Emergency Medicine Flashcards
Reversible causes of cardiac arrest
Hypoxia
Hypovolaemia
Hyperkalaemia/hypokalaemia, hypoglycaemia, hypocalcaemia
Hypothermia
Thrombosis
Tension pneumothorax
Tamponade
Toxins
Treatment of hypoxia in cardiac arrest
patient adequately ventilated with maximal inspired O2 (15L/min)
Treatment of hypovolaemia in cardiac arrest
o look for haemorrhage and restore volume with fluids and blood products
o Activate major haemorrhage protocol where required
Treatment of thrombosis in cardiac arrest
o Urgent angiography ± PCI
o Thrombolyse if PCI not available or PE
Treatment of tamponade in cardiac arrest
pericardiocentesis
Initial assessment in cardiac arrest
- Assess for response and signs of life
- Call for help and make bed flat
- Open airway using head-tilt chin-lift
- ABCDE
Chest compressions in cardiac arrest
- Ratio chest compressions to ventilation 30:2
Ventilation in cardiac arrest
- Bag-valve mask
- Airway adjuncts used where required
- Continuous with LMA, I-gel or endotracheal intubation
- 10 breaths per minute
Defibrillation in cardiac arrest
- Shockable rhythms: Ventricular fibrillation, pulseless ventricular tachycardia
- Single shock followed by 2 mins of CPR
Adrenaline in cardiac arrest
- Adrenaline 1mg ASAP for non-shockable rhythms (PEA, asystole)
- Shockable rhythms give adrenaline once chest compressions have restarted after 3rd shock
- Repeat adrenaline every 3-5 mins
Amiodarone in cardiac arrest
- 300mg given to patients after 3 shocks
- Further 150mg given after 5 shocks
- Lidocaine used as alternative if amiodarone
Peri-arrest bradycardia adverse signs
- Shock hypotension, pallor, sweating, cold, clammy extremities, confusion, impaired consciousness
- Syncope
- MI
- HF
Management of peri-arrest bradycardia
- 1st line = 500mcg IV atropine
- Continue atropine up to max 3mg
- Transcutaneous pacing
- Isopredaline/adrenaline infusion titrated to response
Risk factors for asystole
- Complete heart block with broad complex QRS
- Recent asystole
- Mobitz type II AV block
- Ventricular pause >3s
Management of peri-arrest tachycardia
- If adverse signs present then synchronised DC shocks (up to 3)
- Broad complex (regular)
o Assume VT (unless previously confirmed SVT with BBB)
o Loading dose of amiodarone followed by 24 hr infusion
o Lidocaine use with cuation in severe LV impairment
o Procainamide
o Electrophysiological study
o Implantable cardioverter-defibrillator - Broad complex (irregular)
o Seek expert help
o AF with BBB
o AF with ventricular pre-excitation
o Torsade de pointes - Narrow complex (regular)
o Vagal manoeuvres
o IV adenosine
o Atrial flutter BB - Narrow complex (irregular)
o AF
o Onset <48 hr consider electrical or chemical cardioversion
o BB
Causes of hypothermia
- Primary hypothermia environmental exposure with no underlying medical condition
- Secondary hypothermia
o Decreased heat production hypothyroidism, hypoadrenalism, malnutrition
o Increased heat loss vasodilation, burns, erythroderma
o Impaired thermoregulation CNS trauma, stroke, sepsis, pancreatitis
Presentation of hypothermia
- Mild (32-35 degrees)
o Shivering
o Lethargy
o Confusion
o Tachycardia
o Vasoconstriction
o Loss of motor coordination - Moderate (28-32)
o Dysrhythmias
o Bradycardia
o Hypotension
o J waves (frosty Jacks)
o Reduced reflexes
o Reduced GCS
o Dilated pupils - Severe (<28)
o Agitation/delirium
o Arrhythmias
o Apnoea
o Non-reactive pupils
o Coagulopathy
o Oliguria
o Pulmonary oedema
Investigations of hypothermia
- Rectal/ear temp
- ECG J waves or other arrhythmias
- Bloods U&Es, plasma glucose, amylase, TFTs, FBC, coagulation studies, blood cultures
- ABG
- CXR
