Emergency Medicine Flashcards
Definition of Acute dystonia?
It’s a movement disorder characterized by involuntary painful muscle contractions and abnormal postures that involves the face, neck and trunk.
Torticolis (head rotated in an odd angle).
Causes of a acute dystonia?
Medications, namely:
•Antipsychotics:
-Haloperidol
-Chlorpromazine
-Risperidone
•Antiemetics:
- Metoclopramide
Time onset for acute dystonia?
Quick onset after initiation of the medication to 5 days after the initiation of the causative medication.
Treatment of acute dystonia?
First line:
-Procyclidine (IV or IM it’s anticholinergic)
2nd line:
-Diazepam IV (benzodiazepine)
What is the management of acute exacerbation of COPD?
1.Brochodilators
- Salbutamol (B2 agonist) nebulized 5mg
- (Consider) Nebulized ipratropium bromide 0.5mg (anticholinergic).
2.Corticosteroids
- Prednisolone 30 mg STAT (continue 30mg PO/day for 1-2 weeks)
OR
- Hydrocortisone 100mg IV;
3.Aminophylline
- In cases refractory to the treatment with bronchodilators;
4.Antibiotics if:
- Purulent sputum;
- Fever;
- ↑CPR;
- Signs of pneumonia.
5.O2 therapy
- Initiate with venturi mask with FiO2 of 24-28%;
- The goal is SPO2 in between 88-92%;
- SPO2 <80% will lead to anaerobic metabolism and metabolic acidosis;
- SPO2 >92% will lead to retention of CO2 and respiratory acidosis (inhibition of respiratory drive; the respiratory drive is “driven” by CO₂).
➜ In a patient with COPD, they become desensitised to higher levels of CO2 in the blood, and so they need a higher level of CO2 to generate enough respiratory drive to breathe properly.
6.NIV use when:
- ↓PH (<7.35) + ↑PCO2 (which will lead to resp. acidosis) in spite of adequate O2 therapy offering;
7.Invasive ventilation if:
- Failure of NIV: ↓↓PH (<7.26) + ↑↑PCO2 in spite of NIV;
- Contraindications of NIV: resp. arrest; ↓consciousness level; High aspiration risk.
8.Scenarios
- ↓PH + ↑PCO2 ➜ NIV or Invasive (depends of the case);
- Normal PH + ↑PCO2 ➜ Venturi mask
- Normal PH + Normal/↓PCO2 +↓PO2 (hypoxemia) ➜ Titrate O2 to achieve target 88-92%.
Define Anaphylaxis.
It’s an acute allergic reaction, with rapid onset of symptoms that can lead to death.
What are the causes of Anaphylaxis?
- Food
- Insects bites/venom
- Medications
Symptoms of anaphylaxis?
Skin
• Erythema
• Pruritus
• Urticaria
• Angiodema
Oral
• Lips, tongue and uvula oedema.
Respiratory
• Oedema of pharynx, epiglottis and larynx;
•Dyspnoea;
•Chest thightness;
•Cough;
• Wheeze
• Congestion, rhinorrhoea, sneezing.
Cardiovascular
- Hypotension/Shock due to peripheral vasodilation and increased vascular permeability leading to leakage of plasma from the circulation.
- Dizziness
- Syncope
- Tachycardia
Ocular
- Periorbital oedema.
Anaphylaxis management?
1- ABCD
2- Epinephrine IM (middle 3rd of the anterolateral thigh)
• <6 years: 150mcg IM (0,15 ml 1 in 1000)
• 6-12 years: 300 mcg IM (0,3ml 1 in 1000)
• >12 years: 500 mcg IM (0,5ml 1 in 1000)
• Chlorphneramine should be given after Epi.
3- High flow O2
4- (If) Hypotension: IV fluids.
Arterial blood gases
Is the patient hypoxic?
- PAO2 = 80-100 mmHg / 10.7-13.3 kPa
- Type 1 respiratory failure: ↓PO2 + Normal/low PCO2
- Type 2 respiratory failure: ↓PO2 + ↑PCO2
Acid-base balance
Is the patient acidotic or alkalotic?
- PH <7.35: Acidosis
- PH >7.45: Alkalosis
Acid-base balance
PH↓ + ↑PCO2
Whats’s the cause of this acid-base disorder?
Respiratory acidosis
* CO2 makes the blood acidotic ➜ Patient retains CO2 acutely;
HCO3 = 24-30 mmol/L
* It is produced by the kidneys to act as a buffer to neutralize the acid in order to maintain normal levels of PH;
* It is a slow process, it takes time so:
1. Acute resp. acidosis: normal HCO3 (it cannot be produced fast enough to compensate for the ↑ of CO2);
2. Chronic resp. acidosis: ↑HCO3 is indicative of a chronic retention of CO2 (e.g.: COPD).
- In an acute episode of COPD, the patient cannot compensate fast enough so it becomes acidotic even though it has an elevated levels of HCO3.
Whats’s the cause of this acid-base disorder?
↑PH + ↓PCO2
Respiratory alkalosis
* An increase in RR will get rid of CO2.
1. Hyperventilation: ↑PH ↓PCO2 ↑PO2
2. Pulmonary embolism: ↑PH ↓PCO2 ↓PO2 (hypoxemia)
Whats’s the cause of this acid-base disorder?
↓PH + ↓HCO3
Metabolic Acidosis
* ↑Lactate : -Raised in anaerobic metabolism, indicative of tissue hypoxia.
* ↑Ketones: -Diabetic ketoacidosis
* ↑H+ ions : - Renal failure; - Type 1 renal tubular acidosis; - Rhambomyolysis;
* ↓HCO3: -Diarrhoea; - Renal failure; -Type 2 renal tubular acidosis.
Whats’s the cause of this acid-base disorder?
