Emergency - Level 1 Flashcards
Definition of anaphylactic shock?
- Anaphylaxis is generalised immunological condition of sudden onset, which develops after exposure to foreign substance
Mechanism of anaphylactic shock?
o Type 1 IgE mediated reaction which patient has been previously exposed
o Complement mediated
o Unknown
Pathology of anaphylactic shock?
o Mast cells and basophils release histamine, prostaglandins, leukotrienes, platelet activating factors
Causes of anaphylactic shock?
o Drugs and vaccines (Abx, penicillin, streptokinase, aspirin, suxamethonium, NSAIDs, IV contrast)
o Bee/Wasp sting
o Food (nuts, shellfish, strawberries, wheat)
o Latex
o Semen
Symptoms of anaphylactic shock - respiratory, skin, CV and GI?
Onset usually minutes/houra, prodrome of feeling impending doom may present
o Swelling of lips, tongue, pharynx and epiglottis – airway obstruction
o Dyspnoea, wheeze, chest tightness, hypoxia, hypercapnia
o Pruritus, erythema, urticaria, angio-oedema
o Vasodilation, increased vascular permeability – hypotension and shock
o Arrhythmias, ischaemic chest pain
o Nausea, vomiting, diarrhoea, abdominal cramps
ALS algorithm management for anaphylaxis - 1 - diagnosis?
o Acute onset
o Life-threatening ABC problems
Airway: swelling, hoarseness, stridor
Breathing: rapid breathing, wheeze, fatigue, cyanosis, SpO2 < 92%, confusion
Circulation: pale, clammy, low blood pressure, faintness, drowsy/coma
o Usually skin changes
ALS algorithm management for anaphylaxis - 2 - ABCDE?
o Call for help
o Lie patient flat
o Raise patient’s legs
ALS algorithm management for anaphylaxis - 3 - 1st drug and dose?
- Adrenaline
o IM 1:1000 adrenaline (repeat after 5 mins if no better)
Adults or child >12 years - 500mcg IM (0.5ml)
Child 6-12 years – 300mcg (0.3ml)
Child <6 years – 150mcg (0.15ml)
o IV given by experienced specialists
Titrate adults 50mcg, children 1mcg/kg
ALS algorithm management for anaphylaxis - 4 - when available?
o Establish airway
o High flow oxygen
ALS algorithm management for anaphylaxis - 5 - 3 other drug management?
o IV fluid challenge o Chlorphenamine (IM or slow IV) o Hydrocortisone (IM or slow IV)
Doses of IV fluids in anaphylaxis?
o IV fluid challenge
500-1000ml - 0.9% saline bolus
Child 20ml/kg – 0.9% saline bolus
Doses of chlorphenamine in anaphylaxis?
o Chlorphenamine (IM or slow IV) Adult or child > 12 years - 10 mg Child 6 - 12 years 5 mg Child 6 months to 6 years 2.5 mg Child less than 6 months 250 micrograms/kg
Doses of hydrocortisone in anaphylaxis?
o Hydrocortisone (IM or slow IV) Adult or child > 12 years - 200 mg Child 6 - 12 years - 100 mg Child 6 months to 6 years - 50 mg Child less than 6 months - 25 mg
Monitoring in anaphylaxis?
o Pulse oximetry
o ECG
o BP
Further management in anaphylaxis?
o ICU – adrenaline, aminophylline and nebulised salbutamol may be needed
Management after emergency treatment of anaphylaxis?
Document time of reaction and triggers identified in notes
Mast Cell Tryptase ASAP & 2nd sample within 1-2 hours from onset of symptoms
Admission for children <16, observe adults for 6-12 hours
Refer to specialist allergy service
Adrenaline injector as interim measure, teach how to use it
Diagnostic, monitoring and management
Definition of SIRS?
o SIRS = 2 or more of:
Temperature >38 or <36
Tachycardia >90bpm
RR >20 or PaCO2 <4.3kPa
WBC >12x109/L or <4x109/L
Definition of sepsis?
