Emergency med 2 Flashcards
Approach to head injury?
ABCDE assessment
Involve neurosurgeons at an early stage, especially with comatose patients, or if raised icp suspected.
- Examine the cns - basic obs + pupils every 15min.
- Assess anterograde amnesia and retrograde amnesia—its extent correlates with the severity of the injury.
After assessment consider CT head
when is CT head requiired in head injury?
- gcs <13 at any time, or gcs 13 or 14 at 2h following injury
- Focal neurological deficit
- Suspected open or depressed skull fracture, or signs of basal skull fracture (haemotympanum, ‘panda’ eyes, csf leak through nose/ears, Battle’s sign)
- Post-traumatic seizure
- Vomiting >once
- Loss of consciousness and any of the following:
- Age ≥65
- Coagulopathy
- ‘Dangerous mechanism of injury’, eg car crash or fall from great height
- Anterograde amnesia of >30min
On assessment of patient with head injury, which situations require immediate ventilation?
- Coma ≤8 on Glasgow coma scale
- PaO2 <9kPa in air (<13kPa in O2) or PaCO2 >6kPa
- Spontaneous hyperventilation (PaCO2 <3.5kPa)
- Respiratory irregularity
criteria for admission after head injury?
- Difficult to assess (child; postictal; alcohol intoxication)
- cns signs; severe headache or vomiting; fracture
• Brief loss of consciousness does not require admission if well and a responsible adult is in attendance
for a drowsy trauma patients (gcs 8-14) smelling of alcohol, how do we know if their signs a due to alcohol?
- Blood alcohol
- Alcohol is an unlikely cause of coma if plasma alcohol <44mmol/L - Osmolar gap
- if blood alcohol ≈ 40mmol/L then osmolar gap ≈ 40mmol/L
List complications of a head injury?
Early:
Extradural/subdural haemorrhage, seizures.
Late:
Subdural haemorrhage,
Diabetes insipidus,
Parkinsonism, dementia.
What is the mx of increased ICP?
- IV Mannitol:
- short term use, lest rebound ICP occurs
1b. Corticosteroids
- if effusion around tumour
- Fluid restriction
- to less than 1.5L a day - Monitor carefully
which brain herniation presents as;
causing a dilated ipsilateral pupil (3rd nerve palsy),
then ophthalmoplegia.
This may be followed (quickly) by contralateral hemiparesis
uncal herniation
which brain stem herniation presents as;
Ataxia, vith nerve palsies, and upgoing plantar reflexes occur first, then loss of consciousness, irregular breathing, and apnoea
Cerebellar tonsil herniation
which brain stem herniation presents as;
may be silent unless the anterior cerebral artery is compressed and causes a stroke—eg contralateral leg weakness ± abulia (lack of decision-making).
subfalcine herniation
complications of MI?
DARTH VADE
Death Arrhythmias Myocardial rupture Tamponade Heart failure
Valve disease
Aneurysm
Dressler syndrome - Pericarditis 2nd or 3rd day
Embolism
others: Recurrent ischaemia Infarct extension/expansion causing; Mural thrombus Cardiogenic shock
How do we approach a suspected STEMI?
- ABCDE
- Circulation:
A. 12 lead ECG
B. IV access: Blood tests on admission: u&e, troponin, cardiac enzymes, glucose, cholesterol, fbc. - Take brief history, do a quick physical examination eg CCF signs, JVP
3b. Imaging; CXR - Dual antiplatelets; Aspirin 300mg +
- 2021: Followed by another anti-platelet; Ticagrelor 180mg
- Use prasugrel if getting PCI - IV Morphine 5-10mg + IV Metoclopramide (a-emetic) 10mg
- PCI - if presenting within 12h of sx onset and pci can be done within 2 hrs
- Fibrinolysis if PCI not around in 120 mins (2 hours)
- and if no contraindications
- IV alteplase
- afterwards give aspirin + ticagrelor
• Oxygen is recommended if patients have SaO2 <95%, are breathless or in acute lvf.
when would GTN be indicated in STEMI?
if hypertensive
or acute LVF
what does PCI involve?
2021 - NICE
Done in the cathlab
Angiography done first before PCI
anticoagulation is given as part of this;
Bivalirudin is preferred, if not available use enoxaparin ± a gp iib/iiia blocker.
Also give Prasugrel (unless high bleeding risk then give ticagrelor)
Radial access should be considered in preference to Femoral access which is what is usually used.
contraindications to thrombolysis?
- Previous intracranial haemorrhage
- Ischaemic stroke <6months
- Cerebral malignancy or avm
- Recent major trauma/surgery/head injury (<3wks)
- gi bleeding (<1 month)
- Known bleeding disorder
- Aortic dissection
- Non-compressible punctures <24h eg liver biopsy, lumbar puncture
ECG signs of NSTEMI?
ecg: st depression; flat or inverted t waves; or normal.