↑PH + ↑HCO3
Metabolic alkalosis
* There’s loss of H+ ions due to:
* Vomiting: stomach produces hydrochloric acid ➜ loss of H+ ions;
* Kidneys loss of H+ ions by the kidneys can be due to: ↑Aldosterone ➜ will lead to excretion of H+ ions.
↑Aldosterone can be due to:
- Conn’s syndrome (1ry aldosteronism);
- Liver cirrhosis;
- Heart failure;
- Use of loops/thiazide diuretics.
Acid-base balance
Base excess
BE=±2
* BE >+2 = Metabolic alkalosis OR Compensated resp. acidosis
* BE < -2= Metabolic acidosis OR compensated resp alkalosis
In ADULTS
What is the management of acute exacerbation of Asthma in adults?
-
Initial immediate treatment
* O2 administration if SPO2<92% (goal is SPO2= 94-98%)
* Bronchodilators: -Salbutamol nebulized 5mg OR Terbutaline nebulized 10mg
* Corticosteroids: - Prednisolone 40-50mg PO OR Hydrocortisone 100mg IV
2.If life threatening features present :
* O2 administration;
* Nebulized salbutamol: -5 mg every 15 min OR 10mg continuous nebulization; - Add Ipratopium bromide 0.5mg to the salbutamol nebulizations.
* MgSO4 IV 1.2-2g (single dose) over 20 min.
* If symptoms are refractory to the treatment: - Salbutamol IV or Aminophylline IV.
3.If improvement of symptoms in 15-30min:
* Salbutamol nebulizations every 4h;
* Prednisolone 40-50mg PO for 5-7 days.
ATLS: Blood loss / Hypovolemia
Describe the 4 different classes
-
Class 1:
* Blood loss: <750ml / <15%
* HR: 60-100 bpm
2.Class 2:
* Blood loss: 750 - 1500ml / 15 - 30%
* HR: 101-120 bpm
3.Class 3:
* Blood loss: 1500 - 2000ml / 30 - 40%
* HR: 120 - 140 bpm
4.Class 4:
* Blood loss: >2000ml / >40%
* HR: >140 bpm
BURNS
ATLS formula for fluid requirements?
2ml x TBSA% x Weight in Kg
BURNS
Parkland formula for fluid requirements?
4ml x TBSA% x Weight in Kg
BURNS
After calculating the fluid requirements, how to administer the fluids?
- Hartmamnn’s solution used
- 1/2 of the total fluid requirements to be administered in the first 8h (from the time of burn injury and not arrival to the hospital);
- 2nd 1/2 of the total fluid requirements to be administered over the next 16h.
Calculate the fluid requirements using the ATLS or Parkland formulas.
BURNS
Describe the Wallace Rule of 9’s
Percentage of burned area
- Head and neck (front & back) : 9% (4.5% each side);
- Upper limbs (front & back each): 9% each (total 18% for both limbs);
- Thorax and Abdomen (front): 18%
- Thorax and Abdomen (back): 18%
- Lower limbs (front & back each): 9% each (total 18% for both limbs);
- Perineum: 1%
BURNS
When to administer the fluids
Burn percentage to start fluids
- Children: 10% of TBSA burned.
- Adults: 15% of TBSA burned.
BURNS
When to refer to burns facilities?
-
Children: >2% TBSA burned;
Adults: >3% TBSA burned;
2.Burns involving these areas:
- Face
- Hands
- Feet
- Genitalia
- Perineum
- Major joints
3.All deep dermal and full thickness burns;
4.All electrical and chemical burns;
5.All inhalation burns;
6.All non-accidental injury burns;
7.All burns not healed within 2 weeks.
BURNS
What is the management of full thickness circumfential burns affecting a limb or the torso?
Escharotomy
1. Limbs: full thickness circumfential burns can cause compartment syndrome ➜ urgent escharotomy.
2. Torso: full thickness circumfential burns can impede respiration.
Compartment syndrome: severe pain + paraesthesia + ↓ or absent pulses.
What are the causes of Carbon monoxide poisoning?
- Car exhausts
- Fire
- Faulty gas heaters
- Paint remover (stripper)
- Industrial solvent.
What is the mechanism of action of Carbon monoxide poisoning?
- It bonds to haemoglobin forming carboxyhaemoglobin (COHg).
- It reduces the capacity of the blood to carry oxygen.
- Oxygen delivery to the tissues will be decreased resulting in tissue hypoxia.
What are the symptoms of Carbon monoxide poisoning?
- Headache
- Nausea and vomiting
- Vertigo
- Confusion
► Severe toxicity
- Pink skin and mucosae (cherry skin)
- Hyperventilation
- Arrhythmias
- Fever
- Coma
- Death
What is the management of Carbon monoxide poisoning?
- Clear the airway;
- Give 100% O2:
1. If patient is conscious put a tight fitted mask with O2 reservoir;
2. If patient is unconscious intubate and ventilate in IPPV on 100% O2.
➨ The elimination half-life of CO is:
- 4h in breathing air;
- 1h on 100% O2
- 23 min on O2 at 3 atmosphere pressure.
What is the investigation / test in CO poisoning?
Sphectophotometry
It’s the COHgB levels in blood.
In CO poisoning, when to consider hyperbaric O2 treatment?
Controversial type of treatment
* >20% of COHb levels;
* Pregnacy
* Myocardial ischaemia
* Neurological signs other than headache.
Intoxications
What are the symptoms of Paracetamol poisoning?
Initial sypmtoms
* Nausea
* Vomiting
* Pallor
After 24h
* ↑ levels of hepatic enzymes;
After 48h
* Jaundice
* RUQ pain
* Hepatomegaly
Other symptoms
* Hypoglycaemia
* Hypotension
* Encephalopathy
* Coagulopathy
* Coma
Intoxications
Patients at ↑ risk of hepatotoxicity
In a scenario of paracetamol poisoning
Taking drugs that ↑ liver enzymes levels
- Rimfamphicin
- Phenytoin
- Carbamazepine
- Chronic alcohol abuse
- St. John’s Wort (flower that is used in the treatment of depression)
Malnourished patients
- HIV
- Hepatitis C
- Anorexia
- Bulimia
- Cystic fibrosis
- Alcoholism
People who haven’t eaten in a few days.