SIRS in presence of infection
Definition of severe sepsis?
Sepsis with organ hypoperfusion or altered cerebral function
Definition of septic shock?
Severe sepsis with hypotension (<90 SBP or MAP <65) despite adequate fluid resuscitation or requiring vasopressors
Pathology of sepsis?
- Infection with any organism causes acute vasodilation from inflammatory cytokines
- Increased risk in very young and older people, immunodeficient, long-term steroids, surgery within 6 weeks, indwelling catheters, pregnancy
Symptoms of sepsis?
o Warm, vasodilated (can be cold to touch) o Fever o Tachycardic o Tachypnoea o High WCC o Hypotension
Assessment of sepsis?
o Temperature, HR, RR, BP, level of consciousness and O2 sats
o CRT in children
Risk assessment of sepsis - moderate-to-high risk?
New-onset behaviour change Impaired immune system Trauma/surgery/invasive procedure in past 6 weeks RR 21-24 HR 91-130 or new-onset arrhythmia BP 91-100 Not passed urine for 12-18 hours Temperature <36
Risk assessment of sepsis - high risk?
New altered mental state RR >25 New need for 40% O2 to maintain O2 sats >92% HR >130 BP <90 or <40 below normal Not passed urine in previous 18 hours Mottled or ashen Cyanosis of lips or tongue Non-blanching skin rash
What is sepsis 6 bundle?
o Bloods & cultures o Urine output o Fluids o Abx o Lactate o Oxygen o ABG
Initial management of sepsis?
o Get senior help
o Oxygen 15L/min - Targets 94-98% or 88-92%
o ABG if indicated
o IV access & Bloods – FBC, U&Es, CRP, clotting, glucose, VBG, 2 or more blood cultures
o Fluids IV 0.9% saline 500ml bolus (20ml/kg) - If no improvement, give second bolus
o Catheterise patient – measure urine output
o Antibiotics within 1 hour
Adults - Tazocin 4.5g TDS <3 days then focus
If child <17 – give IV ceftriaxone 80mg/kg OD
If meningococcal disease: IM benzylpenicillin in community, IV ceftriaxone in hospital
What investigations to perform in sepsis to look for cause?
Do blood & urine cultures, sputum cultures, CSF if suspected source of infection
Consider urinalysis and CXR in all people
Consider abdomen and pelvis CT if no source identified
CI of lumbar puncture in sepsis?
- GCS<9 or drop of 3 points or more
- Relative bradycardia and hypertension
- Focal neurological signs
- Abnormal posture
- Unequal or poorly responsive pupils
- Papilloedema
- Shock
- Extensive purpura
- Platelets <100x109/L or anticoagulation
- Local infection at lumber puncture site
When to perform lumbar puncture in sepsis?
• Infant <1 month, aged 1-3 months and unwell, aged 1-3 months with WCC <5x109/litre or >15
Monitoring in sepsis?
o Monitoring continuously or every 30 minutes if high/moderate risk
o Repeat BP and ABG after fluid challenge
Management after repeating BP and ABG after fluid challenge?
Alert consultant if after 1 hour of Abx and fluids:
• Systolic BP <90
• Reduced consciousness
• RR>25
• Lactate not reduced by >20% within 1 hour
If SPB<90 or lactate >4 then refer to critical care for central venous access and inotrope and vasopressors
What should be completed within 1 hours in surviving sepsis campaign?
Lactate levels
Blood Cultures
Administer Abx
Administer crystalloid fluids for hypotension or high lactate
What should be completed within 6 hours in surviving sepsis campaign?
Vasopressors (for unresponsive hypotension) to maintain MAP >65mmHg
• Noradrenaline +/- adrenaline
Measure CVP, central venous saturation and lactate if elevated
Definition of cardiogenic shock?
