EMERGENCY Flashcards
Anaphylaxis
- Generalized or systemic hypersensitivity reaction
- Sudden onset and rapid progression of Sx
- Specific IgE Ab (type 1 hypersensitivity –> release histamine
- CF: Rash, urticaria, laryngeal oedema, angio-oedema, broncosmapsm, itching, vom + diarrhoea
- Management: Check for serum mast cell trypase to confirm global mast cell degranulaition 02, fluid A-E + Raise legs (ACHRS) - Adrenaline 0.5MG = 500mcg of 1 in 1000 Chloramphenine IV 10mg Hydrocortisone 200mg Ranitidine(H2 antagonist) Salbutamol
FLUID BOLUS
Anyone that comes in after using an epipen must stay in for 8 hours on HDU due to the risk of biphasic reaction (30% cases) at 6 hours
Septic shock
Hypotension despite fluid challenge/ Needs vasopressors or ionotropes
• SIRS = systemic inflammatory response syndrome
o HR >90
o RR >20 or PaCO2 <4.3
o Temp <36 or >38.3
o WCC <4 or >12
• Sepsis = SIRS+Infection
Severe sepsis = sepsis + signs hypoperfusion or organ failure
Cause: e.g. pneumonia, cellulitis, endocarditios, UTI
CF: Dizziness, SOB, sweat, N+V, breathless, confusion
Sign: fever, BP <100, warm peripherires
IVX: Bloods, cultures - 2 sets from diff sites plus lines
ABG, ECG, Urine dip, cxr
MANAGEMENT:
help, elevate legs, high flow 02, fluid challenge, vasopressors, PEEP, IV abx
Blood cultures Uruine output- catheter Fluid challenge Antibitics broad spec Lactate O2 non rebreathe 15L
Cardiogenic shock
Heart pump failure
- sustained hypotension and tissue hypoperfusion
Causes: MI, aortic dissection, dysrhythmia, PE, pneumothorax
CF: chest pain, N+V, dyspnoea, profuse sweating, palpitations, faintness, raised JVP, syncope, pale, tachy/Brady. quiet heart sounds
IVX: A-E, ECG, CXR: look for peneumothorax, cardiomegaly, fluid overload
ABG, bloods, Echo
Management: A-E, 15L 02, vasporessors if needed
(often caused by MI so early coronary revascularisation).
Hypovolaemic shock
Worrying signs
Pathology
Sx underlying disease?
IVX
Management
Worrying signs e.g BP <90 and low GCS + Unresponsive to fluid challenge
Cause: Haemorrhage- Trauma, Ruptured AAA, GI bleed, Salt and water loss, 3rd space loss, Acute pancreatitis, Ascites
Clinical Features: Dizziness on standing, SOB, Chest pain
Signs: BP <100, Tachy, Weak/thread pulse, Postural hypotension, Cool peripheries/cap refill >2secs
IVX: bloods, ABG, ECG, CXR, pelvic x ray, abdo uss
Management: HELP
lay flat elevate legs
02 + IV access –> bloods and cross match + 1L 0.9% saline
compression to stop bleed –> blood transfusion O neg if Hb under 70, 1 UNIT = 10 hb
–> Refer to surgeon
Complications: kidney injury, gut ischemia, hypoxia + metabolic acidosis
Acute respiratory failure
CF:
(hypoxia) +/- (hypercapnia)
· Type 1 Resp failure (hypoxia) = COPD / asthma, Pneumonia, Pul oedema, Pul fibrosis, Pneumothorax, PE, Cyanotic congenital heart disease
· Type 2 Resp failure (hypoxia and hypercapnia), COPD/ Severe asthma, Drug overdose, CNS / muscle disorders
CF: Confusion and reduced consciousness Restlessness, Anxiety, Confusion, Seizures, Tachycardia and arrhythmias + Cyanosis
IVX: ABG, CXR, Bloods, echo, ECG
Complications: PE, pul fibrosis, cor pulmonale
TX: o2, nebulisers, steroids, treat underlying cause, definitive airway
ACS
3 conditions?
Syx
immediate treatment acs
immediate for confirmed stemi and nstmei
aftercare
Acute coronary syndrome (ACS)
1) Unstable angina and NSTEMI – not treated w/ thrombolysis
2) STEMI – must undergo reperfusion therapy on presentation
- Common symptoms:
- Chest pain radiating to arms, back or jaw > 15 mins
- Acute dyspnoea
- Nausea, vomiting and sweating
- Haemodynamic instability
IMMEDIATE treatment for suspected ACS (MONA)
Morphine, Oxygen, GTN, Aspirin 300mg PO
ECG + blood markers (Trop T+I, CK)
IMMEDIATE MANAGEMENT for confirmed STEMI or NSTEMI (MMONACH)
ECG + blood markers + Secure IV access
Morphine 2.5-10mg (treat nausea)
Metoclopramide 10mg IV
O2 high glow if sats <94%
Nitrates - GTN spray 2 sprays + BB - Bisoprolol
Aspirin 300mg PO
Clopidogrel 300mg
Heparin (if within 12hrs of Sx onset and undergoing rimary PCI) OR Fondaparinux (NSTEMI – LMWH continue for 2-5d, CI with PCI)
Bloods: FBC, U+E, glucose, lipid profile (LDL, HDL, triglycerides)
CXR
After care for all patients with recent NSTEMI or STEMI (ABC’S):
ACEi – indefinite
BB – 12 months
anti-Coagulants X 2 (Aspirin and Anti-plat = ticagrelor or clopidogrel) 12 months
Statin
Overdose: paracetemol
· Risk of severe liver damage
o >250mg/kg = likely
o >12g total = fatal
Gluthathione stores depleted –> NAPQI reacts –> liver necrosis
CF: Often asymptomatic for first 24hrs · Nausea, Vomiting, Acidosis · Hepatic necrosis develops after 24hrs --> o Elevated transaminases o RUQ pain o Jaundice
ask: no. tablets taken, time, staggered? with alcohol?