Intoxications
In a scenario of paracetamol poisoning, when to discharge home?
Ingestion of <150mg/Kg (child or adult), with no hepatic risk factors.
Intoxications
In paracetamol poisoning, when to admit to the hospital?
- Patients presenting within 8h of ingestion of >150mg/Kg (24 tablets/12g) ;
- Unknown amount ingested.
Intoxications
In paracetamol poisoning, when to measure paracetamol plasma concentration levels?
≥ 4h post ingestion of >150mg/Kg of paracetamol.
Intoxications
In paracetamol poisoning, when to administer activated charcoal?
If the patient presents in <1h post ingestion of >150mg/Kg of paracetamol.
1g/Kg, máx 50g
Intoxications
When to administer N-acetylcysteine?
In paracetamol poisoning
- If after 4h post ingestion, the plasma concentration of paracetamol is above the appropriate line (100mg/L);
- If 15h post consumption, the plasma paracetamol levels are above 15mg/L;
- If time of consumption is unknown, regardless of plasma concentration of paracetamol;
- If the patient presents late (>8h) post ingestion of >150mg/Kg of paracetamol;
- If there was a staggered overdose (not all the pills were not taken within 1h. e.g.: Consumption of 6g, 12 tablets of paracetamol everyday for 6 days. This is an overdose!)
- Jaundiced;
- Comatose.
What are the Kings’s College criteria for Liver transplant?
In paracetamol poisoning
Arterial PH <7.3 after 24h of ingestion
OR ALL of the following:
1. Prothrombin time > 100s (normal 11 - 13.5s)
2. Creatinine >300mmol/l
3. Grade 3 or 4 encephalophaty
What is the time of onset of TCA (Tricyclic antidepressants) Intoxication?
Rapidly time of onset, sometimes within 1h of ingestion.
What are the symptoms of TCA Intoxication?
Dryness
- Dry mouth
- Dry flushed skin
- Urinary retention
Eyes
- Dilated pupils
- Blurred vision
ECG + cardiovascular
- Sinus tachycardia
- Arrhytmias
- Hypotension
Neurological
- Agitation
- Drowsiness
- ↓ level of counsciness
- Seizures
- Severe sedation
- Coma
Acid-base disorder
- Metabolic acidosis
What are the ECG changes found on TCA intoxication?
- Sinus tachycardia
- Widening of the QRS complex >100ms (as toxicity worsens)
- Prolongation of the QT interval (as toxicity worsens)
- Widening of the PR segment (as toxicity worsens)
- Broad complex tachycardia
What is the Acid-base disorder found on TCA intoxication?
- Metabolic acidosis
What is the management for TCA intoxication?
- ABC
- Cardiac monitoring looking for widening of the QRS complex;
- IV bicarbonate in suspected or confirmed TCA poisoning with a QRS>100ms
➜ 250ml NaCl 0.9% bolus + Sodium bicarbonate 50ml -100 ml (50mmol) of 8.4% SLOWLY IV injection
➜ Sodium bicarbonate will correct ECG changes and arrhytmia
Bicarbonate in TCA intoxication management?
IV bicarbonate in suspected or confirmed TCA poisoning with a QRS>100ms
➜ 250ml NaCl 0.9% bolus + Sodium bicarbonate 50ml -100 ml (50mmol) of 8.4% SLOWLY IV injection
➜ Sodium bicarbonate will correct ECG changes and arrhytmias
- Aim for PH of 7.5-7.55
- Plasma protein binding of tricyclic antidepressants tend to bind in a more alkaline ph environment, which will lead in ↓ amount availability of the active unbound drug.
What are the symptoms of salicylate intoxication?
GI tract
- Nausea
- Vomiting
**Hearing** - Tinnitus - Vertigo - Deafness / Impaired hearing
Respiratory
- Hyperventilation
Neuro
- ↓ GCS
- Seizures
Cardiovascular
- Hypotension
- Heart block
Metabolic
- Mixed acidosis: Initially respiratory alkalosis due to stimulation of the central respiratory centre (hence the hyperventilation) ➜ Later metabolic acidosis
- Hypokalemia
What are the symptoms of opioid overdose
- ↓RR / respiratory depression;
- Miotic pupils;
- ↓ counscious level
- Constipation;
- Bradycardia;
- Hypotension
What is the antidote drug for opioid overdose?
Naloxone
* 0.8mg IV
* Fast onset (2 min to begin action)
* Short duration: - Can be given 2-3 times; -Need to be careful with intoxication using certain opioids with longer duration of action than Naloxone; -Naloxone will finish its effect whiles the opioid has not, which will prompt the intoxication symptoms to re-start.
- Naloxone has a shorter half life compared to Methadone.
What are the symptoms of opioid withdrawal?
- Increased body secretion:
- Sweating;
- Tearing;
- Runny nose;
- Diarrhoea.
- Pain:
- Muscle aches;
- Joints (arthralgia);
- Abdominal pain;
- Others:
- Dilated pupils
- Agitation
- Insomnia
- Anxiety
✾ Think of heroin as a girlfriend that has left you:
- You cry a lot: Watery eyes, runny nose, sweating
- You can’t sleep: Insomnia
- You miss her: Agitation, anxiety
What is the time onset for opioid withdrawal symptoms?
- Withdrawal symptoms begins 12h after last use;
- It peaks in between 24-48h;
- May last up to weeks.
