Emergency Medicine Flashcards
rx: thyroid storm
Symptom control:
IV propanolol
IV digoxin if propanolol fails or is contraindicated (e.g. asthma, low BP)
Reduce thyroid activity:
Propylthiouracil - preferred because it inhibits peripheral thyroxine conversion
Lugol’s iodine 4 hours later
Methimazole/carbimazole is considered second-line
IV hydrocortisone to reduce thyroid inflammation
Treat complications: (e.g. heart failure, hyperthermia)
symp: lifethreatening asthma attck
The best way to remember the features of a life-threatening asthma attack is A CHEST 92:
Altered consciousness
Cyanosis
Hypotension
Exhaustion
Silent Chest
Threatening Peak Flow: <33% best or predicted
Oxygen saturations <92%
ECG shocking
Advanced Life Support
Pulseless Electrical Activity and Asystole definitions
According to the adult advanced life support algorithm, Pulseless Electrical Activity (PEA) and Asystole fall under the non-shockable rhythms.
PEA is where the ECG shows electrical activity that should produce a pulse, but where cardiac output is absent, or insufficient, such that a pulse is not clinically detectable.
Asystole is a cardiac arrest rhythm with no discernible electrical activity on the ECG monitor
Management of PEA and Asystole
These rhythms are not compatible with life, and CPR should be commenced immediately with interruptions minimised.
Adrenaline 1mg IV is given in the first cycle, and, should a non-shockable rhythm persist, every other cycle (i.e. cycles 1, 3, 5 etc.).
Ventricular Fibrillation and Pulseless Ventricular Tachycardia definitions
According to the adult advanced life support algorithm, VF and pulseless Ventricular tachycardia fall under the category of shockable rhythms.
Ventricular tachycardia presents as a regular broad complex tachycardia on cardiac monitoring.
Ventricular fibrillation presents as as chaotic irregular deflections of varying amplitude
Management of VF and pulseless VT
Defibrillation and CPR are the mainstays of treatment. However if persistent, Amiodarone 300mg IV (same dose used to treat monomorphic VT) and Adrenaline 1mg IV (1:10,000) can be given after the third shock has been delivered.
Amiodarone is given as a one-off dose. However Adrenaline may be repeated every other cycle following a shock (i.e. cycles 3, 5, 7 etc.)
most important investigation in tca overdose
12 lead ECG - QRS prolongation and PR and QT interval prolongation, which can easily progress to heart blocks and ventricular arrhythmias
tx: torsades de pointes
magnesium sulfate
ECG lead placement
Ride Your Green Bike - red, yellow, green black going clockwise from right shoulder
def: critically ill patient
patients with acute pathology and orgna dysfunction that is life-threatening if not recognised and treated promptly
NEWS scores monitoring
0 = min 12 hrly
1-4 = min 4-6 hrly
3 in single parameter = min 1 hrly
5+ = urgent response and min 1 hrly
7+ = continuous monitoring ?ICU
type 1 v type 2 RF
type 1 = hypoxia and no effect on CO2 (pneumonia/pulm. oedema/ARDs)
type 2 = hypoxia and hypercapnia (COPD/respiratory depression/drug overdose)
signs: type 1 RF
- tachypnoea
- tachycardia
- dyspnoea
- cyanosis
- confusion
- irritability
- arrhytmia
- fits
signs: type 2 RF
- warm extremeties
- change of behaviour
- headache
- coma
- papilloedema
- astrexis
symptoms and signs: acute asthma adult
severe:
3392 CHEST
PEF <33%
sats <92%
cyanosis
hypotension
exhaustion
silent chest
tachycardia
altered consiousness, poor resp effort, normal PPCO2, hypoxia
severe
PEF 33-50%
sats <92%
HR >110
RR >25
inability to complete sentences
moderate
PEF 50-75%
sats >92%
increasing symptoms
10 puffs salbutamol not helped
signs and symptoms: acute asthma children
moderate:
* able to talk in sentences
