Emergency Management Flashcards
Hyperkalaemia
10ml 10% calcium gluconate 100ml 20% glucose + 10u insulin (Actrapid) Salbutamol 5mg nebuliser Calcium resonium 15mg PO or 30mg PR Haemofiltration (if anuric)
Acute pulmonary oedema
PODMAN
Position - Sit up
Oxygen - give controlled O2
Diuretic (20-40 mg intravenously (slowly) produces transient venodilation and subsequent diuresis - and fluid restriction
Morphine* 2.5mg IV
Antiemetic metoclopramide 10mg IV
Nitrates (unless SBP<100) - two puffs sublingual, or 1-3 mg buccal isosorbide dinitrate
If no response consider CPAP and haemofiltration
*Opiates: the use of opiates is controversial and opiates should not be given to patients with acute decompensated heart failure
Anaphylaxis/angioedema
GET HELP!
Remove trigger, maintain airway, 100% O2
• Intramuscular adrenaline 0.5 mg
(Repeat every 5 mins as needed to support CVS)
• IV hydrocortisone 200mg
• IV chlorpheniramine 10 mg
• If hypotensive: lie flat and fluid resuscitate
• Treat bronchospasm: NEB 5mg salbutamol
• Laryngeal oedema: NEB adrenaline
Massive Haemoptysis - definition and management
Massive Haemoptysis
>240mls in 24 hours
OR
>100mls / day over consecutive days
Management of Massive Haemoptysis
ABCDE
Lie patient on side of suspected lesion (if known) Oral Tranexamic Acid for 5 days or IV
Stop NSAID’s / aspirin / anticoagulants
Antibiotics if any evidence of respiratory tract
infection
Consider Vitamin K
CT aortogram – interventional radiologist may beable to undertake bronchial artery embolisation
Tension pneumothorax
Large bore intravenous cannula into 2nd ICS MCL
Chest drain into the affected side
Pulmonary embolism
Oxygen if hypoxic
Fluid resuscitation (if hypotensive)
Thrombolysis should be considered if a massive PE is confirmed on Echo or CT scan - consider without imaging if there is
substantial clinical suspicion and cardiac arrest is imminent
check for contraindications
Should be fully anticoagulated
Pneumothorax
As per BTS guidelines:
Primary – If symptomatic and rim of air >2cm on
CXR give O2 and aspirate. If unsuccessful
consider re-aspiration or intercostal drain. Removedrain after full re-expansion / cessation of air leak. Secondary – as above but lower threshold for ICD If persistent air leak >5 days (bronchopleural
fistula) refer to thoracic surgeons
Discharge advice – No flying or diving until
resolved
Indication for urgent chest drain insertion for a new effusion
Underlying empyema (pH of pleural fluid <7.2 or visible pus on aspirate)
Initial STEMI management
Give:
Diamorphine (2.5-10mg IV, plus antiemetic)
Oxygen -CONTROLLED, SATS 94-98
Nitrates (GTN spray 2 puffs sublingually)
Aspirin (300mg)
Clopidogrel 300-600mg (then 75mgOD)
plus start atorvastatin 80mg ON, bisoprolol 2.5mg OD,
Thrombolysis - indications and contraindications
< 12 hours onset pain
+ any 1 of the following:
- ST elevation >1mm in 2+ consecutive limb
leads - ST elevation >2mm in 2+ consecutive chestleads
- Posterior infarct
- New onset LBBB
Thrombolysis Contraindications
Absolute: Haemorrhagic stroke or Ischaemic stroke < 6 months CNS neoplasia Recent trauma or surgery GI bleed < 1 month Bleeding disorder Aortic Dissection
Relative: Warfarin Pregnancy Advanced Liver Disease Infective Endocarditis
Management of Regular Supraventricular Tachycardia (SVT)
ABC + O2 + IV access Vagal Manoeuvres Adenosine SEEK HELP Antiarrhythmic DC cardioversion if haemodynamically unstable
Management of Broad Complex Tachycardia
ABC (if pulseless = arrest protocol) No adverse signs: Amiodarone / Lidocaine K+/Mg2+ if needed Sedation and DC cardioversion
Adverse signs:
Sedation
DC cardioversion
Amiodarone / Lidocaine
Warfarin management in overdose and major bleed
Overdose: INR <6: Decrease / omit Warfarin INR 6-8: Stop Warfarin. Restart when INR<5 INR >8: If no bleeding stop Warfarin & give 0.5- 2.5mg vitamin K if risk of bleeding.
Major bleed: Stop Warfarin. Give prothrombin complex concentrate (Beriplex) contains factors II, VII,IX, X or FFP. Give 5mg vitamin K. Get HELP!
Anaphylaxis in adults/ children >12
Adrenaline - 500 micrograms (0.5ml 1 in 1,000) IM
Hydrocortisone - 200 mg IM
Chlorphenamine - 10 mg IM or slow IV
VF/VT Cardiac Arrest
Ratio of chest compressions to ventilation is 30:2
chest compressions are now continued while a defibrillator is charged
adrenaline 1 mg is given once chest compressions have restarted after the third shock and then every 3-5 minutes (during alternate cycles of CPR).
