Emergency doses & rx Flashcards
Anaphylactic shock
Secure airway: 100% O2, incubate if obstruction imminent
Remove cause (raising feet may help restore circulation)
Adrenaline IM 0.5mg (0.5mL of 1:1000). Repeat every 5min if needed, as guided by BP, pulse, resp function
IV access
Chlorphenamine (antihistamine) 10mg IV + Hydrocortisone 200mg IV
Fluid challenge: IVI 0.9% Saline (500ml over 15mins - up to 2L). Titrate to BP
If wheeze: treat for asthma / may need ventilators support
If still hypotensive: ICU admission + IVI adrenaline (0.5mL of 1:10,000) +/- aminophylline, nebulised slabutamol. Senior r/v
Further Rx: admit, ECG, mast cell tryptase 1-6h post, medic alert bracelet, eduction re: self-injected adrenaline, skin prick test (specific IgE allergens)
Acute STEMI
12 lead ECG
IV access: FBC, U&E, glucose, lipids, cardiac enzymes (Trop I/T, CK)
Brief ax: hx CVD, risk factors IHD, pulse, BP (both arms), JVP, murmurs, signs of CCF, upper limb pulses, scars (prev cardiac surgery), CXR (if will not delay rx)
Contraindications to PCI (cannot be transferred to primary PCI centre in 120 mins) or fibrinolysis (>24h post admission, ideally <30mins, ST depression alone, T wave inversion inversion alone, normal ECG)
Aspirin 300mg (unless already given)
Morphine 5-10mg IV + anti-emetic (e.g. Metoclopramide 10mg IV)
Oxygen if sats <95%, breathless or acute LVF
Primary PCI (if meets indication criteria)
Or
Fibrinolysis then transfer to PCI centre (rescuer PCI if fibrinolysis unsuccessful or for angiography)
(GTN now not recommended in acute setting unless hypertensive or acute LVF)
ACS without ST elevation
Admit to CCU & monitor closely
If sats <90% or breathless, low flow O2
Analgesia (e.g. Morphine 5-10mg) + Metoclopramide 10mg IV
Nitrates: GTN or sublingual tablets
Aspirin: 300mg PO + 2nd antiplatelet (clopidogrel, ticagrelor, prasugrel) unless contraindicated
Beta blocker PO (e.g. Metoprolol 50mg/12h) if htn/tachycardic/LV function <40% If contraindicated (e.g. Asthma, COPD, LVF, bradycardia, coronary spasm) give rate-limiting Ca antagonist (e.g. Verapamil 80-120mg/8h PO or diltiazem 60-120mg/8h PO)
Anticoagulation: Fondaparinux 2.5mg OD SC or LMWH 1mg/kg/12h SC
If pain continues: Nitrate IV (e.g. GTN 50mg in 50ml 0.9% saline, 2-10ml/h). Titrate to pain & maintain systolic BP >100mmHg
Record ECG whilst in pain
High risk: invasive (infusion glycoprotein IIb/IIIa inhibitor (e.g. Tirofiban) & refer to angiography as inpatient
Low risk: conservative (d/c if repeat Trop -ve, treat medically, further inv e.g. Stress test)
Acute heart failure
Sit patient up
O2: 100% if no pre-existing lung disease
IV access & monitor ECG (treat any arrhythmias e.g AF)
Investigations whilst continue treatment: CXR, ECG, U&E, trop, ABG, echo, BNP
Diamorphine 1.25-5mg IV slowly (caution in liver failure & COPD)
Furosemide 40-80mg IV slowly (larger dose in renal failure)
GTN spray 2 puffs or SL or 2=0.3mg tablet SL (dont give if systolic BP <90mmHg)
Investigations, exam & hx
If systolic BP >100mmHg: start nitrate infusion (e.g. Isosorbide dinitrate 2-10mg/h IVI)
If worsening: further furosemide 40-80mg, consider CPAP (senior help), increase nitrate infusion if dont drop BP <100
If systolic BP <100: treat as cardiogenic shock & refer to ICU
Cardiogenic shock
Manage in CCU/ICU - senior help