* O2>92%
* peak flow >50%
* HR <140 1-5 y
* HR <125 5+y
* RR <40 1-5y
* RR <30 5+y
severe:
* SpO2 <92%
* PEF 33-50%
* HR >140 1-5y
* HR >125 5+y
* RR >40 1-5y
* RR >30 5+y
life-threatening:
* PEF <33%
* Spo2 <92%
* cyanosis
* hypotension
* exhaustion
* silent chest
* tachycardia
confusion/altered consiousness/poor resp effort
signs and symptoms: acute asthma children
moderate:
* able to talk in sentences
* O2>92%
* peak flow >92%
* HR <140 1-5 y
*HR <125 5+y
* RR<40 1-5y
* RR<30 5+y
severe:
* SpO2 <92%
* PEF 33-50%
* HR >140 1-5y
* >125
life-threatening
rx: acute asthma adults
CALL SENIOR HELP AND ANAESTHETICS
* O2 driven nebs (94-98%)
* B2B salbutamol and ipatropium nebs
* IV hydrocortisone
* theophyline/aminophyline
* IV meagnesioum sulfate
* escalate
rx: moderate asthma
- salbutamol via spacer device or pressurised meter-dose inhaler
- oral prednisolone 3-5 days as well as inhaled ICS
rx: COPD exacerbation
- same as asthma
- CXR ?infective cause
- blood cultures and sputum samples
- amox 500mg TID 5 days or calrithro BD 5 days 500mg pen allergy
scoring: community acquired pneumonia
CURB-65
confusion (new onset or worsening)
urea >7mmol/l
respiratory rate >30
BP <90 sys or <60 dias
age >65
3+ admission to hospital 1 or 2 ?hospital assessment
signs and symtpoms: CAP
- cough with sputum
- dyspnoea
- pleuritic chest pain
- rigors/night sweats
- fever
- crackles, decreased breath sounds, dullness to percussion, and wheeze
- tachpnoea
- malaise
- fatigue
rx: CAP
amoxicillin 500mg TID 5days
pen allergy: doxy 200mg day 1, 4 days 100mg OD or calrithromycin BD 500mg 5 days
pregnancy: erithromycin 500mg QIB 5 days
scoring system: PE
Wells score:
* 3= clinical featuers of DVT - leg swelling, pain with palpation of deep veins >3cm compared to toher leg
* 3= alternative diagnosis less likely than PE (resp conditions, ACS, MSK chest pain, GORD)
* 1.5 = HR>100
* 1.5 = immobilisation for >3 days or surgery in past 4 weeks
* 1.5 = previous DVT
* 1 = haemoptysis
* 1 = cancer treatment within last 6 months
> 4 = PE likely
4 or less = PE unlikely - offer D dimer with result within 4 hours -offer oral anticoagulant in interim if >4hr wait
rx: ?PE
- if wells >4 - hospital admission with emergency CTPA
- interim anticoagulant (APIXABAN OR RIAVROXIBAN 1st line) in interim if not arranged immediately
- if wells 4 or less - D dimer within 4 hours, if waiting offer anticoagulant
- if negative D dimer stop anticoagulant and look for other cause
- if positive - CTPA
baseline tests for anticoagulant: LFT, FBC, U+E, PT and APTT - do not wait for results
medication: PE
anticoagulant therapy
1st line = apixaban or rivaroxiban (DOAC)
2nd line = LMWH (enoxaparin
5 days
then dabigatran or edoxaban or LMWH with vit K antagonist for 5 days
pregnancy and PE
Women presenting with symptoms and signs of an acute PE should have an electrocardiogram
(ECG) and a chest X-ray (CXR) performed. [New 2015]
In women with suspected PE who also have symptoms and signs of DVT, compression duplex
ultrasound should be performed. If compression ultrasonography confirms the presence of DVT,
no further investigation is necessary and treatment for VTE should continue. [New 2015]
In women with suspected PE without symptoms and signs of DVT, a ventilation/perfusion (V/Q) lung
scan or a computerised tomography pulmonary angiogram (CTPA) should be performed. [New 2015]
When the chest X-ray is abnormal and there is a clinical suspicion of PE, CTPA should be performed
in preference to a V/Q scan. [New 2015]
Alternative or repeat testing should be carried out where V/Q scan or CTPA is normal but the clinical
suspicion of PE remains. Anticoagulant treatment should be continued until PE is definitively
excluded.