Describe the step by step management of opioid overdose
- ABCD;
- Clear the airway;
- Administer O2 using bag and mask ventilation;
- Naloxone IV;
- Consider intubation (after bag & mask).
What are the drugs used to treat opioid withdrawal?
- Detoxification: Methadone or Buprenorphine.
- Relapse prevention: Naltrexone.
What are the symptoms of benzodiazepines overdose?
- Respiratory depression;
- Sedation;
- Anteretrogade amnesia.
-
Acid-base disorder: Respiratory acidosis
- Resp. depression ➜ apnea ➜ accumulation of CO2 ➜ RA
What is the antidote drug for benzodiazepines overdose?
Flumazenil
- 200mcg over 15 sec ➜ then 100mcg at 60 sec intervals if needed.
- Usual dose range: 300–600mcg IV over 3–6min (up to 1mg; 2mg if on ICU).
What are the symptoms of benzodiazepines withdrawal?
- Panic attacks
- Agitation
- Insomnia
- Anxiety
What is the time onset for benzodiazepines withdrawal symptoms?
- Begins at 1-4 days after cessation of the medicine
- Peaks at 2 weeks
What are the drugs used to treat benzodiazepines withdrawal?
- Diazepam (slowly reduce the dose);
- Propanolol.
What are the symptoms of cocaine overdose?
Unopposed 𝝰-adrenergic vasoconstriction
► ↑HR
► ↑BP
► ↑RR
► Myocardial infarction (coronary vasoconstriction)
► Intracranial haemorrhage
► Mydriasis
► Perforated nasal septum
► Hyperthermia and sweating
► Metabolic acidosis
Think of the symptoms as an association with vasoconstriction.
What are the drugs used to treat cocaine overdose?
- Benzodiazepines: for treatment of cardiovascular symptoms.
-
Phentolamine: for management of refractory hypertension.
* 5 - 15mg IV (every 5-15min) - Nitroglycerine or Nitroprusside as an alternative to phentolamine.
B-blockers are not recommended due to coronary vasoconstriction seen in coke overdose
What is the time onset for cocaine withdrawal symptoms?
- Begins within hours of last dose;
- Peaks in few days.
What are the symptoms of benzodiazepines withdrawal?
- Depression
- Restlessness
- Insomnia
What are the drugs used to treat cocaine withdrawal?
- Propanolol
- Diazepam
What are the symptoms of LSD overdose?
- Colours become more vivid;
- Smelling colours;
- Seeing sounds.
What are the symptoms of ecstasy overdose?
- Seeing spots/flashing/floating colour;
- Tachycardia
- ↑ BP
- ↑RR
- Uncontrolled body movements
- Trismus
- Hyperthermia
- Rhambdomyolisis
- Insomnia
What is the time onset for alcohol withdrawal symptoms?
- Within 24;
-May last a few weeks.
What are the symptoms of alcohol withdrawal?
- Tremors
- Anxiety
- Sweating
- Nausea & vomiting
What is the time onset of Delirium tremens?
➜Begins at 24-72h
What are the symptoms of delirium tremens?
Alcohol withdrawal symptoms + altered mental status + auditory & visual hallucinations
Management of alcohol withdrawal?
-
First line in uncomplicated withdrawal:
-
Chlordiazepoxide (a BZD)
- If complicated with seizures: - Lorazepam
-
Chlordiazepoxide (a BZD)
-
Second line:
- Diazepam. -
Prevention of Wernicke’s encephalopathy:
- IV Pabrinex (Thiamine / vitamin B1). -
Deterrent / abstinence:
- Disulfiram. -
Cravings reduction:
- Acamprosate.
Management of delirium tremens?
First line:
- Lorazepam;
Second line:
- Diazepam.
What is Wernicke’s encephalopathy?
A disorder due to thiamine / vitamin B1 deficiency characterised by:
- Nystagmus / ophtalmoplegia
- Ataxia
- Confusion
What is the treatment for Wernicke’s encephalopathy?
- Thiamine IV
- Thiamine should be given first before Glucose (so that when glucose is given, it will be utilised to form ATP and prevent cell death in the brain).
Define the Wernicke’s- Korsakoff Syndrome.
It’s a syndrome that develops upon improper treatment of Wernicke’s syndrome.
It’s characterized by:
- The Wernicke’s triad;
- Amnesia;
- Confabulation (making up stories).
Describe superficial epidermal burns.
- Red;
- Painful;
- Do not blister.
Former 1st degree burns.
Describe partial thickness burns
It’s divided into:
* Superficial dermal: Blisters.
* Deep dermal: Shiny, intact sensation.
Describe full thickness burns.
- White / Brown / Black;
- No blisters;
- No pain.
Define cardiac tamponade.
It is a critical condition, in which there’s fast development of pericardial effusion that compresses the heart.
What is the triad of symptoms in cardiac tamponade?
Beck’s triad
1. ↑ JVP / Distended neck veins;
2. Muffled hear sounds;
3. Hypotension.
What is the investigation done in cardiac tamponade?
Echocardiography.
What is the initial management / treatment in cardiac tamponade?
Intravenous fluids.
Patients usually present with shock (hypotension).
What is the most appropiate management / treatment in cardiac tamponade?
Pericardiocentesis.
What is the most appropriate management for a patient presenting with cardiac arrest due to cardiac tamponade secondary to penetrating trauma?
Immediate thoracotomy.
Describe the step by step management of clinical suspicion of PE.
Wells score >4:
1. PE likely;
2. Anticoagulation (awaiting CTPA)
3. Order immediate CTPA (computer tomography pulmonary angiogram);
4. Allergy to contrast media / renal impairment ➔ V/Q scan instead of CTPA.
Wells score <4:
1. PE unlikely;
2. Order D-dimers;
3. If D-dimers positive ➔ CTPA (immediate).
4. If negative think of alternate diagnosis.
► In the eventuality of a delay in doing CTPA ➜ Theraupetic anticoagulation until CTPA is done.
