Emergency Flashcards
Glasgow Coma Score
Eyes
4 - spontaneous
3 - to speech
2 - pain
1 - none
Verbal
5 - orientated
4 - confused
3 - inappropriate words
2 - incomprehensible sounds
1 - none
Movement
6 - obeys
5 - moves to localise pain
4 - flex to withdraw from pain
3 - abnormal flexion
2 - abnormal extension
1 - none
Pathophysiology of anaphylaxis
IgE mediated hypersensitivity to an antigen causing mast cell degranulation an histamine release (type 1 hypersensitivity)
Management of anaphylaxis
Initial
If no response
If refractory
Initial management:
- remove trigger
- support airway & high flow O2
- wide bore IV access
- have patient lie flat with legs raised
IM adrenaline:
In adults, inject into anterolateral thigh
If no response after 5 minutes:
- further dose of adrenaline
- fluid bolus 500-1000ml
- IV hydrocortisone 200mg
- IV chlorphenamine 10mg
If refractory:
IV adrenaline
Nebulised bronchodilators
Follow up
mast cell tryptase at 1, 6 and 24 hours
CXR when patient is stable
if first-time reaction: discharge with 2 adrenaline autoinjectors as an interim before specialist allergy appointment
What dose of adrenaline do you give to an adult in anaphylaxis?
500ug (0.5ml, 1:1000 concentration)
Type 1 vs type 2 respiratory failure
type 1 is hypoxic (low oxygen) - this is caused by mismatch of ventilation and perfusion (e.g. pneumonia, oedema, PE)
type 2 is hypoxic and hypercapnia (high carbon dioxide) - this is caused by hypoventilation (e.g. airway obstruction, COPD, reduced respiratory drive)
Hypovolaemic shock
Blood loss (e.g. trauma, GI bleeding)
Fluid loss or redistribution (‘third spacing’ such as burns)
Cardiogenic shock
Primary e.g. MI, arrhythmia
Secondary/obstructive e.g. PE, tamponade
Vasogenic/distributive shock
Sepsis
Anaphylaxis
Neurogenic
What is hyperthermia and how do you manage it?
Core temperature >40 with evidence of CNS dysfunction
Consider neuroleptic malignant syndrome
Management:
- remove clothing, secure airway and provide oxygen
- cardiac monitoring
- circulatory support with IV fluids but avoid K+
- active cooling with ice water emersion, evaporative cooling (wet spray with airflow), ice packs for axillae and groin
Hypothermia: ECG features and management
Hypothermia on an ECG presents as bradyarrhythmia:
- prolonged PR/QRS/QT
- J waves
Management:
- warm room, secure airway, humidified oxygen
- cardiac monitoring
- circulatory support with warm IV fluids if required
Active rewarming:
Mild/moderate (>32): passive external warming, blankets, Bair Hugger
Severe (<32): consider warmed peritoneal/bladder/gastric lavage, warmed haemodialysis or ECMO
Paracetamol overdose
- pathophysiology
- investigations
- management
Overdose = toxic NAPQI = hepatocellular necrosis
Investigations:
- paracetamol level @ 4 hours
- LFTs
- INR & PT best indicator
- ABG
- glucose (hypoglycaemia common in liver damage), U&Es, toxicology
Initial Mx:
- activated charcoal if within 1hr and normal GCS
- immediate acetylcysteine if pt injested >150mg/kg within 8-24h
- acetylcysteine if 4hr level above threshold
- if present >24h and are jaundiced or hepatic tenderness - acetylcysteine if the ALT remains elevated
Uncertain of ingestion time/staggeed: acetylcysteine
Opioid toxicity
- symptoms
- management
Sx:
- low resp rate
- pinpoint pupils
- unconscious
Mx:
- airway support +/- oxygen
- naloxone 0.4mg-2mg or IM titrated to response (may require repeat boluses or infusion)
- if opioid dependent may cause withdrawal (agitation, abdo pain, nausea)
TCA overdose
- symptoms
- ECG
- management
Sx:
- encephalopathy
- anticholinergic Sx: dry mouth, urinary retention, bowel obstruction, dilated pupils, blurred vision, increased HR)