Women with suspected PE should be advised that, compared with CTPA, V/Q scanning may carry
a slightly increased risk of childhood cancer but is associated with a lower risk of maternal breast
cancer; in both situations, the absolute risk is very small
other investigations: PE
CTPA
V/Q if pregnancy
lower limb USS
ABG
D dimer
def: open pneumothorax
- hole in chest - (communicating pneumothorax or sucking chest)
- typically ballsitic (shot gun)
- as pt breathes in, hole in chest competes with normal airway
clinical assessment: open pneumothorax
inspect front and back
small sucking chest wound often audible
tx: open pneumothorax
- surgical repair
- cover wound with sheets of jlonet or chest seal device
- do not occlude all 4 sides to allow for flutter valve effect
- early intubation
- insert chest drain away from wound site if small
- do not insert chest drain if open pneumo large
def: simple pneumothorax
air collects between chest wall and pleura
presentation: simple pneumothorax
oftern young, tall, thin young men ?playing sports
* sudden breathlessness
* pleuritic chest pain
ix: simple pneumothorax
- erect CXR
- showers area between chest wall and ung tissue where there are no lung markings
- measure size by measuring horizontally at hilu from chest wall to lung tissue
rx: simple pneumothorax
no SOB and <2cm on CXR:
* no tx
* spontaneously resolve
* follow up 2-4 weeks
SOB and/or >2cm on CXR:
* 15L non-rebreather O2 resevoir bag)
* simple needle aspiration aspiration followed by reassessment - max 16G caunnula 2nd intercostal space midclavicular line)
* if fails twice - chest drain
unstable/bilateral/secondary pneumothroax - chest drain
* triangle of safety - 5th intercostal space, midaxillary line (lateral edge lat dorsi), anterior axillary line (lateral edge pec major)
chest drain: simple pneumothorax
- insert in triangle of safety (5th IC space, mid axillary line (lateral edge lat dosri), anterior clavicular line (lat edge pec major)
- external adge underwater to create seal
- air exits into water and bubbles
- respiration causes swinging effect on water
- stops when pneumothorax is resolved
surgical rx if fails (air leaks persistently) or pneumothorax reoccurs or surgical emphysema)
def: tension pneumothorax
casued by traume
causes one way valve - lets air in but not out
inspiration - air drawn into pleural space
expiration - air trapped
increases pressure inside thorax
pushes mediastinum across
kink in vsesels can cause cardiorespiratory arrest
signs: tension pneumothorax
- deviated trachea away from side of pneumothorax
- reduced air entry on affected side
- increased resonance on percussion
- tachycardia
- hypotension
rx: tension pneumothorax
- insert large bore cannula into second intercostal space, mid-clavicular line - ATLS say 4/5th IC space mid calvicular line
- chest drain for definitive management
signs: tension pneumo ventialted pateints
- decrease in oxygen saturations this is likely to be prompt
- decrease in BP
- tachycardia
def: massive haemothorax
- haemothorax >1500ml or >1/3rd patients blood volume
- causes haemorrhagic shock
- decreased ventialtion due to lung compression on side of haemothorax
clinical assessment and identification: massive haemothorax
CXR - white out on affected side and FAST to guide
tx: massive haemothorax
1 - restore blood volume (MAJOR BLOOD PROTOCOL) - ATLS suggest no more than 1L crystalloid until blood availble
2 - decrompress chest (chest drain)
def: fail chest
- series of rib (3+) fractured segmentally
- free/floating section of chest wall
clinical assessment and identification: flail chest
- palpation and inspection
- CXR may identify assoc. pneumo, haemo or pulm contusions
tx: flail chest
- intuabtion and ventilation IPPV with major trauma
- address pain
- chest drain insertion and CT scan
- replace fluid and blood loss
- definitive surgery
- ?ICU
def: pulmonary contusion
- bruised lung
- pt risk of hypoxia
- marker of significant injury
clinical assessment and identification: pulmonary contusion
- patchy white areas progressing to frank consolidation - early CXR changes worrying
- blood gas derangement assoc
- ?assoc rib fratures
tx: pulm contusion
- IPPV with PEEP
- discuss with ITU
def: cardiac tamponade
- collection fluid (blood if trauma) in pericardial sac
- causes haemoddynamic compromise
- often if penetrating injury to chest/back/upper abdomen
- can lead to cardiac arrest
diagnosis: cardiac tamponade
FAST scan
ddx: penetrating injury to back, chest or upper abdomen
- cardiac tamponade
- massive haemothorax
- tension pneumothorax
tx: cardiac tamponade
- fluid resus to increase pre-load
- if haemodynamically stable - urgent surgical exploration
- thoracotomy if pt presents within 10mins caridac arrest
4Hs and 4Ts reversible causes: cardiac arrest
hypothermia
hypotension
hypovolaemia
hypo/hyperkalaemia
tension pneumo
tamponade
thrombus
toxins
def: fractured ribs
- 4-10th ribs most common
- if fractured twice = floating rib
- 1-3rd ribs most likely high energy trauma
presentation: rib #
- pain with touch