Management of hypothermia
- ABCDE
- Aim for temp rise of 0.5 per hour using warm IV fluids, warm O2 and blankets
- IV drugs avoided use to risk of drastic response
- IF cardiac arrest, warming as quickly as possible
o Warmed fluids infused into all orifices with access (IV, catheter, NG) - Patients not dead until warm and dead
- If <30 and in arrest no more than 3 shocks administered until rewarmed
- Cardiac monitoring
- Catheterise
- Abx for prevention of pneumonia in patients <65 with temp <32
Management of haemorrhage
- Major haemorrhage protocol
- Call for help
- Try to limit bleeding
- Call blood bank
- Bloods and 2x Group and Save
- Two large bore cannulas
- IV fluid bolus (no more than 1L)
- 2 units of O- blood
- Crossmatched blood
- Additional blood products – platelets, FFP, cryoprecipitate
- Definitive management
Causes of burns
- Thermal Solids, liquids, gases, smoke, fire
- Chemical Acid, alkali, toxins
- Electrical
Severity classification of burns
- Superficial epidermal (1st degree)
o Red and painful, dry, no blisters
o Blanching on pressure
o Will heal without scarring
o Don’t calculate total body surface area
o E.g. sunburn - Partial thickness – superficial dermal (2nd degree)
o Pale pink, painful, blistered, slow cap refill
o Blanching - Partial thickness – deep dermal (2nd degree)
o Typically white but may have patches of non-blanching erythema
o Reduced sensation
o Painful to deep pressure - Full thickness (3rd degree)
o White/brown/ black in colour, leathery appearance
o No blisters, non-blanching
o Loss of sensation no pain
Assessing extent of burn
- Total Body Surface Area
o Wallace’s rule of 9s
o Lund and Browder chart (Paeds)
o Palm rule palm is 1% TBSA
Immediate management of burns
- Stop the burn
o Remove burning/source
o Electrical burns switch of power supply, cardiac monitoring
o Chemical burns Brush any powder off then irrigate with water (do not try to neutralise) - ABCDE
o Airway issues get worse quickly with oedema
o Oxygen and measure CO
o 2x wide bore cannulae fluid resus
o Careful exposure
o Monitor urine output
General burns management
o Within 20 mins, irrigate burn with cool water for 10-30 mins
o Cover burn using cling film, layered, rather than wrapped around limb
o Symptomatic relief – analgesia, emollients
o Tetanus
o Cleanse wound
o Leave blister intact
o Non-adherent dressing
o Avoid topical creams
o Review in 24 hrs
Referral to secondary care for burns
- All deep dermal and full-thickness burns
- Superficial dermal burns of >3% TBSA in adults or >2% in children
- All circumferential burns
- Unhealed burns >2/52
- Need for HDU/ITU
- Pregnancy
- Any inhalation injury
- Suspicion of non-accidental injury
- Discussion
o Superficial dermal burns involving face, hands, feet, perineum, genitalia, or any flexure
o Any electrical or chemical burn injury
o Cold injury
o Febrile/unwell children
Management of more severe burns
- Assess airway
o Smoke inhalation can result in airway oedema
o Look for singed nose hairs, facial burns, oropharyngeal burns, voice hoarseness, stridor
o History of burns in enclosed space
o Consider early intubation as oedema can make intubation more difficult later - Breathing
o ABG Carbon monoxide levels, lactate, oxygenation, cyanide poisoning
o High flow O2 - IV fluids
o Children with burns >10% total body surface area
o Adults with burns >15% total body surface area
o Parkland formula: total body surface area of burn % x weight (kg) x4 (adults) or x3 (children)
o Half of fluid administered in first 8 hrs - Urinary catheter monitor urine output
- Transfer to burns unit
o Complex burns
o Burns involving hand perineum and face