- seizures
- cardiac issues
ECG:
- QRS prolong
- heart block
- risk for VT/VF
Mx:
- airway support +/- oxygen
- ABG
- IV sodium bicarbonate if ECG changes
- benzodiazepines for seizures
ACS:
- diagnostic criteria of a STEMI
- investigations
- ECG territories
- acute management
Diagnostic criteria:
- ST elevation >1mm limb leads
- ST elevation =>2mm contiguous chest leads
- LBBB
Investigations: serial ECGs, troponin (2-3h), CK-MB(6h), electrolytes, FBC, lipids, glucose and HbA1c, CXR, echo
ECG territories:
Anterior - LAD - V2-V4
Lateral - left circumflex - I, aVL, V5, V6
Inferior - right coronary - II, III, aVF
Initial management: oxygen, anti-emetic (e.g. ondansetron), IV morphine or IV GTN is pain persists and BP stable
Give anti platelets:
300mg aspirin & 300-600mg clopidogrel or 180mg ticagrelor (check local guidelines) and LMWH
ST elevation: refer for urgent PCI and consider glycoprotein IIb/IIIa inhibitor
(if you can’t get there within 120mins, give fibrinolysis and if STEMI in 60-90 minutes - PCI)
If patients treated with PCI for MI are experiencing chest pain or haemodynamically unstable post-PCI, urgent CABG
Non-ST elevation: anti-thrombin therapy (e.g. fodaparinux) and coronary angiography within 72h
Cerys note: only give glycoprotein IIb/IIIa inhibitors in NSTEMI if high GRACE score and if PCI is going to be carried out
Pulmonary oedema:
- CXR
- Typical ABG
- Management
CXR findings: ABCDE
Alveolar oedema
Bats wing hilar shadowing (Kerley B lines)
Cardiomegaly
Diversion to upper lobes (pul vein distension)
Effusion’s (blunting of costophrenic angle)
ABG:
- low PaO2 due to decreased ventilation perfection
- low/normal PaCO2 (if rising indicates patient is fatigued)
- metabolic acidosis and raised lactate due to hypoperfusion
Mx:
- sit patient upright
- give O2 if normal PaO2
- diuresis: 40mg IV furosemide
- monitor urine output, weight and renal function
- consider vasodilators (e.g. GTN) for ischaemia and normal BP
- consider NIV (e.g. CPAP, intubation)
Cerys note: sometimes lots of diuresis in a patient can cause an AKI in which you treat with haemodialysis
Malignant hypertension
- definition
- causes
- define hypertensive crisis
- investigations
- mx
- complications
Definition: BP >180mmHg systolic or >120mmHg diastolic and retinal haemorrhages & papilloedema
Causes: aortic dissection, catecholamine excess (e.g. phaeochromocytoma) or pregnancy
Hypertensive crisis: presence of end-organ damage as a result
Investigations: U&Es, FBC, thyroid, urinalysis, ECG/trop, CXR, head CT, thoracic CT, echo
Mx:
- hypertensive crisis requires ICU continual BP monitoring
- IV treatment includes labetalol, nicardipine and nitroprusside
- hypertensive urgency treated via oral antihypertensives to reduce BP over 24-48h
Complications: excessive falls in BP can cause cerebral, coronary or renal ischaemia. Reduce BP by 10% in first hour and 15% in next few hours.
3rd degree heart block
- defintion
- initial management
- other pharmacological mx
- non-pharmacological options
- definitive mx
No association between P waves and QRS complexes. Patient is unstable and has Sx of pul oedema and syncopal episode.
Initial:
- A-E
- continuous ECG monitoring
- IV wide bore access and send bloods
- correct hypovolaemia with fluids
- atropine (500ug-1mg IV) every 3-5 minutes up to max 3g
Other pharm:
- if no response consider isoprenaline or adrenaline
- beta blocker overdose: glucagon
- calcium channel blocker overdose: calcium and adrenaline
Non-pharm: transcutaneous pacing with sedation and analgesia for painful skeletal muscle contractions
Definitive Mx: pacemaker insertion.