- pain with inspiration/sneezing/coughing
- patient takes shallow breaths which can cause atelectasis and pneumonia
diagnosis: rib #
CXR
CT
rx: rib #
- analgesia
- incentive spirometry to prevent atelectasis
- intercostal nerve blocks
- may need surgery
- can rtake 3 months to heal
ind: FAST scan
tension pneumo
cardiac tamponade
massive haemothorax
restrictive v obstructive pulmonary function tests
normal FEV1 = >80%
normal FVC = >80%
normal FEV1/FVC = >0.7
obstructive - FEV1 reducev, FVC reduced slightly but to lesser extent therefore FEV1/FVC reduced
restrictive - FEV1 reduced, FVC reduced, FEV1/FVC normal
restrictive v obstructive pulmonary function tests
normal FEV1 = >80%
normal FVC = >80%
normal FEV1/FVC = >0.7
obstructive - FEV1 reducev, FVC reduced slightly but to lesser extent therefore FEV1/FVC reduced
restrictive - FEV1 reduced, FVC reduced, FEV1/FVC normal
examples or restrictive and obstructive lung pathology
obstructive - COPD, asthma, emphysema, bronchiectasis, CF
pulmonary restrictive - fibrosis, pulmonary oedema, lung tumours
non-pulmonary restrictive - skeletal abnormalities, NMD - Guillain barre/MS/MND or CT tissue or obesity/pregnancy
def: minute volume
amount of gas inhaled or exhaled from lungs in 1 minute
def: dead space
colume that does not participate in gas exchange
CPAP v NIPPV v IPPV
CPAP - continuous positive pressure (BiPAP provides different inhalation and exhilation pressures)
NIPPV - augments contiuous postitive airway pressure with superimposed inflations set to peak ressure (nasal prongs or mask)
IPPV - intermittent positive pressure ventilation is manually or mechanically ventilating patient that is apnoeix
signs: hypovolaemic shock
- low BP
- tachycardia
- peripherally shut down
- prolonged CRT
causes: hypovolaemic shock
haemorrhagic - trauma, GI bleed, haemorrhage, aneurysm rupture, post-op bleed
non-haemorrhagic - DKA, burns, severe N+V
def: distributive shock
peripheral vasodilation leading to abnormal volume distribution and inadequate perfusion
causes: distributive shock
sepsis
neurogenic - spinal cord injury (failure of sympathetic tone)
anaphylactic shock
presentation: distributive shock
septic : haemodynamic instability, tachypnoea, altred mental status, reduced urine output and pyrexia
neurogenic - ?brdycardia
anaphylacitc: hypotension, larygeal oedema, wheeze, rash, stridoe, swelling, SOB, tachycardia
rx: sepsis
qSOFA score:
* altered mental status (1)
* RR >=22 (1)
* systolic BP <=100 (1)
* sepsis 6 - give 3, broad spectrum abx, IV fluids and take 3 blood cultures, urine output and lactate within 1 hour
def: cardiogenic shock
cardiac dysfunction leading to inadequate cardiac output (SVxHR)
* MI
* valve pathology
def: obstructive shock
mechanical obstruction causing inadeuquate CO
* PE
* tension pneumo
* cardiac tamponade
*
def: dissociative shock
- normal function and volume
- perfusion problems with decreased ability to give O2 to tissues
- CO poisoning, cyanide or anaemia
def/equations: HR, SV, CO, systemic vascular resistance and BP
HR - heart rate
SV = end diastolic volume - end systolic volume
CO = HR x SV
systemic vascular resistance = (mean arterial pressure preload - central venous pressure afterload)/cardiac output
BP = CO x SVR
signs and symptoms: ACS
- chest pain
- pain/discomfort if 1/both arms, jaw, neck, back or stomach
- SOB
- feeling dizzy/lightheaded
- nausea
- sweating
rx: ACS
MONA
* morphine
* oxygen if <94%
* GTN spray
* aspirin 300mg
take resting ECG 12 lead
diagnosis: DKA
- glucose >11
- ketones >3 or urinary ++
- pH <7.3 or HCO3 <15
mainstays: DKA
A-E
* fluid resus 1L over 1hr, 2hrs, 2hrs, 4hrs, 4hrs, 6hrs, 6hrs (add KCl in if 3.5-5.5 from 3 hours on from VBG and call for help <3.5)
* fixed insulin infusion 0.15units/kg/hr (max 15units) in 50ml 0.9%NaCl
* when cap glucose <14mmol/l give 10% glucose infusion @125m/hr
* find cause
* VBG @1hr, 2hr and 2hrly
* cap glucose and ketones hrly
* keep long acrting insulin going
* restart normal insulin reigime when physiology normal and E+D ok at mealtime
* variable insulin infuson if not E+D but physiology ok
mainstays: anaphylaxis
- A-E
- remove source
- IM adrenline 500micrograms 1:100 12+y, 300mg 6-12y, 150mg 6m-6y, 100-150 <6m)
- repeat after 5mins if required
- fluid bolus 500ml over 15mins or 10ml/kg child
- refractive anaphylaxis - IV hydrocortisone or oral pred and IV adrenline infusion
rx: hypoglycaemia
uncoscious:
200ml 10% glucose or 100ml 20% glucose IV stat (repeat if necessary)
IM glucagon1mg IM if no IV access (once only)
conscious but cannot swallow: 2 tubes 40% glucose gel around teeth if mild and patient conscious
can swallow: 15-30g fast acting carbohydrate (5glucose/dextrose tablets/200ml fruit juice or lucozade/2-4tsp sugar) AND long acting carbohydrates
all:
check cap glucose 10 minutes later and repeat treatment as req
give long acting carb when able to swallow - biscuits or toast
determine and correct cause
ddon’t omit insulin afterwards - reduce dose
Beck’s triad
hypotension
raised JVP
muffled heart sounds
= cadiac tamponade