O2: titrate to maintain stays 94-98 (88-92 in COPD)
Diamorphone 1.25-5mg IV for pain/anxiety
Investigations & monitoring (ECG, U&E, trop/cardiac enzymes, ABG, CXR, echo +/- CT thorax, VQ scan)
Correct arrhythmia, U&E abnormalities, acid-base disturbance
Optimise filling pressure: ax pulse, BP, JVP/CVP (PICCO, trans-oesophageal doppler, Swan-Gants catheter in ICU)
Underfilled: plasma expander - 100ml every 15min IV (aim MAP 70/CVP 8-10 mmHg)
Well/overfilled: Ionotropic support (e.g. Dobutamine IVI) (aim MAP70)
Treat any reversible causes (e.g. Thrombolysis, surgery)
Broad complex tachycardia
No pulse: arrest protocol
Pulse:
O2 if sats <90%
Iv access
12 lead ECG
No adverse signs (hypotensive, chest pain, HF, tachy):
Correct electrolyte probs
Rhythm:
Regular (VT): amiodarone 300mg IV over >20min then 900mg/24h via central line
Irreg (AF with BBB) (pre-excited AF): amiodarone (torsade do point): Mg 2g IVI
If unsuccessful: sedation & synchronised DC shock (150-200J / 150-360J x 2 biphasic)
Adverse signs:
Senior help
Sedation
3 synchronised DC shocks: 150-200J 1st then 150-300J subsequently
Amiodarone 300mg IV over >20min then 900mg over 24h via central line
Check/correct K & Mg
Further cardioversion if needed
Narrow complex tachycardia
ECG
IV access
O2 if hypoxic
Irregular rhythm: manage as AF
Regular rhythm:
Continuous ECG
Vagal manoeuvres (caution in digoxin toxicity, acute ischaemia, carotid bruit)
Adenosine (vasodilator/antiarrhythmic) 6mg bolus injection then 12mg, then 12mg if necessary (alternative: Verapamil)
No Adverse signs (hypotensive, HF, reduced conscious, tachy): Beta blocker (metoprolol IV 1-10mg) or Digoxin (IV max 100 micrograms) or Amiodarone (300mg IV over 1h)
Adverse signs:
Sedation
Synchronised cardioversion 150J 360J 360J
Amiodarone 300mg over 20-60min then 900mg over 24h
Acute severe asthma
Ax severity
(PEF, ability to speak, RR, pulse, sats)
Warn ICU if severe/life threatening
Salbutamol 5mg nebulised with O2
Hydrocortisone 100mg IV (or prednisolone 40-50mg PO)
O2 if sats <92 (+ check ABG)
Life threatening features (PEF <33%, silent chest, cyanosis, poor resp effort, bradycardia, hypotensive, exhaustion, confusion, coma, ABG resp acidosis/type 2 resp failure)
Inform ICU/seniors
Salbutamol nebs every 15mins or 10mg continuously. Monitor ECG
Ipatropium 0.5mg added to nebs
Magnesium sulfate 1.2-2g IV over 20min (single dose)
Not improving:
ICU
If improving within 15-30mins:
Salbutamol nebs every 4h
Prednisolone 40-50mg PO OD
Monitor peak flow & sats
Acute exacerbation COPD
Nebulised bronchodilators:
salbutamol 5mg/4h
Ipatropium 500micrograms/6h
Investigations: CXR, ABG
Controlled O2 if sats <88 or PaO2 <7kPa
Start at 24-28% & aim sats 88-92 (94-98 if no hypercapnia on ABG)
Steroids: IV hydrocortisone 200mg + oral prednisolone 30mg OD
Abx if evidence of infection (e.g. Amoxicillin 500mg/8h PO)
Physio: sputum expectoration
If no response to nebulisers: IV aminophylline
If no response:
NIPPV (if RR >30 pH <7.35 & CO2 rising)
Intubation/ventillation (if pH <7.26 & CO2 rising)
Resp stimulant drug (e.g. Doxapram 1.5-4mg/min IV) if not suitable for mechanical ventillation
Pneumonia
ABC assessment:
Hypoxia (sats <88%): O2 (start at 24-28% if hx COPD/hypercapnia)
Treat hypotension/shock from infection
Ax dehydration: IV fluids
Investigations:
CXR