Broad complex tachycardia vs narrow complex tachycardia Mx
Broad:
- DC cardioversion if unstable (up to 3 attempts)
- IV amiodarone 300mg
Narrow:
- DC cardioversion if unstable
- vagal manoeuvres
- IV adenosine (6mg - 12mg - 18mg)
- if unsuccessful use verapamil or beta-blocker (metoprolol)
Pericardial tamponade:
- symptoms
- ECG
- investigations
- aetiology
- mx
Symptoms - raised JVP, low BP, ankle oedema, distended neck veins, bibasal crackles, quiet heart sounds
ECG - electrical alternans (QRS amplitude alternates), sinus tachycardia
Investigations - ABG, FBC, WCC (elevated), CRP, ESR, troponin, CXR, echo
Aetiology:
- pericarditis/pericardial effusion due to malignancy, radiotherapy, infection, drugs (isoniazid)
- haemorrhage - penetrating trauma, aortic dissection
Mx:
- IV fluids
- if non-haemorrhagic then pericardiocentesis if haemodynamic compromise (BP <110, pulsus paradoxus)
- if haemorrhagic surgical drainage and repair
Acute exacerbation of asthma
- risks
- severity
- ABG results
- management
Risk factors - previous hospital admission, multiple therapies, increasing beta-2-agonists, smoking
Distress:
moderate - minimal
severe - marked
life-threatening - severe
Accessory muscles?:
moderate - no
severe - yes
life-threatening - yes
Peak flow:
moderate - >50%
severe - 33-50%
life-threatening - <33%
Other:
severe - RR>25, HR >25
life-threatening - hypoxia, normal PCO2, silent chest, exhaustion, hypotension
ABG for life threatening:
normal/raised PCO2 (should be low because of hyperventilation)
severe hypoxia (PaO2 <8kPA)
Management:
Target sats >94%
High dose beta-2-agonists and nebulised if severe (e.g. 2.5mg salbutamol) every 15-30mins or continuous if life-threatening
Ipatropium bromide: 0.5mg every 4-6h
Steroids: prednisolone 30-50mg oral daily or hydrocortisone 100mg every 6h if no oral intake
IV therapies:
- consider magnesium sulphate 1.2-2mg IV over 20 minutes
- consider IV aminophylline if life-threatening or bad response
No improvement or deterioration: ICU
Discharge if PEFR is >75% of best or predicted
Acute exacerbation of COPD
- clinical signs of severity
- ABG
- Mx
Severity: resp rate >30, tachy, cyanosis, use of accessory muscles, pursed lip breathing, altered mental status
ABG:
- type 2 resp failure with hyperaemia and acute resp acidosis
- patients with COPD may have baseline chronic compensated hypercapnia
Mx:
Controlled O2 therapy if O2 <88% or PaO2 <7kPa (BiPAP)
Nebulised bronchodilators:
2.5-5mg salbutamol
0.5mg ipatropium
Steroids:
30-50mg oral prednisolone
100-200mg IV hydrocortisone
ABX if infective trigger
Pneumothorax:
- risks for a primary/spontaneous
- risks for secondary
- acute complication with signs
- management for primary and secondary
Risk for primary: smoking, being tall (esp Marfans), FH of pneumothorax
Risk for secondary: trauma, lung disease, infection, iatrogenic (inserting a subclavian line can cause a pneumothorax)
Acute complication:
tension pneumothorax (pulsus paradoxus, raised JVP, hypotension, reduced expansion and hyper resonant percussion)
Management:
primary <2cm: discharge and review in 2weels
primary <2cm and breathless: aspirate with 16G cannula
secondary <1cm: admit and O2
secondary <2cm: aspirate with 16G cannula and admit
secondary >2cm: chest drain
aspiration needle: into the 2nd intercostal space mid clavicular line
cheers drain: between 4th-6th intercostal space anterior to mid-axillary line on affected side
PE
- ECG findings
- ABG
- Massive PE Sx (need thrombolysis)
- Scoring
- Short and long-term Mx
ECG findings: sinus tachycardia, right axis deviation, RBBB, rarely S1Q3T3
ABG: mild respiratory alkalosis due to hyperventilation
Massive PE: tachycardia (>120), hypotension (BP<90 sys), resp rate >30, hypoxia (pO2 <8kPA)
Wells score:
>4 PE likely = CTPA
=<4 = d-dimer
Acute:
- O2 in non-rebreather
- echo
- D-dimer or CTPA
- VQ if can’t tolerate CTPA
Long-term:
- anticoagulate with LMWH initially
- unprovoked: 6 months DOAC or warfarin
- provoked (cancer): 6 months DOAC or warfarin
- provoked (non-cancer): 3 months warfarin or DOAC
Acute upper GI bleed
- 2 common causes
- anatomical location
- management
- 2 scoring systems
Causes: peptic ulcer bleed (PUD) or chronic alcohol abuse causing portal hypertension then varices