Mx of NSTEMI?
- Admit to CCU
O2 if sats <90%
6drugs:
IV Morphine 5-10mg + IV Metoclopramide 10mg (antiemetic)
GTN spray or sublingual
300mg Aspirin + Clopidogrel 300mg (or another P2Y12i)
Fondoparinux 2.5mg SC PO (or lmwh) - inject on abdomen
- IV nitrate (GTN 50mg in 50ml saline 0.9%)
before discharge;
aspirin + clopidogrel 75mg - may need clop for 12m
PO Beta-blocker (atenolol) unless contraindicated
start of ACEi + Statin. Make sure troponin has normalised
what meds should someone be on after an MI (ongoing care) ?
5 drugs
Dual antiplatelet therapy:
A. Aspirin - 300mg loading then 75mg
B. Clopidogrel - 300mg loading then 75mg
(or prasugrel or ticagrelor)
Ramipril 2.5mg BD
Atorvastatin
Spirinolactone - if signs of heart failure (K sparing diuretic - or epleronone)
(may also be given BBlocker and SGLT2i - dapagliflozin (if lvef<40)
What is the mx for when symptoms recur in an NSTEMI
refer to cardiologist for urgent;
Imaging; angiography
Rx; pci or cabg.
iivx findings in STEMI and NSTEMI?
see y3 folder
list some differentials for Broad complex tachycardias?
Regular complexes:
• Ventricular tachycardia (VT) - most common
• Ventricular fibrillation—chaotic, no pattern
Irregular complexes;
• SVT - eg AF but only IF with bundle branch block it becomes broad complex
• Polymorphic VT - including torsades de pointes.
—–
• Pre-excitation tachycardias,
AVRT with underlying wpw
summary of broad complex tachycardia mx?
If haemodynamically stable;
- correct electrolyte disturbance - low K,Mg,Ca
- Below
Regular;
Amiodarone 300mg IV over > 20mins
Irregular;
if SVT - IV adenosine 6mg
Torsades - IV Mg2+
- If haemodyn unstable;*
1. Call for specialist input
2. Synchronised DC shocks
3. steps above
after correction of VT / BCT whats next?
Oral anti-arrhythmic agent; Sotalol
If BCT happened after MI, continue Amiodarone infuson for 12-24h
Might need implantable cardioverter defibrillator (icd)
what is the difference ini managing ventricular fibrillation?
Use NON-synchronised shocks
what are the commonest post-mi arrhythmia?
ventricular ectopics
what are the commonest post-mi arrhythmia?
ventricular ectopics
patients describe palpitations, a thumping sensation, or their heart ‘missing a beat’.
On ecg, ventricular ectopics are broad qrs complexes; they may be single or occur in patterns.
how do we mx torsades de pointes with long-qt syndromes (usually found together)
stop all predisposing drugs,
correct hypokalaemia, and give magnesium sulfate (2g iv over 10min).
Alternatives include: overdrive pacing
Torsades is VT, so amiodarone etc
list the causes of pulmonary oedema
- Cardiovascular, usually left ventricular failure (post-mi or ischaemic heart disease). Also valvular heart disease, arrhythmias, and malignant hypertension.
- ARDS from any cause, eg trauma, malaria, drugs. Look for predisposing factors, eg trauma, post-op, sepsis. Is aspirin overdose or glue-sniffing/drug abuse likely? Ask friends/relatives.
- Fluid overload.
- Neurogenic, eg head injury.
list signs / sx off pulmonary oedema?
Dyspnoea, orthopnoea (eg paroxysmal), pink frothy sputum. nb: note drugs recently given and other illnesses (recent mi/copd or pneumonia).
Signs;
Distressed, pale, sweaty, ↑pulse, tachypnoea,
pink frothy sputum, pulsus alternans,
↑jvp, fine lung crackles, triple/gallop rhythm, wheeze (cardiac asthma).
Usually sitting up and leaning forward.
ivx for pulmonary oedema?
• cxr:
cardiomegaly, signs of pulmonary oedema: look for shadowing (usually bilateral), small effusions at costophrenic angles, fluid in the lung fissures, and Kerley b lines (septal linear opacities).
- ecg: signs of mi, dysrhythmias.
- u&e, troponin, abg.
- Consider echo.
- bnp - may be helpful if diagnosis in question (high negative predictive value).
list the causes of cardiogenic shock?
- Myocardial infarction.
- Arrhythmias.
- Pulmonary embolus.
- Tension pneumothorax.
- Cardiac tamponade
- Myocarditis; myocardial depression (drugs, hypoxia, acidosis, sepsis) .
- Valve destruction.
- Aortic dissection
Mx of DKA - ketoacidosis?
see paeds DKA cards
How do we manage Hyperglycaemic hyperosmolar state?