Define compartment syndrome.
↑ in pressure in a closed anatomical space (due to trauma), that results in insuficient blood flow to the muscles and nerves causing ischemia.
What are the symptoms of compartment syndrome?
- Intense pain (that does not match the extense of the injury) despite analgesia;
- Pain on passive movement;
- Sensory deficit;
- Pulse is present (arterial pulse > compartment pressure) ➨ lack of pulse is late finding.
Investigation of choice for compartment syndrome?
Intracompartment pressure device.
What is the treatment in compartment syndrome?
Emergency fasciotomy.
In compartment syndrome
What condition can develop after fasciotomy?
Reperfusion injury:
* When the ischaemic tissue starts being perfused (after fasciotomy), it releases myoglobin into the circulation.
* Myoglobin will cause AKI.
How to prevente it?
* Adequate hydration;
* Alkanisation of urine;
* In severe cases ➔ dialysis.
What are the risk factors for PE?
- Surgery;
- Pregnacy (postnatal period included);
- Lower limb injury;
- Immobility;
- Malignancy;
- Previous VTE (venous thromboembolism).
What is the gold standard / most appropriate diagnostic method for PE?
CTPA.
Computed tomography pulmonary angiogram.
What is the initial investigation method for PE?
X-ray.
To rule out other causes of dyspnoea.
In pulmonary embolism
Describe the anticoagulation management.
Haemodinamically stable:
1. First line:
- Apixaban or Rivaroxaban;
2. Second line:
- LMWH for 5 days, followed by Dabigatran or edoxaban;
OR
- LMWH + Warfarin.
Haemodinamically unstable:
1. Unfractioned heparin;
2. Consider thrombolysis.
Treatment doses and not the prophylathic doses.
Describe the pain in costochondritis.
- Usually in patients >40 yo;
- Sharp pain that is aggravated by movement, inspiration, sneezing, coughing;
- Sides of sternum tender.
Treatment for costochondritis?
NSAIDS
How is CPR in adults performed?
- 30 chest compressions;
- Two rescue breaths;
- Continue with 30:2.
How is CPR in children performed?
- Five rescue breaths;
- 15 chest compressions;
- Continue with 15:2.
How to administer breaths in infants during CPR?
- With your mouth, cover / seal the infant’s nose and mouth before administering a breath.
- If the above is not possible, cover / seal the mouth or nose with your mouth, while closing the other with your hand before administering a breath.
How to administer breaths in >1 YO during CPR?
Seal / cover the child’s mouth with yours before administering a breath over 1 sec.
How to administer chest compressions in infants during CPR?
➨ Chest compressions are started after rescuing breaths (if there’s no sign of life) at a rate of 100 bpm.
➨ The sternum should be compressed by at least 1/3rd of it’s depht.
- Encircling techique: Place both thumbs over the lower half of the sternum for compression (the rest of the hand will encircle the lateral thorax and the back).
- Two-finger technique: Place the tips of the index and middle finger on the lower sternum and compress.
How to administer chest compressions in >1 YO children during CPR?
➨ Chest compressions are started after rescuing breaths (if there’s no sign of life), at a rate of 100 bpm.
➨ The sternum should be compressed by at least 1/3rd of it’s depht.
- Start compressions with the heel of one hand placed on the lower sternum.
- In a large children use 2 hands, as you would in an adult.
CPR
Name the pulseless shockable rhythms.
- Ventricular fibrillation;
- Ventricular tachycardia (pulseless).
CPR
Name the pulseless non-shockable rhythms.
- Asystole;
- Pulseless electrical activity.
CPR in Advanced Life Support
Describe the step by step management in ALS.
► Adult patient is unresponsive with absent / abormal breathing
- Give CPR 30:2;
- Assess rhythm:
➔ Pulseless shockable rhythms:
* Shock;
* Assess rhythm every 2 min;
* Administer adrenaline every 3-5 min;
* After 3 shocks give Amiodarone.
➔ Non-shockable rhythms:
* Continue chest compressions;
* Assess rhythm every 2 min;
* Administer adrenaline as soon as IV line is inserted and continue every 3-5 min;
GCS: eyes assesment
4 pts - Eyes opes spontaneously;
3 pts - Eyes open in response to voice commands;
2 pts - Eyes open in response to pain stimulus;
1 pt - No response.
GCS: verbal assesment
5 pts - Oriented;
4 pts - Confused;
3pts - Inappropriate words;
2 pts - Incomprehensible sounds
1 pt - No response.
GCS: motor assesment
6 pts - Obeys command;
5 pts - Localizes pain;
4 pts - Withdraws from pain;
3 pts - (abnormal) Flexion in response to pain;
2 pts - (abnormal) Extension in response to pain;
1 pt - No response.
Pupillary response to light
Unilateral dilated pupil
Name the causes.
► Unilateral space occupying lesion:
* Haematoma;
* Tumors;
* Abscess.
Pupillary response to light
Bilateral constricted pupils
Name the causes.
- Cerebrovascular accident affecting the brainstem;
- Opioid overdose.
Pupillary response to light
Bilateral dilated pupils
Name the causes.
- TCA overdose
- Stimulants
When can you indicate a CT scan within 1h in adults after a head injury?
- GCS <13 on arrival to the hospital;
- 2h after the 1st evaluation a GCS of <15 ;
- Suspected open or depressed skull fracture;
- Any sign of basal skull fracture;
- Post-traumatic seizure;
- Focal neurologic deficit;
- More than 1 episode of vomiting.
If any of the above present.
When can you indicate a CT scan within 8h in adults after a head injury that present with loss of consciousness & amnesia?
- ≥ 65YO;
- Patient on anticouagulation;
- History of bleeding or clotting disorder;
- Dangerous mechanism of injury;
- > 30 min retrograde amnesia
If any of the above present.