- Failure of pump action of heart, resulting in decrease in cardiac output causing reduced end-organ perfusion
- Leads to acute hypoperfusion and hypoxia of tissues/organs, despite adequate intravascular volume
- Defined as:
o Sustained hypoperfusion SBP<90 for >30 minutes
o Tissue hypoperfusion (cold peripheries, oliguria <30ml/h or both)
Causes of cardiogenic shock - cardiac?
Myocardial Infarction (anterior wall) Arrhythmias Acute mitral regurgitation (due to ruptured papillary muscle/chordae tendinae) VSD HOCM Myocarditis Valve disease – AS, IE Aortic dissection
Causes of cardiogenic shock - other?
PE Pericardial tamponade Constrictive pericarditis Tension pneumothorax Sepsis Suppression of contractility - BB, acidosis, hypokalaemia, hyperkalaemia, hypocalcaemia Thyrotoxic crisis
Symptoms of cardiogenic shock?
o Chest pain o N&V o SOB o Profuse sweating o Confusion o Palpitations o Syncope
Signs of cardiogenic shock?
o Pale, mottled skin with slow CRT and poor pulses o Hypotension o Tachy/Bradycardia o Raised JVP o Peripheral oedema o Quiet heart sounds o Bilateral basal crackles o Oliguria o Altered mental state
Management of cardiogenic shock - ABCDE?
o A
Oxygen – aim 94-98% (88-92% in COPD)
o B
ABG, CXR
o C BP & CVP IV access – bloods – FBC, U&E, troponin, glucose IV fluids 500ml ECG & Echo Urinary Catheter
o Others
CTPA if PE and stable
Further management of cardiogenic shock?
- Diamorphine 1.25-5mg IV for pain
- Monitor CVP, BP, ABG, ECG, urine output
- Correct arrhythmias, U&E abnormalities or acid-base disturbances
- Optimise filling pressure:
o If underfilled – give plasma expander 100ml every 15 mins IV (aim MAP 70mmHg, CVP 8-10mmHg)
o If well/over-filled – Inotropics (dobutamine 2.5-10ug/kg/min IVI) Aim MAP 70mmHg
What reversible causes to look for in cardiogenic shock?
o MI – acute angioplasty/thrombolysis
o PE – thrombolysis
o Surgery – VSD, Mitral or aortic incompetence
Description of cardiac tamponade?
o Pericardial fluid collects – intrapericardial pressure rises – heart cannot fill – pumping stops
Causes of cardiac tamponade?
o Trauma, lung/breast cancer, pericarditis, MI, TB, raised urea, dissecting aorta, coronary artery dissection, ruptured ventricle
Signs of cardiac tamponade?
o Beck’s triad - Falling BP, rising JVP, muffled heart sounds
o Kussmaul’s sign – high JVP on inspiration
o Pulsus paradoxus
Investigations of cardiac tamponade?
o Echo – diagnostic
o CXR – globular heart, left heart border convex or straight
o ECG – low QRS voltage, electrical alternans (consecutive, normally conducted QRS complexes vary in height)
Management of cardiac tamponade?
o Senior help immediately
o Urgent pericardiocentesis
Effusion sent for culture, ZN stain/TB culture, cytology
o Give O2, monitor ECG and set up IVI
o Take group and save as cardiac surgery may be indicated
Description of hypovolaemic shock?
- When volume of the circulatory system is too depleted to allow adequate circulation to the tissues of the body
Causes of hypovolaemic shock?
o Bleeding – trauma, ruptured AAA, GI bleed
o Fluid loss – vomiting, burns, ‘third space’ losses, heat exhaustion
Symptoms and signs of hypovolaemic shock?