- Rehydrate slowly (according to deficit) with 0.9% saline IVI over 48h
- Replace K+ when urine starts to flow
- Only use insulin if blood glucose not falling by 5mmol/L/h with rehydration or if ketonaemia
complications of taking metformin?
Lactic acidosis
A rare but serious complication of dm with metformin use or septicaemia. Blood lactate: >5mmol/L
how shall we ivx an acute asthma attack?
PEF—but may be too ill; abg if saturations <92% or life-threatening features
CXR (if suspicion of pneumothorax, infection or life-threatening attack)
FBC & u&e
side effects of salbutamol?
(β2-agonist)
tachycardia, arrhythmias, tremor, ↓K+.
differentials for acute asthma
pulmonary oedema,
upper respiratory tract obstruction, pulmonary embolus,
anaphylaxis
inifective exacerbation of cold
how do we ivx infective exacerbation of copd?
- abg
- cxr to exclude pneumothorax and infection.
- fbc; u&e; crp. Theophylline level if patient on therapy at home.
- ecg.
- Send sputum for culture if purulent.
- Blood cultures if pyrexial.
causes of upper GI bleeding?
- Peptic ulcer disease (pud) 35–50%.
- Gastroduodenal erosions 8–15%.
- Oesophagitis 5–15%.
- Mallory–Weiss tear 15%.
- Varices 5–10%.
- Other: upper gi malignancy, vascular malformations
signs and sx of upper GI bleed?
depends on cause really:
Haematemesis, or melaena, dizziness (especially postural), fainting,
abdominal pain, dysphagia? Hypotension (in young may be postural only), tachycardia (not if on β-blocker),
↓jvp, ↓urine output, cool and clammy, signs of chronic liver disease (p[link]), eg telangiectasia, purpura, jaundice. nb: ask about previous gi problems, drug use, alcohol.
Gastro-oesophogeal varices may be secondary to increased portal pressures. list causes of oncreased portal pressures?
Causes of portal hypertension
Pre-hepatic:
Thrombosis (portal or splenic vein).
Intra-hepatic:
Cirrhosis (80% in uk); schistosomiasis (commonest worldwide); sarcoid; myeloproliferative diseases; congenital hepatic fibrosis.
Post-hepatic:
Budd–Chiari syndrome ; right heart failure; constrictive pericarditis; veno-occlusive disease
what are the causes of stroke?
- Small vessel occlusion/cerebral microangiopathy or thrombosis in situ.
- Atherothromboembolism (eg from carotids).
- CNS bleeds (↑bp, trauma, aneurysm rupture, anticoagulation, thrombolysis).
- Cardiac emboli - >30% of cases
- Atrial fibrillation
- Cardioversion - why we anticoag 1st
- Prosthetic valves
- Acute myocardial infarct with large left ventricular wall motion abnormalities on echocardiography.
- Patent foramen ovale/septal defects.
- Cardiac surgery.
- Infective endocarditis (gives rise to septic emboli;
How do we mitigate stroke in some1 with AF - atrial fibrillation?
Cha2ds2vasc score can be used to calculate risk of STROKE in patients with af.
Offer anticoagulation in patients with a score of 2 or above.
Take bleeding risk into account: calculate the risk of major bleeding using the HAS-BLED score.
Caution and regular review of oral anticoagulants are required if the HAS-BLED score >3.
Do not offer stroke prevention therapy in patients with af if <65y and cha2ds2vasc score is 0 for men or 1 for women.
Offer anticoagulation with a direct‑acting oral anticoagulant to people with atrial fibrillation and a CHA2DS2‑VASc score of 2 or above, taking into account the risk of bleeding. Apixaban, dabigatran, edoxaban
Mx of stroke?
Summarised:
300mg Aspirin
Admit to specialised stroke unit
CT head to rule out haemorrhage
IV Alteplase - if no haemorrhage or CI to thrombolysis
Ongoing:
- 300mg aspirin 2 weeks after stroke - if not haemorrhagic
- Switch to long term Clopidogrel (or dipyridamole)
Haemorrhagic;
1a. If GCS score ≤8 - Consider endotracheal intubation and maintain sats above 94%
1b. admit to acute or hypera-acute stroke unit
2. neurosurgeon input
3. reduce BP (if no cx or upcoming surgery)
4. reverse anticoagulation
(warfarin: prothrombinase complex + vitamin k)
(Fxa inhibitors: prothrombinase complex)
Neurosurgery may want to evacuate haematoma
Monitor:
Basic obs, Conscious level, Glucose, ECG
complications of stroke?
- Complications related to immobility such as pressure sores, aspiration pneumonia, constipation, and contractures
- Mental health - depression in them + carer
- Significant morbidity - reduced indepence in ADLs (try to mobilise them asap after treatment)
how may cerebral infarcts present (signs)?
