Emergency Med Flashcards
You are called to a situation of anaphylaxis, how do you proceed?
ABCDE Approach
- assess, is this life threatening needing senior input?
Lie them down, put their legs up, Call for help
Adrenaline 500mcg 1:1000 IM (adult) - if had epipen may be enough or need 2nd dose
IV Fluids: 500ml-1L
IV Chlorphenaramine 10mg
IV hydrocortisone 200mg
when are iv fluids given in anaphylaxis? how much to give and which?
fluid if hypotension does not rapidly respond to adrenaline.
Rapid infusion of 1–2L IV 0.9% saline
What situation during ABCDE indicate life threatening situation needing seniors?
From Resus council:
Airway: Swelling, hoarseness, stridor
Breathing: Tachypneoa, wheeze, cyanosis, fatigue, sats <92, confusion
Circulation: Pale, clammy, drowsy/coma, hypotension,
what do we do in the following situations:
- profound shock or immediately life-threatening situations,
- Give CPR/Advanced Life Support (ALS) as necessary
- Consider slow IV adrenaline 1:10,000 or 1:100,000 solution.
- Glucagon 1–2mg intramuscular (IM)/IV every 5min
- If no response to adrenaline
->This is recommended only for experienced clinicians who can also obtain immediate IV access.
What are the key bits of info iewth chest compressions?
Press down to depress the sternum 5–6cm.
• Release all the pressure and repeat at a rate of 100–120/min.
• Compression and release phases should take the same time.
• Use a ratio of 30 chest compressions to two ventilations (30:2).
Which are the shockable rhythms?
what is the importance of a pulse?
Ventricular fibrillation (VF)/ventricular tachycardia (VT)
patients with pulseless VT/VF: give a single precordial thump
best airway to use?
- Gold standard - Tracheal intubation
- only attemptif experienced
- End-tidal CO2 monitoring to confirm correct placement - Supraglottic airway
- igel, LMA
which are the Non-shockable rhythms?
management?
PEA and asystole
Mx:
Continue CPR
Give adrenaline every 3-5 mins (asystole)
asystole has very poor prognosis.
List some measures by which to detect an unwell/ septic patient?
what do they entail?
which scores can indicate sepsis?
NEWS2; - systems that alert to deteriorating adult patients in hospital • RR. • SpO2. • Systolic BP. • Pulse rate. • Level of consciousness or new confusion (delirium). • Temperature. - score 5+ = consider sepsis
qSOFA;
- septic organ failure assessment
• RR ≥22 breaths/min.
• Systolic BP ≤100mmHg.
• Altered mental state (lower GCS than usual).
- score 2+ = increased risk of death or ITU stay. Act fast
components of the sepsis 6 bundle?
All must be done within 1 hour:
- Call seniors
- O2 100%
- IV access (2 large bore) - blood cultures, UEs, clotting, lactate, glucose, FBC, CRP
- IV antibiotics - Piptazobactam + Gentamicin (dep. local)
- IV fluids, 20-30kg/kg
- Monitor; blood lactate measurement, urine output
- may need to start vasopressors (such as a noradrenaline infusion) for persistent hypotension
how do we manage neutropaenic sepsis?
giving broad-spectrum antibiotics according to local protocols—an example of one regime is:
- Piperacillin–tazobactam IV 4.5g every 8hr or
- If penicillin-allergic: ceftazidime IV 2g every 8hr.
define sepsis
define shock
Sepsis occurs when life-threatening organ dysfunction is associated with infection.
Shock is circulatory failure resulting in inadequate perfusion and oxygenation of organs.
clinical features of shock?
Defined by;
1. low bp— systolic <90mmHg or
mean arterial pressure (map) <65mmHg
- with evidence of tissue hypoperfusion;
eg mottled skin,
urine output (uo) of <0.5mL/kg for 1 hour,
serum lactate >2mmol/L
• Poor peripheral perfusion: cool peripheries, clammy/sweaty skin, pallor, and ↓ capillary return
- Tachypnoea.
- Purpuric rash.
- Oliguria: ↓ renal perfusion with urine output <50mL/hr (in adults
- Altered consciousness and/or fainting
- Hypotension:
how do we approach shock generally
ABCDE approach
O2
Bloods - inc glucose and lactate, cultures if needed
ABG, ECG (hypoxia?), CXR
Monitor urine output hourly - catheter
Iv fluids - 0.9% saline, if low volume shock
Ivx & Treat underlying cause of shock eg ECG, Echo
How do you approach a patient with Burns injury?
Check: Airway, Breathing, and Circulation
Particular problems associated with burns are:
- Airway burns: suggested by hoarseness, stridor, dysphagia, facial and mouth burns, singeing of nasal hair, soot in nostrils or on palate.
