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