When can you indicate a CT scan within 1h in children after a head injury?
- On arrival to the hospital, GCS<15 if < 1 YO ;
- On arrival to the hospital, the GCS is < 14 if > 1 YO;
- 2h after the head trauma a GCS of <15 ;
- Post-traumatic seizure;
- Suspected open or depressed skull fracture or tense fontanelle;
- Signs of basal skull fracture;
If any of the above present.
Criteria to indicate a CT scan within 1h in children after a head injury with ≥ 2 of it present?
- Loss of consciousness > 5 min;
- Abnormal drownsiness;
- Amnesia > 5 min;
- ≥ 3 episodes of vomiting;
- High speed RTA;
- Fall from a height >3m.
2 or more of the above to do the CT.
What are the signs of basal/basilar skull fracture?
- Racoon / panda eyes (bilateral periorbital bruising);
- Batle’s sign (retroauricular / mastoid process bruising without direct trauma);
- Haemotympanum or bleeding from the auditory meatus;
- CSF rhinorrhea or othorrhea.
What is the bone affected in basal/basilar skull fracture?
Temporal bone
CT scan of epidural (extradural) haematoma?
An expanding lemon.
CT scan of subdural haematoma?
Banana.
Describe what is Flail chest
It is when multiple ribs (>3) are broken due to trauma, causing paradoxical respiration (chest in during inspiration, and out during expiration).
Describe the presentation of Flail chest
- RTA;
- Chest pain;
- Dyspnoea.
What is the management of Flail chest?
- High flow O2;
- Analgesia (3 steps analgesia, intercostal block / T4 thoracic epidural);
- If fatigue of breathing: Intubation + Positive pressure ventilation
What are the 3 features of DKA (diabetic ketoacidosis)?
- Hyperglycaemia;
- Acidosis;
- Ketonaemia.
What are the (most common) causes of DKA?
- Infections;
- Missed insulin doses;
- Cardiovascular disease’s (MI, cerebral stroke).
What are the symptoms of DKA?
- Polyuria, polydipsia, vomiting, dehydration;
- Abdominal pain;
- Kussmaul respiration;
- Acetone smelling breath;
- Altered mental status —> Coma.
How is the diagnosis of DKA made?
All of the following must be present
- Capillary glucose > 11 mmol/L or known DM.
- Capillary ketones > 3mmol/L or urinary ketones > ++.
- Arterial blood gas PH< 7.3 and/or HCO3 < 15.
What is the initial management of DKA?
Hydration / fluid replacement with NaCl 0.9%.
After the initial management with saline, what is the follow up management of DKA?
After appropriate saline infusion
- Correct potassium (if needed) with KCl 40mmol/L
- Insulin therapy (if given early, before the IV fluids, can cause cerebral oedema);
- When plasma glucose reaches 14, add dextrose 10% alongside the saline infusions and consider reducing the IV insulin.
What glucose value is considered hypoglycaemia?
4 mmol/L.
What are the causes of hypoglycaemia?
- Anti-diabetic medications.
- Binging of alcohol;
- Post gastric surgery.
Symptoms of hypoglycaemia?
- Sweating
- Anxiety
- Hunger
- Tremors
- Dizziness
- Palpitations
- Confusion
- Seizures
- Coma
What is the management of hypoglycaemia?
Conscious patient
- Carbohydrated snack
- Glucose gel.
Unconscious patient
- 1mg glucagon IM (if outside the hospital);
- Glucose IV:
Glucose 20% 75ml IV (10-15 min);
Glucose 10% 50ml IV, every 2 min until patient is conscious or 250 ml has been given.
Glucose 50% 25-50ml (in large vein followed by saline flush, hypertonic solution that can damage veins).
What are the contraindications for the use of Glucagon?
- Alcohol intoxication
- Chronic alcoholism
- Liver failure
- Hypoglycaemia due to sulfonylurea drugs
When to suspect foreign body aspiration in toddlers?
Story of a child playing with a toy, followed by a cough, wheeze, stridor (acute respiratory symptoms).
What is the management in a unstable toddler with suspected or confirmed foreign body aspiration?
Unconscious & basic life support already done.
Laryngoscopy.
What is the management in a stable toddler with suspected or confirmed foreign body aspiration?
No cyanosis, mild wheezing, child relatively well.
- X-ray;
- Bronchoscopy (even if normal x-ray).
Define haemothorax.
Blood accumulation in lung pleural cavity. Usualy caused by RTA or stab injury.
What are the symptoms of haemothorax?
- Hypotension
- Tachycardia
- Dullness on percussion
- Chest x-ray: homogenous opacity on the lower lung field.
What is the initial management of haemothorax?
- Oxygen;
- Insertion of 2 large venous cannulae and request blood.
What is the definitive management of haemothorax?
- Chest drain insertion;
- Surgery (rarely done).
Define pneumothorax.
It is air accumulation in the pleural cavity that results in lung collapse on the affected side.
What are the symptoms of pneumothorax?
- Sudden onset of chest pain;
- Dyspnoea;
- Hyperressonance on the affected side.
What is the classification of pneumothorax?
-
Based on the cause
* Primary / Spontaneous: No identifiable cause;
* Secondary: idenfiable cause such as COPD/Asthma. -
Based on the nature
* Closed: the volume of air doesn’t change in the pleural cavity;
* Open: Communicates with the athmosphere;
* Tension: volume of air int pleural cavity expands.
What is the management of primary / spontaneous pneumothorax?
- Erect chest x-ray, to confirm the diagnosis;
- ≤ 2cm: O2 & conservative management.
- > 2cm or distressed patient: Needle aspiration;
What is the management of secondary pneumothorax?
- < 1cm: O2 & conservative management.
- 1-2 cm: Needle aspiration.