- Hypotension - SBP <90mmHg or MAP <65mmHg
- Tachycardia >100bpm
- Altered Consciousness
- Cool peripheries
- Clammy/Sweaty skin
- Pallor
- Increased cap refill time
- Oliguria
- Tachypnoea
Classification of hypovolaemic shock?
o Class 1 <15% blood loss – physiological compensation and no clinical changes appear
o Class 2 15-30% blood loss – postural hypotension, generalised vasoconstriction, reduced urine output (20-30ml/h)
o Class 3 30-40% blood loss – hypotension, tachycardia >120bpm, urine output <20ml/h, patient confused
o Class 4 40% blood loss – unrecordable, tachycardia, tachypnoea, no urine output and unresponsive
ABCDE management of hypovolaemic shock?
o Airway
High-flow O2
o Breathing
Monitor pulse, SpO2, BP, RR
o Circulation
Venous access – 2 large bore cannulas in ACF
Bloods – FBC, U&Es, glucose, LFT, lactate, coagulation screen, VBG
ABG
ECG and CXR
Insert urinary catheter and monitor urine output hourly
IV Saline 0.9% 500ml bolus +/- blood (according to aetiology and response)
Further management of hypovolaemic shock?
Stop bleeding
ICU referral if no improvement with 2 boluses
Descriptions of acute respiratory failure?
- Results from acute or chronic impairment of gas exchange between lungs and blood
- Type 1 (PaO2<8kPa with normal/low PaCO2)
- Type 2 (PaO2 <8kPa with hypercapnia >6kPa)
Causes of type 1 acute respiratory failure?
- Type 1 (PaO2<8kPa with normal/low PaCO2)
Pneumonia Pulmonary oedema PE Asthma Emphysema Pulmonary fibrosis ARDS
Causes of type 2 acute respiratory failure?
- Type 2 (PaO2 <8kPa with hypercapnia)
Asthma COPD Pneumonia Pulmonary fibrosis Sedative drugs (opiates), CNS tumours Cervical cord lesions, GBS, myasthenia gravis Flail chest, kyphoscoliosis
Symptoms and signs of acute respiratory failure?
- Hypoxia o SOB o Restlessness o Confusion o Cyanosis
- Hypercapnia
o Headache, peripheral vasodilation, tachycardia, bounding pulse, CO2 flap, confusion, drowsiness
Investigations of acute respiratory failure?
- O2 sats
- Bloods
o FBC, U&E, CRP - CXR
- ABG
- ECG
Management of type 1 acute respiratory failure?
o Treat cause
o Oxygen given via face mask (35-60%)
Aim 94-98%
o Assisted ventilation if PaO2 <8 despite 60% oxygen
NIV (BiPAP or CPAP)
Endotracheal intubation and mechanical ventilation
Management of type 2 acute respiratory failure?
o Treat cause
o Controlled oxygen therapy (start at 24-28% O2 via Venturi mask, if critically unwell then give high-flow)
Aim 88-92%
o Repeat ABG after 20 mins, increase oxygen or consider NIPPV if acidotic
o May need endotracheal intubation and mechanical ventilation
Examples of TCAs?
o Amitriptyline, Lofepramine, imipiramine
Mechanism of TCAs?
o Inhibit neuronal reuptake of serotonin (5-HT) and noradrenaline from the synaptic cleft
o Increase availability for neurotransmission
o Block muscarinic, histamine (H1), α-adrenergic (α1 and α2) and dopamine (D2) receptors – adverse effects
Symptoms of TCA overdose?
- Overdose symptoms
o Tachycardia, dry skin, dry mouth, dilated pupils, urinary retention, ataxia, jerky movements and drowsiness - Unconscious patients
o Divergent squints, increased muscle tone and reflexes, myoclonus - Deep coma
o Muscle flaccidity with no reflexes and respiratory depression
Investigations of TCA overdose?
o ECG
Sinus tachycardia
Increased PR interval, QRS duration, terminal R wave in aVR
P wave superimposed on preceding T wave
Severe poisoning may give ventricular arrhythmias and bradycardia
o Bloods
Paracetamol levels
FBC, U&Es, LFTs, INR, glucose
o ABG (if appropriate)
o ECG (if appropriate)
o TOXBASE used for managing drug overdose
Initial management of TCA overdose?
