Emergency Management Flashcards
Anaphylaxis - Pathophysiology
Allergen exposure leads to Type 1 HS reaction (IgE mediated)
IgE cross-linking results in mast cell degranulation
Results in release of vasoactive mediators e.g. Histamine result in distributive shock
Lipid mediators e.g. leukotriene are released, resulting in bronchial constriction
Early phase: within minutes
Late phase: 2-24h (response sustains and amplified by eosinophils)
Anaphylaxis acute management
- ABCDE Approach
- Raise legs
IM Adrenaline 1:1000, 0.5ml
- Repeat every 5 mins if needed
- Secure IV Access
- Fluid bolus 0.9% NaCl
IV Drugs:
- IV Hydrocortisone 10mg IV AND
- IV Chloramphenicol 10mg IV
If wheezing:
- Salbutamol 5mg and Ipratropium 0.5mg nebulisers
Anaphylaxis discharge management
- Give 2 epipens and teach how to use
- Advise to wear a medic alert bracelet
- Arrange OPD follow-up
Sepsis management
ABCDE
- Airway
- Breathing: give oxygen
Sepsis Six: to be done within 1 hour TAKE: - Blood cultures - Blood lactate - Measure urine output
GIVE
- Oxygen (aim >94%)
- Broad-spectrum Abx
- Fluids
CALL FOR SENIOR HELP
Keep assessing and reassessing
May need a vasopressor e.g. noradrenaline
How long should clopidogrel be given after ACS?
- STEMI: 1 month
- NSTEMI: 1 year
Mx of a patient with a high GRACE score?
- Tirofiban
- Angioplasty ± PCI within 96h
Causes of severe pulmonary oedema
Cardiogenic causes
- MI
- Arrhythmia
- Iatrogenic fluid overload
- Renal fluid overload
Non-cardiogenic causes
- ARDS
- Upper airway obstruction
- Head injury
How to manage cardiogenic shock?
- Sit the patient up
- 100% O2 via non-rebreathe mask
- Diamorphine 5.2-5mg IV + metoclopramide 10mg IV
- Correct any underlying causes
- Consider dobutamine
Causes of cardiogenic shock
Cardiac causes: MI HEART
- MI
- Hyperkalaemia
- Endocarditis
- Aortic dissection
- Rhythm disturbances
- Tamponade
Non-cardiac causes:
- Tension pneumothorax (compressing mediastinum)
- Massive PE
How to manage meningitis?
- Look for features of meningitis vs meningococcal septicaemia
- Do Sepsis 6
Mainly Meningitis
- Do LP if no contraindications
- Give IV Dexamethasone 0.15mg/kg QDS
- IV Ceftriaxone after LP
Mainly Meningococcal Sepsis
- Do not do LP
- IV Ceftriaxone
Household contacts: Rifampicin
Contraindications to LP
- Where it will delay Abx
- Infection over the puncture site
- Raised ICP
- Thromobocytopenia or bleeding disorders
- Haemodynamically unstable
- Focal neurological signs
Encephalitis - Ix
Bloods: FBC, U+Es, cultures, viral PCR
Contrast CT head: bilateral focal temporal involvement suggests HSV
LP: if no contraindications (viral PCR)
Encephalitis mx
- Once suspected give IV ACICLOVIR STAT for 14 days
- Phenytoin for seizures
Features of raised ICP
- Headaches (worst in morning)
- Vomiting
- Seizures
- Pupils go from constricted to dilated
- Cheyne-Stokes breathing
- Cushing’s triad: High BP, Low HR and irregular breathing
- Papilloedema
Management of raised ICP
- ABCDE approach
- Ventilation (aim for PaO2 >13 and PaCO2 <4.5)
- Sedation
- Can give IV mannitol or hypertonic saline (these provide short term reduction in ICP but there can be rebound rise in ICP)
How does tonsillar herniation present?
- CN6 palsy
- Upgoing plantars
- Irregular breathing
- Apnoea
How does transtentorial herniation present?
- Ipsilateral CN3 palsy
- Contralateral hemiparesis
How does subfalcine herniation present?
- Compression of ACA – STROKE
How to manage an acute asthma attack?
