic sepsis
poor nutrition
mucosal barrier defect
central venous lines
abnormal host colonisation
most common bacteria causing neutropenic sepsis
Staphylococcus epidermidis
neutropenic sepsis prophylaxis
if it is anticipated that patients are likely to have a neutrophil count of < 0.5 * 109 as a consequence of their treatment they should be offered a FLUOROQUINOLONE (e.g. ciprofloxacin)
mx neutropenic sepsis
start IV abx asap
- piperacillin with tazobactam (TAZOCIN)
do not wait for blood test results
switch to oral if improving after 24-48 hrs IV tx
if no imp after 48 hrs add 2nd line abx e.g. meropenem+/- vancomycin
if no imp after 5 days look for opportunistic infections e.g. fungal
which cancer px are most likely to get malignant spinal cord compression
lung
breast
prostate
myeloma
features of malignant spinal cord compression
BACK PAIN
- the earliest and most common symptom
- may be worse on lying down and coughing
- worsening
do not weight for neuro deficit if px has this
lower limb weakness
sensory loss + numbness
neurological signs depend on the level of the lesion.
- above L1 -> UMN signs in the legs and a sensory level
- below L1 -> LMN signs in the legs and perianal numbness.
- tendon reflexes tend to be increased below the level of the lesion and absent at the level of the lesion
ix malignant spinal cord compression
whole MRI spine within 24 hours of presentation
tx malignant spinal cord compression
high-dose oral dexamethasone
(w PPI + monitor BMs as they can increase)
urgent oncological assessment for consideration of radiotherapy or surgery (once established this sld be done in 24hrs)
VTE proph + pressure sore prevention
mx of malignant hypercalcaemia
correct dehydration
- 0.9% saline
IV bisphosphonates - zolendronic acid / pamidronate
- inhibit osteoclasts so reduce bone turnover
if persistent / relapsed
- denosumab (inhibs RANK ligand)
presentation of SVCO
dyspnoea
chest pain - often at rest
cough
neck + face swelling
arm swelling
dizzy, headache, visual dist, nasal stuffy, syncope
dilated veins over arms, neck + anterior chest wall
oedema of upper torso, arms, neck + face
cyanosis
engorged conjunctiva
convulsions + coma
SVCO
superior vena cava obstruction (by tumour)
usually provides the venous drainage for the head, neck, upper limbs + upper thorax
when obstructed, collateral pathways form to provide an alt route for blood to return to the RA
mx SVCO
elevations of the head + O2 therapy for sx relief
high dose steroids
endovascular stenting
anticoag if central vein thrombosis
tx of tumour that caused it
What is an acute transfusion reaction?
occurs during, or up to 24 hours following, blood transfusion
Febrile, Allergic and Hypotensive Reactions (FAHR) presentation
increase in temperature by 1-2°C above baseline, or absolute temperature ≥ 38°C in isolation (mild)
An increase in temperature >39°C or a rise ≥ 2°C from baseline (moderate)
may also have chills/rigors
isolated rash (mild)
angioedema, dyspnoea, hypoxia, urticaria (moderate)
allergic features + airway comp/haem unstability (severe)
hypotension
Acute haemolytic transfusion reaction AHTR) presentation + how is dx confirmed
rise in temp
pain at infusion site
anxiety
if severe: hypotension, decreased UO, spontan bleeding due to DIC
dx confirmed by lab testing - evidence of haemolysis w falling Hb in the presence of a red cell antibody
Transfusion assoc circulatory overload (TACO) presentation
resp comp (exc allergy/anaphylaxis)
pulmonary oedema
unexpected changes in cardiovasc status - HTN, tachy, increased JVP, enlarged heart CXR, peripheral oedema
objective signs of left atrial hypertension - new/worsening cardiac failure on echo, NT-proBNP 1.5x risk on pre and pst trans sample (normal excludes TACO)
fluids - imp in resp status after diuretic tx , was the fluid balance signif +ve
what is the most common cause of morbidity in patients undergoing transfusion
Transfusion assoc circulatory overload (TACO)
what is transfusion related acute lung injury (TRALI)
a clinical syndrome in which there is acute, noncardiogenic pulmonary edema associated with hypoxia that occurs during or after a transfusion
usually due to HLA antibodies in the donor
when to suspect transfusion related acute lung injury (TRALI)
px devs acute dyspnoea w hypoxia + bilateral pulmonary infiltrates during, or within six hours of, transfusion
what is transfusion assoc dyspnoea (TAD)§
characterised by respiratory distress, not due to the patient’s underlying condition, within 24 hours of transfusion and does not meet the criteria of TRALI, TACO or allergic reaction
Presentation of transfusion transmitted infection (TTI)
rare and bacterial contamination is usually the only TTI to present as an acute reaction
sx v shortly after trans:
Rise in temperature, rigors;
Hypotension;
Tachycardia.