suicide risk
IVX: paracetemol levels 4 hrs post ingestion, bloods, INR every 12 hours, LFTs
Management: timed plasma paracetemool level plotted on chart
IV acetlycysteine –> PARVOLEX
150mg/kh = 1 hour, 50 = 4 hour, 100 = 16 hr
–> Refer to ICU if fulminant liver failure
–> List for transplant if ph <7.3 or lactate >3 after fluid resus
REfer to MHT
Overdose: Salicylate
In aspirin
ingested >250mg/kg = toxicity
Syx: n+v, tinnitus, lethargy, dizziness, dehydration, restlessness, deafness, convulsions
Chronic poisoning: insidious onset, diff concentrating, anxiety
IVX: Plasma salicyate conc + 2hr and 4hr after ingestion
Bloods- raised INR, U+E, FBC, Urinary ph
ABG: see mixed resp alkalosis with metabloic acidosis !?
Management: oral activated charcoal + gastric lavage
Rehydration aggressively
Glucose
Haemodialysis
Overdose: TCAD
E.G. amitryptilline
CF:
IVX
management
CF: Cardiovascular- sinus tachy, prolonged PR/QRS/QT Heart block, vasodialation, hypotension CNS- drowsiness, coma, pyramidal signs Anticholinergi effects
IVX: bloods, ECG, ABG = often acidosis and hypokalaemia
Management: gastic lavage within 1 hr ingestion.
–> Activated charcoal + IV bicarbonate
Antiarryhtmic treatment avoided unless URGENT
Noradrenalien for hypotension
Cardiac massage (high success after TCA MI)
Seizures- treat wth BZ’s.
Overdose: Iron
Management?
Syx: N+V, abdo pain, diarrhoea, GI bleeds. Serious –> Hepatocellular necrosis. Jaundice, hepatic failure.
Management: IV DESFERRIOXAMINE antidote
- lie patient down but turn to side if vomiting
Assess respiration
A-E
Consult TOXBASE
Consider gastric lavage if >1hr since overdose
Consider urine toxocolgy
Falls in eldeerly
RF:
Clinical frailty score?
50% over 80s falling at least once/yr
RF: · >80yrs · Female · Low weight · Hx fall in previous year · Dependency in activities of daily living · Orthostatic hypotension · Medication – benzos, antidepressants, antipsychotics, BP lowering drugs and anticonvulsants · Polypharmacy · Alcohol misuse · Diabetes · Confusion and cognitive impairment Disturbed vision, balance or co-ordination
CF: ask about pattern, precipiating factor, exertion, LOC, witness account, eyesight?
IVX: Timed up anD go test, get patient to turn 180 degrees,
Urinalysis, ecg, visual assessment, bloods and random glucose + b12
ROCKWOOD = clinical frailty scale “rocky” on their feet
Acute and chronic confusion / delerium
· Abnormalities in thought, perception and levels of awareness
· Acute onset and intermittent
· Can by hypoactive or hyperactive
RF: · Age ≥65 years.
· Male sex.
· Pre-existing cognitive deficit - eg, dementia, stroke.
· Severity of dementia.
· Severe comorbidity.
· Previous episode of delirium.
- operations esp hip fracture/ emergency
Cause: acute infection, prescribed drugs, post op, toxic substances, vascular disorders, metabolic disorders, vitamin def, endocrinopathies, trauma epilepsy
IVX: AMTS, Bloods, urine dip,
Management: supportive, environmental, sedation- haloperidol
ANAPHYLAXIS = ARCH
Adrenaline 500mcg of 1:1000
Ranitidine -
Chloramphenine - 10mg
Hydrocortisone 200mg
Secondary treament ACS = ABC’S
Ace inhibiter
B blocker
anti-Coagulants - aspirin and clopidogrel
Statins
ACS = MONA
MI Confirmed = MMONACH
Morphine O2 Nitrates (GTN) Aspirin 300mg
Morphine, Metocloprimide, 02, Nitrates, Aspirin 300mg, Clopidogrel 300mg, Heparin or Fondaparinoux
+ b blocker