o Burns >10% in adults and 5% in children
o Laser doppler imaging - Deroof blisters
- Escharotomy
o Divide burnt tissue in circumferential burns affect limb or severe torso burn impeding respiration
o Relieve pressure to prevent compartment syndrome - Excision/debridement and skin grafting for complex burns
o Remove necrotic tissue and aim to create viable tissue bed for healing
o Autologous harvest of healthy skin
o Meshed, fixed in place
Short term complications of burns
o Inhalation injury/poisoning
o SIRS
o Shock
o DIC
o Compartment syndrome
o Multi-organ failure
o Corneal ulceration
Medium term complication of burns
o Burn-associated infection
o Paralytic ileus
o Curling’s ulcer (acute gastric ulcer develop in response to severe physiological stress)
Long term complication of burns
o Contractures
o Marjolin ulcer
o Heterotopic ossification
o PTSD, depression
Causes of airway obstruction
- Coma loss of protective airway reflexes
- Blood or vomit
- Direct trauma
- Haematoma
- Oedema (following burns)
- Choking
Airway maintenance
- Chin lift or jaw thrust manoeuvres
- Airway control by holding mask onto face; inserting laryngeal mask airway; or intubation
- Look in mouth and pharynx for foreign bodies, blood and vomit
- Remove any obstruction with Magill’s forceps or Yankauer sucker
Management of choking
- Severe patient cannot speak or breathe, attempts at coughing are silent
- Mild patient can speak, cough and breathe
- Encourage to cough if mild
- Cycle of 5 black blows (heel of hand between scapulae) and 5 abdominal thrusts (from behind, placing clenched hand under xiphisternum and pulling upwards and inwards
- If lose consciousness, commence ALS protocol and try to retrieve object with foreceps/suction
Risk factors for sepsis
- Extremes of age
- Immunosuppression chemo, splenectomy, steroids, immunosuppressant meds, pregnancy
- Recent trauma, Invasive procedure, Surgery in past 6 weeks
- IVDU
- Indwelling lines, drains or catheters
NICE criteria for sepsis
- 1 red criteria or 2 yellow criteria + symptoms, fever
- Red = objective altered mental state, RR >25 or increased O2 requirement, HR >130, SBP <90 or >40 below normal, urine output <0.5ml/kg/hr or no output for >18h
- Yellow = history of altered behaviour, RR >20, HR >100, SBP <100, urine output <1ml/kg/hr or no output for >12h, deterioration in function, rigors, immunosuppression, recent surgery
SOFA scoring in sepsis
PaO2, platelet count, bilirubin, MAP, GCS, creatinine, urine output
Assessment in sepsis
- A: normally patent but beware reduced conscious level
- B: tachypnoeic and low SpO2
- C: hypotensive, establish IV access, take bloods, 500ml IV saline boluses, escalate to ICU
- D: GCS decreased consciousness level
- Erect CXR
- Other Ix: abdo USS, CT, LP, echo, bronchoscopy,laparoscopy, sputum culture, skin/wound swabs, joint aspirate, ECG
Management of sepsis
(SEPSIS 6) = give 3, take 3/ BUFALO
- Oxygen through non-rebreathe mask
- IV fluid boluses to maintain SBP
- IV broad spec Abx co-amoxiclav or taxocin
- ABG lactate
o Lactate >4 = high risk of death
- Urine output catheterise or commence hourly urine output monitoring
- Blood cultures
Complications of sepsis
- Hypovolaemia/shock SBP <90 or lactate >4 in absence of hypovolaemia
- ARDS increased O2 requirement to maintain sats
- AKI urine output <0.5ml/kg/hr, creatinine >75
- Hyperbilirubinaemia >35
- DIC platelets <100, INR >1.5
- Encephalopathy new confusion/decreased GCS
Management of status epilepticus
- ABCDE
- Insert cannula
- IV lorazepam 4mg (repeat after 10 mins if seizure continues)
- If seizure persists = IV phenobarbital or phenytoin
Causes of shock