- Spinal injury: particularly seen with blast injuries and in those who have jumped from buildings to escape fire.
- Breathing problems: contracting full-thickness circumferential burns (‘eschar’) of the chest wall may restrict chest movement.
- Circulatory problems: hypovolaemic shock is a feature of severe burn
Then take a history
what are the components of assessing a burn?
Assess the:
Extent - 9% etc
Depth - full/partial thickness
How do you manage a burn?
ATLS protocols !!!
Deal with shock before thinking about burns
- Airway and cervical spine protection
- high flow o2, c-spine immobilisation if needed
- intubation if impending obstruction - IVs
- 2 large bore grey cannulas
- Take bloods
- IV Morphine sulphate (pain), IV Cyclizine (antiemetic) - IV Fluid resus
- 0.9% saline
- follow local guides, may request colloid
- burns >10% may ned red cells - Breathing
- check COHb, get CXR, escharotomy? - Burns
- Cover the burn with cling film or dry sterile sheets
- Call burns specialist (ie dont start burns dressing yet)
- Tetanus prophylaxis
Note: no mention of abx!
causes of cyanide poisoning and treatment?
burnt plastic furniture in a house fire
Mx: give an appropriate antidote, eg dicobalt edetate
what are the Clinical features of smoke inhalation injury?
After exposure to smoke or fire in an enclosed space;
- confusion or altered/loss of consciousness
- oropharyngeal burns,
- hoarseness/loss of voice, singed nasal hairs,
- soot in nostrils or sputum, wheeze,
- dysphagia, drooling or dribbling, and stridor.
How do we ivx smoke inhalation injury ?
ABG - Hypoxia, hypercapnia, and acidosis
CXR - ARDS may develop
COHb - as SPO2 doesn’t detect CO poisoning
ECG - arrhythmias, ischaemia, or even MI
How do we mx smoke inhalation injuries?
Secure airway
High flow humidified O2
Salbutamol for bronchospasm
IV fluids
Treat cyanide poisoning
For simple burns, when do we consider escalation?
Refer patients (to a burns specialist eg regional burns unit) with the following:
- Airway burns.
- Significant full-thickness burns, especially over MAJOR joints.
- Burns >10%.
- Significant burns of special areas (hands, face, perineum, feet).
perhaps:
in pregnant patients, chemical/electrical ones
what are the sx of CO poisoning?
Early features are headache, malaise, nausea, and vomiting
(sometimes misdiagnosed as a viral illness or gastroenteritis, especially if several members of a family are affected).
If severe:
coma with hyperventilation, hypotension,
↑ muscle tone, ↑ reflexes, extensor plantars, and convulsions.
Cherry-red colouring of the skin may be seen when dead
List some complications of CO poisoning?
Cardiovascular - such as myocardial ischaemia, infarction, dysrhythmias, and cardiac arrest, MI.
Neurological symptoms include acute stroke-like symptoms, altered mental status, confusion, coma, and syncope.
MSK - Rhabdomyolysis
Management of CO poisoning?
• Clear the airway and maintain ventilation with as high a concentration of O2 as possible.
- ECG —arrhythmias and signs of acute MI.
- VBG or ABG—SpO2 - acidosis
• COHb levels
- COHb >20% - serious poisoning.
• Correct metabolic acidosis by ventilation and O2—try to avoid bicarbonate, which may worsen tissue hypoxia.
- Consider mannitol if cerebral oedema is suspected.
- Hyperbaric O2 therapy is logical, but of no proven benefit for CO poisoning.
how do we mx salicylate poisoning?
Mild: discharge if normal vbg
Moderate:
within 1 hour - activated charcoal/
sodium bicarbonate
Severe: haemodialysis/haemodiafiltration
What is the difference between 2nd and 3rd degree burns?
2nd - has sensation, blanches
3rd - doesnt do the above, is leathery and dry
how do we calculate fluid requirement in burns patient in first 24 hrs?
4ml x patient weight kg x % burn
give half in first 8 hrs
what are the causes of sepsis?
Common;
- Staphylococcus aureus
- Enterobacteriaceae e.g. Escherichia coli, Klebsiella sp., Enterobacter sp.,
- Pseudomonas sp.
- Neisseria meningitidis
what do NEWS scores mean?
- Low risk (aggregate score 1 to 4) – prompt assessment by ward nurse to decide on change to frequency of monitoring or escalation of clinical care.
- Low to medium risk (score of 3 in any single parameter) – urgent review by ward-based doctor to determine cause and to decide on change to frequency of monitoring or escalation of clinical care.