o Clear airway and intubate/ventilate if necessary
o Observation continuously
o Monitor ECG and ABG in unconscious patient
Medical management of TCA overdose?
o Activated Charcoal if >4mg/kg taken within 1h
o IV lorazepam or diazepam (if fits frequent and prolonged)
o Correct hypoxia and acidosis
Sodium bicarbonate
Oxygen
o Hypotension
Elevate feet and IV fluids
Glucagon/Dopamine if severe, not responding
o Intralipid for severe arrhythmias
Management of benzodiazepines overdose?
o Flumazenil 200ug over 15s, then 100ug at 60s intervals
o Needs expert advice
Features, ECG changes and management of Beta-blocker overdose?
o Features: Hypotension, cardiogenic shock, sinus bradycardia
o Late features: coma, cardiac arrest, convulsions
o ECG changes: prolonged QRS, ST and T wave abnormalties (sotalol prolongs QT)
o Antidote
Atropine up to 3mg IV
Glucagon 2-10mg IV bolus + 5% glucose then infusion
May need pacing
Physiology, symptoms and management of cyanide overdose?
o High affinity for Fe, inhibits cytochrome system and decreases aerobic respiration (acidotic with raised lactate)
o Mild: Dizziness, anxiety, tachycardia, nausea, drowsiness
o Moderate: Vomiting, reduced consciousness, convulsions, cyanosis
o Severe: Deep coma, fixed unreactive pupils, cardiorespiratory failure, arrhythmias
o Treatment
100% O2
GI decontamination <1hr ingestion
Sodium nitrate/sodium thiosulfate 300mg IV over 1 min, then IV 50ml 50% glucose
Hydroxocobalamin (Cyanokit) 5g over 15 min repeated once
Senior help
Symptoms and management of digoxin overdose?
o Symptoms: Decreased cognition, yellow-green visual halos, arrhythmias (prolonged QT)m nausea and anorexia
ECG in digoxin use - Downsloping ST depression, shortened QT, flattened/biphasic T wave
ECG in digoxin toxicity - Sinus bradycardia, AV block, premature PVCs, ventricular bi and trigeminy, slow AF
Treatment Activated charcoal Treat hypokalaemia Digoxin antibody fragments (DigiFab) Consult poisons information line
Symptoms and management of ethylene glycol (antifreeze)?
o Features: Looks drunk, ataxia, dysarthria, nausea and vomiting, convulsions and coma
o Late Features: Hyperventilation, pulmonary oedema, tachycardia and arrhythmias
o Cardiac failure, AKI and hypocalcaemia occur
o Treatment
Gastric lavage <1hr
Toxbase/Poisons information services
Observe for >6hr
Fomepizole or ethanol
Sodium bicarbonate to correct metabolic acidosis
Calcium gluconate
Symptoms and management of iron overdose?
o Features: Nausea and vomiting, diarrhoea, abdominal pain, vomit and stool soften grey/black, convulsions, coma, metabolic acidosis, shock
o Treatment
Gastric Lavage <1hr
Desferrioxamine 15mg/kg/h IVI (max 80mg/kg/d)
Symptoms and management of MDMA overdose?
o Effects: nausea, muscle pain, blurred vision, amnesia, fever, confusion and ataxia
o Late Effects: Tachyarrhythmias, hyperthermia, DIC, hyperkalaemia, AKI, muscle necrosis, ARDS
o Treatment
Supportive
Activated charcoal < 1h and monitor for >12 hours
Anxiety: Diazepam PO/IV
Metoproplol if narrow complex tachyarrhythmias
Nifedipine for hypertension
Cool down, dantrolene if T>39
Description of delirium?
- An acute, fluctuating syndrome of disturbed consciousness, attention, cognition and perception
- Develops over hours to days
Epidemiology of delirium?