Sats & ABG if sats <92
Bloods: FBC, U&E, LFT, CRP, atypical serology
Urine: pneumococcal (& legionalla) antigen
Viral throat swabs
Blood cultures if pyrexial
Pleural fluid aspirate for culture
Bronchoscopy/BAL if immunocompromised or on ICU
Abx: depending on local guidelines
Co-amoxicalv 1.2g/8h IV (Pen allergic: Cephalosporin) + Clarithromycin 500mg/12h IVI (or Cipro)
ATYPICAL - Legionalla: add Leofloxacin + rifampicin, Chlamydophilia: add tetracycline, Pneumocystis jiroveci: add co-trimoxazole
HOSP ACQUIRED - Aminoglycoside IV (e.g gentamicin) + antipseudomonal penicillin (e.g. Ticarcillin)
Large PE
O2 if hypoxic (10-15L/min)
Morphine 5-10mg IV + anti-emetic if pain/distressed
Massive PE (ie peri-arrest): consider immediate thrombolysis (e.g. 50mg alteplase)
IV access & start heparin (LMWH e.g. Tinzaparin 175u/kh/24h SC or UFH 10,000U IV then 18u/kh/h IVI)
Systolic BP <90:
Colloid infusion
ICU input
Systolic BP>90:
Warfarin loading e.g. 5-10mg PO
Acute upper GI bleed
Protect airway + NBM
2 large bore cannulae
Urgent bloods: FBC, U&E, LFT, glucose, clotting, Xmatch 6 U
Rapid IV crystalloid infusion up to 1L
Grade III or IV shock: give blood (group specific of O-ve)
Otherwise, slow crystalloid infusion
Transfuse as needed
Correct clotting (e.g. Vit K, FFP, platelet conc)
Consider ref IDU/HDU, CVP line
Catheterise & monitor UO (aim >30ml/h)
Monitor vital signs every 15 min until stable, then hourly
Notify surgeon of severe bleed
Urgent endoscopy for dx +/- bleeding control
Bacterial Meningitis
ABC ax:
IVI + fluid resus
Nurse to draw up Cefotaxime 2g
Septicaemic (e.g. Reduced cap refill, cold hands/feet, rash): Dont attempt LP Cefotaxime 2g IV Help from critical care team Ax for signs of shock
Meningitic (e.g. Neck stiffness, photophobia): Dexamethasone 4-10mg/6h IV If signs RICP: ICU & dont attempt LP If no shock or signs RICP: LP 2g cefotaxime IV post-LP immediately
Status elepticus
Open & maintain airway: recovery position, remove obstructions, incubate if necessary
O2 100% +/- suction
IV access
Bloods: U&E, LFT, FBC, glucose, Ca, toxicology screen, anticonvulsant levels
Slow IV blous phase - stop seizures (e.g. Lorazepam 2-4mg) 2nd dose if no response in 10min
Thiamine 250mg IV over 30min if alcoholism/malnourishment
Glucose 50ml 50% IV unless glucose known to be normal
Treat severe acidosis
Correct hypotension (fluids)
IV infusion phase:
If seizures continue: phenytoin 15-20mg/kg IVI <50mg/min
Monitor ECG & BP
100mg/6-8h maintinence dose
General anaesthesia phase: continuing seizures - expert help (ICU, paralysis, ventillation, continuous ECG monitoring)
DKA
ABC ax:
2 large bore cannulae
Saline 500ml fluid challenge if BP <90. 2nd bolus if no response
Tests:
ECG, CXR, urine dip & MSU, bloods: glucose, ketones U&E, HCO3, amylase, osmolality, ABG/VBG, FBC, blood culture
Insulin: 50u actrapid in 50ml 0.9% saline. Continuous infusion 0.1u/kg/h & continue patients long acting insulin
(Aim fall ketones/rise bicarb & if not, increase insulin infusion by 1u/h)
Check VBG 1h, 2h and then 2hourly
Ax need for K replacement
Consider catheter if not passed urine by 1h
Aim UO 0.5ml/kg/h
NG tube if vomiting/drowsy
LMWH
Avoid hypo: when glucose <14mmol/L start 10% glucose at 135ml/h to run alongside saline
Continue fixed rate insulin until ketones <0.3mmol/L, pH >7.3, bicarb >18