- > 2cm: Chest drain.
What are the symptoms of tension pneumothorax?
- Acute respiratory distress;
- Hypotension;
- Tracheal deviation from the pneumothorax side;
- ↓ air entry on the affected side;
- ↑ JVP.
What is the management of tension pneumothorax?
- High flow O2;
- Needle decompression: Insert large bore cannula (14-16G) into the 5th mid-axillary intercostal space;
- Chest drain;
- X-ray.
Causes of hypercalcaemia?
- Primary hyperparathyroidism;
- Malignacy: Multiple myeloma, Lung carcinoma (produces PTH like molecule);
- Sarcoidosis;
- Immobilization.
Symptoms of hypercalcaemia?
- Gastro (Moans): Constipations due to ↓ bowel activity;
- Renal (Stones): Kidney stones & nephrolithiasis due to calcium deposits in kidney. Polyuria & polydipsia due to induction of diabetic insipidus;
- Neuro & Psych (Groans): Lethargy, confusion and depression;
- Bone pain (Bones): seen in hyperthyroidism.
What is the management of hypercalcaemia?
- Hydration with (3-4L) of NaCl 0.9% to induce urinary output and excretion of calcium;
- Bisphosphonates IV (Zoledronic acid or pamidronate);
- In sarcoidosis: steroids;
- 2ry hyperparathyroidism: Cinalcet hydrochoride;
- Renal failure: hemodialysis;
What ECG changes are seen in Hyperkalaemia?
- Tall tented T waves;
- Flattening of the P wave;
- Widening of the QRS complex ➜ sinusoidal pattern ➜ asystole.
What is the classification of hyperkalaemia based on severity?
- Mild: 5.5-5.9 mmol/L
- Moderate: 6.0-6.4 mmol/l
- Severe: ≥6.5 mmol/L
What are the causes of hyperkalaemia?
- Potassium sparing diuretics / ACE-inhibitors / ARB’s / Spironolactone;
- Acute renal failure;
- Metabolic acidosis;
- Addison’s
What is the management of moderate or severe hyperkalaemia with ECG changes?
- Stop caustive drugs (if any);
- Calcium gluconate (if ECG changes or K>6.5)
- Insulin IV & Dextrose.
Other methods:
* Calcium resonium (binds K+ to the gut);
* Salbutamol
* Bicarbonate
* Hyperventilation
* Loop diuretics;
* Dialysis.
What is the most initial management of hyperkalaemia with ECG changes?
Calcium gluconate.
What is the most aproppriate management of hyperkalaemia with ECG changes?
Dialysis.
What is the management of mild or moderate hyperkalaemia asymptomatic and without ECG changes or signs of AKI?
- Stop the causative drugs;
- Repeat K+ levels in 1-3 days in primary care.
What are the causes of hypovolaemic hyponatremia?
►Develops when Na+ and water are lost but only water gets replaced
* GIT losses (diarrhoea, vomiting);
* Skin loss (burns, sweating);
* Diuretics (Na & water are lost through renal excretions but only water gets replenished by mouth);
* Addison’s disease (Aldosterone causes renal Na reabsortion and K excretion, when aldosterone is lost, there is Na and water loss and accumulation of K).
What are the causes of euvolaemic hyponatremia?
- SIADH
- Diuretics
- Psychogenic polydipsia
What are the causes of hypervolaemic hyponatremia?
- Excess water;
- Cirrhosis;
- Congestive heart failure;
- Nephrotic syndrome;
- Renal failure (free water is not excreted).
What are the other causes of hyponatraemia?
- Pseudohyponatraemia: In hyperglycaemia, the high glucose amount causes a shift of water without Na from cells and into the vascular space.
- SSRI;
- ACEi;
- Elderly patients (prone to SIADH cause they’re unable to suppress ADH effectively) (investigations necessary only if Na <130)
What investigations / lab analysis should be requested in hyponatraemia?
- Urinary sodium (High sodium in urine = hypovolaemia).
- Volume status of patient
What is the management of hyponatraemia?
- Emergency cases (coma/seizure): IV hypertonic solution 1.8% or 3% NaCl & furosemide;
- Hypovolaemic: Normal saline 0.9%
- Euvolaemic: Normal saline 0.9% given slowly (1L over 8h); Euvolaemic due to SIAHD: Fluid resctrition / demeclocycline or vaptans if fluid resctritions is inadequate;
- Hypervolaemic:Treat the underlying cause.
What are the symptoms of panic attacks?
- Numbness or tingling sensation: Hyperventillation ➔↓CO2➔Respiratory alkalosis➔Hypocalcaemia.
- Palpitations;
- Chest pain
- Sweating;
- Tremors;
- Difficulty breathing.
How long do panic attacks last for?
10-20 min.
Management of panic attacks?
- Acute: breathing into a bag;
- Long term: CBT, Antidepressants (SSRI)
Define sepsis
Life threatening organ dysfunction caused by desregulation of host’s response to infection.
What are the red flags in sepsis?
- SBP <90mmHg / a fall of >40 mmHg from the baseline;
- HR >130 bpm;
- Lactate >2 mmol/L;
- SPO2 <91% (<88% in COPD);
- RR >25 breaths/min;
- Neuro: unresponsive / responds to voice or pain only;
- Urine output <0.5ml/Kg/h in ≥ 2h;
If ≥1 red flag present, complete the Sepsis six within 1h.
What are the sepsis 6?
If ≥1 red flag present, complete the Sepsis six within 1h.
Take 3 & Give 3
Take 3:
* Blood cultures;
* FBC, U&E, clotting, serial lactate;
* Urine output (monitor);
Give 3:
* High flow O2;
* IV fluids;
* IV antibiotics.
What is the initial management of sepsis ?
- High flow O2;
- IV fluids;
- IV antibiotics.
If all options given then follow ABC protocol according to the symptoms.