presentation of delayed haemolytic transfusion reaction (DHTR) + dx
A fever;
and/or a failure to increment to the transfusion as expected (i.e. minimal rise or subsequent rapid fall) in Hb;
and/or otherwise unexplained increase in bilirubin.
dx lab testing (evidence of haemolysis in the presence of a red cell antibody)
what is post transfusion purpura + when to suspect
severe but rare immune mediated complication which can occur 5-12 days after transfusion of red cells or platelets
Any unexplained platelet drop > 50% following transfusion should be discussed with a haematologist
what is transfusion assoc graft-versus host disease (TA-GvHD) + what increases its risk
In patients with impaired T cell function, lymphocytes from the transfused blood can engraft, mounting an immune response against the recipient’s cells.
> 95% mortality and multi-organ failure can occur from a few days up to a few months following transfusion
Risk:
Transfusing irradiated blood to patients with impaired T cell immunity (e.g. post stem cell transplant, but not patients with HIV), prevents proliferation of lymphocytes and thus TA-GvHD.
immediate tx of life threatening acute transfusion reaction
PAUSE TRANSFUSION
CALL FOR URGENT MEDICAL ASSISTANCE VIA YOUR EMERGENCY NUMBER.
Initiate resuscitation – ABCDE.
Is haemorrhage likely to be causing hypotension?
If SO - CONTINUE transfusion.
If not- disconnect transfusion (keep indicated units).
Maintain venous access.
Frequent vital signs monitoring.
2ndary tx of life threatening acute transfusion reaction
If likely anaphylaxis/severe allergy - follow anaphylaxis pathway.
If bacterial contamination likely, start antibiotic treatment.
Use BP, pulse, urine output (catheterise if necessary) to guide intravenous 0.9% saline administration.
Inform transfusion laboratory.
Return unit to transfusion laboratory.
If bacterial contamination suspected, contact transfusion laboratory to discuss recall of associated components.
Perform relevant investigations (as recommended on the transfusion reaction form).
Contact haematologist if required.
Document outcome/action taken in notes.
Complete adverse event report form.
Transfusion Practitioners refer to MHRA/SHOT, as appropriate.
mx of mild transfusion reactions
Treat mild pyrexia with oral paracetamol;
Treat mild allergic reactions with antihistamines;
If the reaction is confirmed as mild, you may restart the transfusion at a slower rate following a full clinical review (including patient ID/component label check) with close observation.
may be start of more severe reaction, observe px closely
mx of moderate transfusion reactions
Manage the patient symptomatically and according to severity of symptoms e.g. with paracetamol, antihistamines and if needed for respiratory symptoms, inhaled short-acting beta-2 agonists and/or oxygen.
The transfusion may be restarted if:
A full clinical review by medical staff (including patient ID/component label check) has been undertaken; and either:
The patient recovers with only symptomatic intervention or;
There is an obvious alternative explanation for the symptoms/signs.
If the transfusion is resumed, the patient must be closely observed.
what to do in the event of an ABO incompatible transfusion
Give fluid resuscitation;
Send samples for FBC, PT/APTT/fibrinogen, renal function, G&S;
Monitor urine output closely;
Contact ITU for early review for inotropic, renal, and/or respiratory support;
Discuss urgently with haematology re further treatment e.g. steroids +/- intravenous immunoglobulin.
If checks show ABO incompatibility due to transfusion of a unit intended for another patient, contact your transfusion laboratory immediately to prevent a further incident.
what is hyperhaemolysis
where there is destruction not just of transfused blood but the patient’s own as well
comps of rapid blood transfusion
DIC
hypocalcaemia
hypothermia
TACO
VTE
hyperkalaemia
features cocaine OD
agitation, confusion, delirium
hyperthermia
tachycardia
hypertension
arrythmias
ACS + strokes
tx cocaine OD
benzo
supportive
CCVs (verapamil), labetalol
what is cushing’s triad
increased BP
bradycardia
irregular breathing
physiological response that is seen in the context of raised ICP
reversible causes of cardiac arrest
4 “Hs” and 4 “Ts”
hypoxia
hypokalaemia/hyperkalaemia
hypothermia/hyperthermia
hypovolaemia
tension pneumothorax
tamponade
thrombosis
toxins
Local anesthetic toxicity reversal agent
IV 20% lipid emulsion