Depending on site there may be contralateral sensory loss or hemiplegia—initially flaccid (floppy limb, falls like a dead weight when lifted), becoming spastic (umn); dysphasia; homonymous hemianopia; visuo-spatial deficit.
what are the scoring systems for patietns with acute coronary syndromes? their meaning?
They both predict mortality;
GRACE score - for ACS
- also used to decide if someone with NSTEMI should have PCI immediately or just medical management.
TIMI score - for NSTEMI and UA.
how to tell difference between NSTEMI and unstable angina?
troponin is increased in NSTEMI because cardiac myosite death.
Which medications are known to cause falls?
The most common drug causes are:
- Benzodiazepines and other hypnotics
- Antidepressants (tricyclics and selective serotonin reuptake inhibitors (SSRIs)
- Antipsychotics
- Opiates
- Diuretics
- Antihypertensives, especially ACE inhibitors and α-blockers
- Antiarrhythmics
- Anticonvulsants
- Skeletal muscle relaxants, e.g. baclofen, tizanidine
- Hypoglycaemics, especially long-acting oral drugs and insulin
What are the differentials for falls?
1 • Frailty and unsteadiness
2 • Syncope (if LOC)
- Reflex; vasovagal
- Cardiac;
a. arrhythmia; SVT, VT, bradycardia, fast AF, heart block, bradycardia etc
b. structural (aortic stenosis, HOCM) - Orthostatic:
a. drugs, dehydration, sepsis (vasodilation = intravascular volume loss) - Cerebrovascular
a. aortic dissection, subclavian steel
3 • Neurological problems
epileptic seizures,
psycogenic seizures
Head truama, narcolepsy
- Metabolic
- hypoglycaemia
- intoxication; alcohol
How to treat postural hypotension?
- Treat the cause. Stop, reduce, or substitute drugs incrementally
- Reduce consequences of falls (e.g. pendant alarms)
- Modify behaviour—stand slowly and stepwise; lie down at prodrome
- If still salt- or water-deplete, supplement with:
- Sodium (liberal salting at table or sodium chloride (NaCl) tablets)
- Water (oral or intravenous fluids)
- Consider starting drugs if non-drug measures fail:
- Fludrocortisone (0.1–0.2mg/day)
- α-agonists, contraindicated in vascular disease
management of hyperkalaemia?
Treat if K+ >6.5mmol/L or any with ecg changes (ecg for all K+ >6.0mmol/L):
- 10mL of 10% calcium chloride iv via a big vein over 5–10min, repeated if necessary and if ecg changes persist.
This is cardioprotective (for 30–60min) but does not treat K+ level.
If no ECG changes go to step 2:
- Intravenous insulin (10u soluble insulin) in 25g glucose (50mL of 50%). Insulin stimulates intracellular uptake of K+,
Monitor hourly for hypoglycaemia (in 11–75% of treated patients) which may be delayed in renal impairment (up to 6 hours after infusion).
- Salbutamol - (10–20mg via nebulizer) tachycardia can limit use. don’t use in fast arrhythmias
4 Definitive treatment requires K+ removal. If the underlying pathology cannot be corrected renal replacement - dialysis - may be indicated. Safe transfer to an offsite renal unit requires K+ <6.5mmol/L—discuss with renal team and critical care.
Key monitoring; potassiuim and glucose
how does hyperkalaemia present? complications?
Abdominal pain and diarrhea.
Chest pain.
Heart palpitations or arrhythmia (irregular, fast or fluttering heartbeat).
Muscle weakness or numbness in limbs.
Nausea and vomiting.
complications:
cardiac arrest
arrhythmias and sudden cardiac death
severe muscle weakness/paralysis
careful not to confuse sine waves for ?
Ventricular tachycardia
what are the 5 principles of hyperkalaemia mx?
Protect the heart; if ecg changes -> Ca gluconate
Shift K+ into cells
Remove K+ from body; in life threatneing hyperkalaemia; sodium zirconium
Monitor K+ and Glucose
Prevention
Whereare my p edema mx cards?
And af mx
Glucose is one of the blood tests, what about ketones?
Is it vbg? Urine? Bottle?
Mx of pulmonary oedema?
PODMAN: Position Oxygen Diuretics IV Morphine IV, Anti-emetic; metoclopramide IV, Nitrates: GTN
if worsening:
call anaesthetics
CPAP
Driving cut off times after an MI?
LVEF <40% : cant drive ffor 4 weeks after
normal LVEF afterr PCI: cant drive for 1 week.
which statins to give if intolerant to statin (MI)?
PCKS9 inhibitor eg evolocumab
in dka after first lines of treatment, how might you try to increase ph iff it hasnt resolved itself?
IV 1.26% bicarbonate is given - a very small amount
given by specialists
given REALLY SLOWLY
or might cause intracerebral acidosis what is called “Paradoxical acidosis”