- General prevalence 0.5%
- Most common acute disorder in hospital
- > 50% occur after admission, common in surgical wards
Pathology of delirium?
o Mechanisms including cholinergic deficiency, dopaminergic excess and inflammation
Risk factors of delirium?
o Older age (>65 years) o Cognitive impairment o Comorbidities o History of alcohol excess o Sensory impairment o Poor nutrition
Causes of delirium? CHIMPS PHONED
Constipation Hypoxia Infection Metabolic disturbance Pain Sleeplessness
Prescriptions
Hypothermia/pyrexia
Organ dysfunction (hepatic or renal impairment)
Nutrition
Environmental changes
Drugs (over the counter, illicit, recreational, their partner/neighbour/pets’, alcohol and smoking)
Subtypes of delirium?
o Hyperactive delirium
• Inappropriate behaviour, hallucinations, agitation, restlessness
o Hypoactive delirium
• Lethargy, reduced concentration, appetite, quiet and withdrawn
o Mixed delirium
• Symptoms of both hyperactive and hypoactive
Symptoms of delirium?
Cognitive functions
• Poor concentration, slowed responses, confusion, disorientated, sleep-cycle disturbances (such as daytime drowsiness, night-time insomnia, disturbed sleep, or complete sleep cycle reversal)
Perception
• Visual or auditory hallucinations, delusions
Physical function
• Reduced mobility, reduced movement, restlessness, agitation, changes in appetite, fluctuating behaviours
Social behaviour
• Lack of cooperation, withdrawal, alteration in mood/attitude
Assessment of delirium?
- Cognitive Assessment
o AMTS, MOCA
Investigations of delirium?
AMTS
NEWS Score
Bloods
o FBC, U&Es, LFTs, TFTs, glucose, CRP, ESR, Ca, folate, B12, INR
o Cultures (if sepsis)
ECG
Urine Dipstick
Imaging
o CT, CXR, LP
When to assess risk of delirium?
People at risk: • Age >65 • Cognitive impairment and/or dementia • Current hip fracture • Severe illness Assess for indicators Cognition/concentration
How to diagnose delirium?
Use Confusion Assessment Method (CAM) (1, 2 & 3/4 present)
- Acute onset and fluctuating course
- Inattention – easily distracted or difficulty focusing
- Disorganised thinking – disorganised, incoherent, rambling, illogical, unpredictable
- Altered level of consciousness - vigilant (hyper-alert), lethargic (drowsy, easily aroused), stupor (difficult to arouse), or
coma (unarousable)
Supportive care in delirium?
o Avoid moving wards
o Appropriate lighting, clear signage, clock and calendar
o Re-orientate them
o Prevent dehydration, nutritional needs
o Mobilise regularly
o Sleep hygiene
o Discouraging napping and encouraging bright light exposure in the daytime
Drug management of delirium?
Treat underlying cause
For agitation when verbal or non-verbal de-escalation failed
• Haloperidol oral, IV, IM 0.5mg in elderly (first line)
• Lorazepam 0.5mg IV (can be used but only after APs)
Complications of delirium?
o Increased mortality, length of hospital stay
o Increased incidence of dementia
o Falls, pressure sores, continence problems
o Malnutrition
o Functional impairment
Features of hypovolaemic shock?
Decreased CO
Increased SVR
Hypotension, tachy, low UO, pale, weak pulse
Features of cardiogenic shock?
Decreased CO
Increased SVR
Hypotension, tachy, low UO, pale, weak pulse, crackle on lungs
Features of neurogenic shock?
Decreased CO
Decreased arterial and SVR
Hypotension, Bradycardic, Warm & dry skin
Features of anaphylactic shock?
Decreased CO
Decreased SVR
Features of anaphylaxis
Features of septic shock?
Decreased CO
Decreased SVR
Pink, warm and flushed skin, hypotension, tachy, full bounding pulse