- Medium risk (aggregate score 5 to 6) – urgent review by ward-based doctor or acute team nurse to decide on escalation to critical care team.
- High risk (aggregate score of 7 or over) – emergency assessment by critical care team, usually leading to patient transfer to higher-dependency care area.
How do you figure out the type of shock going on?
Cold and clammy suggests cardiogenic shock or Hypovolaemic shock.
Raised jvp - cardiogenic shock
Signs of anaemia or dehydration, eg skin turgor, postural hypotension? Abdomen; trauma, bleed, aneurysm - Haemorrhagic shock
Warm and well perfused, with bounding pulse points to septic shock.
Any features suggestive of anaphylaxis—history, urticaria, angio-oedema, wheeze? - anaphylactic shock
how do we mx haemorrhage shock?
Depends on ATLS classification 1-4
Stop bleeding if possible.
• If still shocked despite 2L crystalloid or
present with class III/IV shock (1.5L+ loss) then crossmatch blood (request O Rh–ve in an emergency)
• Give FFP alongside packed red cells (1 : 1 ratio) and aim for platelets >100 and fibrinogen >1.
Discuss with haematology early.
how do we mx hypovolaemic shock?
Identify and treat underlying cause.
Raise the legs.
• Give fluid bolus 10–15mL/kg crystalloid
- if shock improves, repeat,
• If no improvement after 2 boluses, consider referral to icu.
causes of tamponade?
Trauma, lung/breast cancer, pericarditis, myocardial infarct, bacteria, eg tb.
coronraty artery dissection
ventricular rupture
signs and sx of tamponade?
↓bp, ↑jvp, and muffled heart sounds (Beck’s triad);
↑jvp on inspiration (Kussmaul’s sign);
pulsus paradoxus (pulse fades on inspiration).
Echocardiography may be diagnostic. cxr: globular heart; left heart border convex or straight; right cardiophrenic angle <90°.
ecg: electrical alternans - alternating amplitude of qrs
how do we manage NCT which is AF?
If NCT is irregular, manage as AF by far the most likely diagnosis;
• Control rate with:
o • β-blocker: eg metoprolol IV
o • rate-limiting Ca2+-channel blocker eg Verapamil 5–10mg iv
- digoxin is an alternative in heart failure PO
- Consider anticoagulation with warfarin or noac to ↓ risk of stroke.
- Synchronised DC cardioversion - If onset definitely <48h, or if effectively anticoagulated for >6wk.
complications of pneumonia?
Respiratory failure
Hypotension
Atrial fibrillation
Pleural effusion
Empyema
septicaemia, pericarditis, myocarditis, cholestatic jaundice, acute kidney injury.
types of respiratory failure and mx?
(See p[link].) Type I respiratory failure (PaO2 <8kPa) is relatively common. Treatment is with high-flow (60%) oxygen.
Transfer the patient to itu if hypoxia does not improve with O2 therapy or PaCO2 rises to >6kPa.
Be careful with O2 in copd patients; check abgs frequently, and consider elective ventilation if rising PaCO2 or worsening acidosis. Aim to keep SaO2 at 94–98%, PaO2 ≥8kPa.
list the causes of bradycardia
- Drug-induced:
• β-blockers, amiodarone, verapamil, diltiazem, digoxin. - Non-cardiac origin:
• Vasovagal—very common (p[link]).
• Endocrine—hypothyroidism, adrenal insufficiency.
• Metabolic—hyperkalaemia, hypoxia.
• Other—hypothermia, ↑icp (Cushing’s triad: bradycardia, hypertension, and irregular breathing -> Emergency). - Physiological: athletes.
- Cardiac:
• fibrosis of conduction pathways
• Post-mi
• Sick sinus syndrome
• Iatrogenic—ablation, surgery.
• Aortic valve disease, eg infective endocarditis
• Myocarditis, cardiomyopathy, amyloid, sarcoid, sle.
how do we manage problemativc bradycardia
IV Atropine 500mcg
- if risk of asystole or no adverse signs
If no response:
Repeat above every 3-5mins
Call anaesthetist for transcutaneous pacing
Give Adrenaline/Isoprenaline whilst waiting
If none of above:
Observe
how to manage CO poisoning (carbon monoxide)
Give 100% O2 until COHb <10%. Metabolic acidosis usually responds to correction of hypoxia. If severe, anticipate cerebral oedema and give mannitol ivi
which types of ventilation are indicated in pulmonary oedema, covid and copd?
cpap – pulmonary oedema, covid
bipap aka non invasive ventilation – COPD
A patient who has 2nd degree heart block. Eventually their hr slows and bp drops and they become brardycardic. treatment?
Atropine wont work because of the heart block.
Give transcutaneous pacing.