Anatomical location: upper GI bleeds are above the duodenal-jejunal flexure (ligament of Treitz)
Management
- A-E
- IV PPI
- urgent endoscopy
Scoring:
Rockall score calculates if the patient is at risk of an adverse outcome after acute upper GI bleed:
<3 = good prognosis
>8 = high mortality risk
Glasgow-Blatchford:
0 = low risk and patient can have outpatient management
>6 = >50% risk of needing medical intervention
Encephalitis
- Diagnosis
- Cause
- Management
Diagnosis: it is diffuse inflammation of the brain parenchyma with altered mental status being the predominant symptom (seizure, confusion, agitation) sometimes with focal deficit
Cause: HSV-1 causing temporal lesions/haemorrhage
Mx: empirical IV aciclovir
Status Epilepticus
- definition
- causes
- management
Seizure lasting >5 minutes or 2+ seizures without regaining consciousness in between
Causes: epilepsy, hypoxia, stroke, electrolyte imbalance, alcohol intoxication, meningitis, encephalitis
Management:
In community: buccal midazolam or PR diazepam
Hospital: IV lorazepam 4mg (up to 2 doses 10-20 mins appart)
If seizures continue: IV phenytoin
If refractory: ITU
Traumatic brain injury
- classification
- presentation
- imaging
- management
- complications
Mild (concussion) - GCS 13-15
Moderate - GCS 9-12
Severe - GCS 3-8
Symptoms:
raised ICP including Cushings reflex: bradycardia, systolic HTN, irregular breathing
Papilloedema
Imaging: non-contrast CT head
Mx:
Raised ICP: raise head of bed to 30 degrees, analgesia, mannitol, intubate and hyperventilate
DKA diagnosis and management
Diagnosis:
blood glucose >11mol/L or known diabetes
blood ketones >3mmol/L or ketonuria (+2 on urine dip)
bicarbonate <15mmol/L or venous pH <7.3
Management:
IV fluids including K+
Fixed-rate insulin at 0.1unit/kg/hr
When glucose is <14mmol/L, add 10% dextrose and consider reducing insulin to 0.05unit/kg/hr
Maintain on sliding scale insulin if not eating: transfer for subcutaneous insulin if eating & drinking
DKA resolved when patient can eat and the metabolic gap closes
Cerys note: DKA can present with an ‘unrecordable’ blood sugar measurement with confusion and abdominal pain
HHS
- presentation
- diagnosis
- management
More insidious than DKA with symptoms developing over several days
Lethargy, confusion, reduced consciousness, weakness, focal neurological symptoms e.g. hemiparesis, polyuria, polydipsia, dehydration
Diagnosis:
blood glucose >30mmol/L without ketonaemia or acidosis
hyperosmolality >320mOsmol/kg
hypovolaemia
hypovolaemia
Management:
A-E
fluid resus
fixed rate insulin
prophylactic LMWH
Febrile neutropenia
- diagnosis/criteria
- risk
- investigations
- management
Febrile neutropenia is fever post-chemotherapy
Temperature >38
Neutrophil <0.5x10^9/L
Risk: age, advanced malignancy, haematological malignancy, combination chemo and radio, previous episode
Investigations:
bloods, coag (DIC), blood culture from peripheral veins, sputum, LP (if meningism), CXR, CT (abscess), echo
Mx:
empirical IV broad spec ABX within 60min (piperacillin/tazobactam)
G-CSF if chance of deterioration
Tumour lysis syndrome:
diagnosis
associations
biochemical abnormalities
initial management
further management
prophylaxis
Diagnosis - occurs from massive cellular breakdown in chemotherapy
Associated with chemo sensitive haematological malignancy
Biochemical:
hyperuricaemia
hyperphosphataemia
hyperkalaemia
hypocalcaemia
Initial management:
IV fluids
Consider loop diuretics (e.g. furosemide)
Consider rasburicase
IV calcium replacement if required
Further management: renal dialysis
Prophylaxis: allopurinol
rasburicase can be used prior to chemo
Cardiac arrest as a result of a pulmonary embolism
Initiate CPR
Give fibrinolytic
Continue CPR for 60 minutes
Spinal cord compression
- symptoms
- investigation
- management
Sx: back pain, lower limb weakness, sensory changes, neurological signs at the level of the lesion (above L1 is UMN and below LMN)
Investigation: urgent MRI of whole spine within 24h
Mx:
- high dose oral dexamethasone
- urgent oncological review
AAA
- features
- diagnosis
- management
Sx:
severe central abdo pain radiating to the back
pulsatile abdo mass
shock (hypotensive, tachycardia)
Diagnosis
clinical if stable and then sent for CT angio
Mx:
Immediate vascular review if haemodynamically unstable