Define septic shock?
Hypotension that is persistent and refractory to fluids administration.
Describe qSOFA?
- RR ≥22 breaths/min;
- Altered mentation;
- SBP ≤ 100mmHg
What is the management for upper GIT bleeding secondary to varices?
- Fluid resuscitation;
- Endoscopy (especially if the patient is unstable) ——> Band ligation;
- Terlipressin 2mg IV 4/4h
- If prolonged INR, give Vit K;
- Platelets transfusion if <50;
- Prophylactic antibiotics (cipro or cephalosporin);
Omeprazole should be avoided unless known peptic ulcer disease.
PPI’s shouldn’t be given prior to endoscopy diagnosis.
How to manage urethral injuries secondary to pelvic fractures / perineal trauma?
- Refer to urology;
- Do not insert an urinary catheter;
ABCDE evaluation
Describe the Airway evaluation.
- Look for signs of airway obstruction:
•Noisy air entry;
•Paradoxical chest and abdominal movements; - Clear airway:
•Airway opening manoeuvre;
•Airway suction;
•Insertion of nasopharyngeal or oropharyngeal airway;
•If all fails, tracheal intubation; - High concentration O2.
ABCDE
Describe the breathing evaluation.
- RR, chest expansion, auscultaste the breathing sounds;
- If RR inadequate or absent —> Bag-mask ventilation;
- NIV and intubation can be consider.
ABCDE
Describe the cardiovascular evaluation.
- Look for signs of circulation problems (BP, HR, peripheral and central pulses);
- If hypotension give 500 ml of crystaloids (saline 0.9% or Hartmann’s).
ABCDE
Describe the disability evaluation.
- Look for common causes of unconsciousness (hypoxia, cerebral hypoperfusion, low glucose)
- Check pupils.
ABCDE
Describe the exposure evaluation.
Expose the patient but do respect their dignity.
Describe the presentation of Orbital blowout fractures.
- Associated with fracture of the maxilla (orbital floor);
- Presents with vertical diploplia due to involvement of inferior rectus muscle;
- Enophtalmos (sunken eye);
- Infraorbital anaesthesia.
What is the management of Orbital blowout fractures?
- Initial: X-ray or the skull.
- Most appropriate/definitive/gold standard: CT scan.
- Surgery.
What are the causes of Mallory-Weiss syndrome
- Persistent vomiting / retching —> Oesophageal tear —> Haematemesis;
- Alcoholism;
- Bulimia nervosa.
What is the investigation in Mallory-Weiss Syndrome?
Endoscopy.
What is the management of Mallory-Weiss Syndrome?
- ABCDE
- IV fluids and blood transfusion if needed;
-Endoscopy immediately after resuscitation.
What is the choking management for an infant?
- While seating down, put the infant on your lap on prone position with the head tilting down;
- Deliver 5 back blows with the heel of the hand, along the spine in between the shoulders blades.
- Turn the infant supine and deliver 5 chest thrusts (less intense than chest compressions).
What is the choking management for a child and adult?
- Deliver 5 back blows;
- Stand behind the patient and give 5 abdominal thrusts as the patient is leaning forward. Clench one fist and grip the fist with the other hand and pull upwards and inwards sharply.
- Alternate in between step 1 and 2.
What is the choking management for an unconscious patient?
- Lay the patient on the floor;
- Call ambulance;
- Start CPR.
Describe what is hereditary angioedema.
It’s an autosomal dominant hereditary condition, due to C1-esterase inhibitor deficiency.
It can be precipitated by:
- Stress;
- Infection;
- Trauma;
- Surgery.
What are the symptoms of hereditary angioedema?
- Lip, mouth and face swelling;
- Dyspnoea and stridor (laryngeal oedema);
- Abdominal pain.
What is the investigation done in hereditary angioedema?
- Serum C4 level;
- C1 inhibitor level.
Management of hereditary angioedema?
- C1 inhibitor concentrate IV or SC;
- Bradykinin receptor inhibitor;
- Kallikrein inhibitor;
- Severe laryngeal oedema —> intubation and ventilation.
What are the symptoms of an acute case of peptic ulcer?
- Epigastric pain;
- Haematemesis;
- Melaena.
What is the management for an acute case of peptic ulcer?
- Endoscopy
- Acid suppression (PPI/H2 antagonist);
What are the risk factors for peptic ulcer
- NSAID’s
- Steroids
- H. pylori infection
What are the symptoms of a perforated peptic ulcer?
- Epigastric pain
- Melaena
- Rebound tenderness
- Guarding
- Abdominal rigidity
What is the investigation in perfurated peptic ulcer?
Erect X-ray: air under diaphragm.
What is the treatment of perforated peptic ulcer?
Laparoscopic or laparotomy repair.
What is the Serotonin syndrome?
Increased levels of serotonin in the synapses due to drug overdose or interaction between MAOI, SSRI and SNRI.
What are the symptoms of Serotonin syndrome?
Autonomic hyperactivity
- Hypertension
- Tachycardia
- Hyperthermia
Neuromuscular abnormalities
- Tremor
- Ocular clonus
- Hypertonicity
Mental status changes
- Anxiety
- Confusion
What is the management of serotonin syndrome?
- Stop the offending drug
- BZD
- IV fluids
- Cyproheptadine
Define status epilepticus
Single epileptic seizure lasting for > 5 min OR two epileptic seizures with less than 5 min in between them without full recovery in between.
What is the management of Status epilepticus?
- ABCDE (including glucose)
- Lorazepam IV (max 2 doses)
- Buccal midazolam or rectal diazepam (if no IV) (max 2 doses)
If after 2 doses or 1 dose of bucal MDZ and then later 1 dose of Lorazepam IV
- Phenytoin IV (1st)
- Phenorbabital IV (if seizures refractory to phenytoin)
- Intubation and ICU.