Amiodarone 300 mg is also given after the third shock
DKA
Normal saline infusion (0.9%) - initial 500ml over 15 mins
Insulin -fixed rate IVII but only after fluid therapy has been commenced. Infuse at a fixed rate of 0.1unit/kg/hr
K (potassium replacement)
Antibiotics (in case of infections)
H (bicarbonate infusion in severe acidosis)
Generally hourly blood glucose (BG) and hourly ketone measurement, with at least 2 hourly serum potassium for the first six hours
Paracetemol - toxicity and treatment
Risk of severe liver damage (ie a peak ALT more than 1000 IU/L)
Based on the dose of paracetamol ingested (mg/kg body weight):
Less than 150 mg/kg - unlikely.
More than 250 mg/kg - likely.
More than 12 g total - potentially fatal.
All patients who have a timed plasma paracetamol level plotted on or above the line drawn between 100 mg/L at 4 hours and 15 mg/L at 15 hours after ingestion, should receive acetylcysteine. This is regardless of any risk factors they may have for hepatotoxicity
Criteria for referral to a specialist unit following paracetemol overdose
Encephalopathy or raised intracranial pressure (ICP).
Signs of CNS oedema include BP >160/90 mm Hg (sustained) or brief rises (systolic >200 mm Hg), bradycardia, decerebrate posture, extensor spasms, and poor pupil responses. ICP monitoring can help.
INR >2.0 at or before 48 hours or >3.5 at or before 72 hours (so measure INR every 12 hours). Peak elevation occurs around 72-96 hours. LFTs are not good markers of hepatocyte death.
Renal impairment (creatinine >200 μmol/L). Monitor urine flow and daily U&E and serum creatinine (use haemodialysis if >400 μmol/L).
Blood pH <7.3 (lactic acidosis results in tissue hypoxia).
Systolic BP <80 mm Hg despite adequate fluid resuscitation.
Hypoglycaemia.
Metabolic acidosis (pH <7.3 or bicarbonate <18 mmol/L).
Suspected alcohol withdrawal
Chlordiazepoxide
Pabrinex & IV thiamine
Upper GI bleed
IV fluids (aim systolic ~100)
In massive bleed - transfuse blood, FFP, platelets as per local protocol
Blood transfusion if Hb<7g/L or <8g/L in non-variceal bleed
Patient must be haemodynamically stable before endoscopy.
Variceal haemorrage: terlipressin, ocreotide, band ligation, slerotherapy
Non-variceal: adrenaline injection into ulcer, PPI
In all patients: correct clotting, prophylactic antibiotics, treat concurrent issues e.g. encephalopathy, alcohol withdrawal.
Sepsis six
Within one hour:
3 in: Oxygen, fluids Antibiotics
3 out: Blood cultures, lactate &hb, catheterise
Hyperglycaemic Hyperosmolar State
Confirm diagnosis (glucose >11mmol, osmolarity>320mml, absence ketones)
Rehydrate (~9L saline over 24 hrs)
Prophylactic LMWH
Insulin - wait 1 hr - infusion 0.05units/kg/hr if glucose not reducing with fluids alone
stop metformin for 2 days (metabolic acidosis)
Hypoglycaemia
Unconscious:
- 150ml 10%glucose or 75ml 20%glucose IV STAT
- Glucagon 1mg IM if no IV access (can repeat 1-2 times)
- Check BM 10mins later and repeat as needed.
Conscious but can’t swallow - 1.5-2 tubes glucose gel around teeth
check BM after 10 mins –then long acting carbohydrate
Can swallow: 15-30g fast acting carbohydrate (5-7 glucose tabs, 150ml fruit juice/Lucozade) AND long acting carbohydrate
ALL: correct cause, don’t omit insulin/tablets (risk of rebound hyperglycaemia) - reduce dose instead
Cardiac effusion/tamponade
ABC - IV access and fluids — ECG – bloods
Get senior help
PERICARIOCENTESIS (pref USS guided)
Acute limb ischaemia
High flow oxygen – to maximise tissue oxygenation
Intravenous heparin – to prevent clot propagation
Analgesia – to make the patient comfortable
Correct hypotension if present
Start treatment for associated cardiac condition – AF/CCF
Definitive treatment of embolism requires embolectomy
Ruptured AAA
Initial management involves:
Oxygen 15L/min
Establish good IV access (large borecannulae in antecubital fossa)
Blood tests – FBC, Clotting screen, U&Es, Glucose,
Group & Save + Cross match 6-8units of blood
Insert urinary catheter
Contact and involve consultant vascular surgeon as soon as the diagnosis of ruptured AAAis suspected.
The decision toperform imaging (such as CT angio) should be taken by the consultant vascular surgeon. If the patient is stable thenimaging may be performed to confirm diagnosis and establish best treatment options (open repair or stent graft). If the patient is unstable, then needs to be transferred to operating theatre ASAP. Survival is dependent upon speed of diagnosis and treatment.
Addisonian crisis
Start treatment immediately, based on clinical features and not delayed for confirmation of adrenal function.
Administration of glucocorticoids in supraphysiological or stress doses is the only definitive therapy. Treatment is as follows:
Immediate administration of hydrocortisone IV or IM:
100 mg for an adult
50-100 mg for a child aged 6 or more.
50 mg for a child aged 1 to 5.
25 mg for a child aged less than 1 year.
At these doses hydrocortisone has mineralocorticoid action so fludrocortisone is not required
Rehydration with normal saline infusion.
Continuous cardiac and electrolyte monitoring.
Following rehydration, administration of 100-200 mg hydrocortisone in 5% glucose over 24 hours by IV infusion.
Treatment of the underlying precipitating disorder - eg, infection with antibiotics.
Once stabilised, gradual reduction of IV steroid dose and re-institution of oral therapy.