- Sit up
- 100% O2 via non-rebreathe mask
- Nebulisers 5mg salbutamol and 0.5mg ipratropium
- Oral prednisolone or IV hydrocortisone
- Keep assessing
If severe:
- contact ITU
- IV MgSO4 2g over 20 mins
- Salbutamol nebulisers every 20 mins — keep monitoring ECG
If still no imporvement:
- Aminophylline: 5mg loading dose followed by infusion
- Transfer to ITU for invasive ventilation
When can someone be discharged after acute asthma attack?
- When PEFR >75%
- Diurnal variation <25%
- Been stable on discharge meds for 24h
Discharge and long-term management post-asthma attach
- Inhaler technique
- Review asthma management plan - Discharge with 5-7 days oral prednisolone
- See GP within 1 week
- See in respiratory clinic within 1 month
Blood gases in asthma
- Respiratory alkalosis: due to high RR
- Arrange transfer to ITU if there is hypoxia or raised CO2 as this indicates exhaustion
Mx of IECOPD
- Sit up
- 24% O2 via Venturi mask - aim 88-92%
- Nebulisers: salbutamol 5mg/6h and Ipratropium 0.5mg/4h (monitor ECG)
- IV hydrocortisone + Prednisolone PO
- Abx
- Monitor ABGs and contact ICU for NIV if increasingly acidotic
Mx of PE
- Once PE is suspected, give LMWH
- 100% O2
- Morphine + metoclopramide
Haemodynamically unstable
- Thrombolysis (alteplase) + UFH
Haemodynamically stable:
Calculate Well’s score
High Wells score:
- CTPA
Low-medium Wells score:
- Measure D-dimer
- D-dimer -ve – no PE
- D-dimer +ve – CTPA
Once PE is confirmed:
- Give warfarin
- Continue LMWH until INR 2-3 and at least for 5 days
- TEDS
How long to continue therapy post-PE
- Remedial cause: 3 mo LMWH
- Non-remedial cause: 6mo LMWH
- Ongoing cause: indefinitely
Mx simple pneumothorax
- Sit up
- 100% O2
- Morphine + Metoclopramide
Primary PTX
<2cm - discharge and repeat CXR
>2cm - aspirate
Secondary PTX
<2cm - aspirate
>2cm - insert chest drain
Mx tension pneumothorax
- Sit up
- Insert large bore cannula into 2nd ICS, MCL
- Insert chest drain
- O2
What are the indications for dialysis in AKI?
- Acidosis: ph < 7.2
- Electrolyte disturbance: K >7
- Intoxication: lithium, aspirin, methylene glycol
- Overload: pulmonary oedema
- Uraemia: encephalopathy, pericarditis
Benzodiazepine OD
Hx and Mx
- Respiratory depression
- Reduced GCS
- Tx: flumenazil
B-blockers OD
Hx and Mx
- Severe bradycardia
- Hypotension
- Tx: Atropine
Cyanide poisoning
Hx and Mx
- Smell of almonds
- Anxiety and confusion
- Then change in pulse
- Then fits and coma
Tx: Dicobalt edentate
Digoxin toxicity
Hx and Tx
- Reduced GCS
- Nausea and vomiting
- Visual halos (yellow/green)
- Arrhythmias (typically SVT or AV block)
Measure levels 8-12h since last dose
Tx: Digibind + correct arrhythmias
Ethylene glycol poisoning
Hx and Tx
- Found in antifreeze
- Confusion and slurred speech
- Metabolic acidosis with high anion gap and high osmolality gap
- AKI
Management
- Fomepizole
- Haemodialysis
Lithium poisoning
- Hx and Tx
- Ataxia
- Coarse tremor
- Confusion
- Polyuria
- Renal failure
Tx: saline
Opiate poisoning tx
Naloxone
TCA OD
Hx and Tx
- Long QT
- Torsades de points
- Metabolic acidosis
- Anticholinergic effects
Tx
- activated charcoal
- IV sodium bicarbonate
Warfarin overdose - Tx
- Vitamin K
- FFP
Aspirin OD presentation and tx
- Respiratory alkalosis + Metabolic acidosis
- Vomiting
- Dehydration
- Vertigo
Tx
- if <1h since ingestion: activated charcoal
Paracetamol OD Tx
- if within 1h, activated charcoal
- Measure INR
- NAC if above line on graph