- Hypovolaemic shock = low blood vol
- Cardiogenic shock = heart not pumping
- Distributive shock
o Septic
o Anaphylactic
o Neurogenic - Anaemic shock = not enough O2 carrying capacity
- Cytotoxic shock = cells poisoned
Presentation of shock
- Pulse is weak and rapid
- Pulse pressure reduced
- Reduced urine output
- Confusion, weakness, collapse, coma
- Skin is pale, cold, sweaty and vasoconstricted
CRT >3s
Management of shock
ABCDE
Give oxygen
IV access and give IV fluids
Tension pneumothorax
- Laceration to lung parenchyma with flap
- Pressure develops in thorax
- Cause mechanical ventilation in patient with pleural injury
- Sx overlap with cardiac tamponade, hyper-resonant percussion note
Flail chest
- Chest wall disconnects from thoracic cage
- Multiple rib fractures (at least 2 per rib in at least 2 ribs)
- Associated with pulmonary contusion
- Abnormal chest motion
- Avoid over hydration and fluid overload
Haemothorax
- Commonly due to laceration of lung, intercostal vessel or internal mammary artery
- Haemothoraces large enough to appear on CXR are treated with large bore chest drain
- Surgical exploration is warranted if >1500ml blood drained immediately
Pulmonary contusion
- Most common potentially lethal chest injury
- ABG and pulse oximetry important
- Early intubation within hour if significant hypoxia
Blunt cardiac injury
- Usually occurs secondary to chest wall injury
- ECG may show features of myocardial infarction
- Sequelae: hypotension, arrhythmias, cardiac wall motion abnormalities
Diaphragm disruption
- Most due to motor vehicle accidents and blunt trauma causing large radial tears
- More common on left side
- Insert gastric tube which will pass into thoracic cavity
Mediastinal traversing wounds
- Entrance wound in one hemithorax and exit wound/foreign body in opposite hemithorax
- Mediastinal haemtoma or pleural cap suggests great vessel injury
- Mortality 20%
What is anaphylaxis
Life-threatening medical emergency caused by severe type 1 hypersensitivity reaction
Presentation of anaphylaxis
- Allergy symptoms
o Urticaria
o Itching
o Angio-oedema with swelling around lips and eyes
o Abdominal pain - Anaphylaxis symptoms
o Shortness of breath
o Wheeze
o Swelling of larynx causing stridor
o Tachycardia
o Lightheadedness
o Collapse
Management of anaphylaxis
- IM adrenaline (repeat after 5 mins if required)
o <6m give 100-150 micrograms 1 in 1000
o 6m-6y give 150 micrograms 1 in 1000
o 6-12y give 300 micrograms 1 in 1000
o Adult and child >12y give 500 micrograms - Refractory anaphylaxis symptoms persist despite 2 doses of adrenaline
o IV fluids for shock
o Expert help and consider IV adrenaline
Post-event management of anaphylaxis
- Period of assessment and observation for biphasic reactions
- Admit to paediatric unit for observation
- Measure serum mast cell tryptase within 6 hours
- Antihistamines = oral chlorphenamine or certirizine
- Education and follow-up of family and child
- Train parents in BLS
- Specialist referral for diagnosis in allergy clinic, education, follow up and training to use adrenalin auto-injector
Presentation of moderate acute asthma attack
Peak flow >50-75% predicted
Normal speech
No features listed
Presentation of severe asthma attack
Peak flow 33-50%
Sats <92%
Unable to complete sentences in 1 breath
Signs of resp distress
Accessory muscles use
Inability to feed
RR >40 in 1-5yrs or >30 in over 5s or >25 in over 12s
HR >140 in 1-5 yrs or >125 in over 5s or >110 in over 12s
Presentation of life-threatening asthma attack
Peak flow <33% predicted
Sats <92%
Exhaustion and poor resp effort
Hypotension
Silent chest
Cyanosis
Altered consciousness/confusion
Cardiac arrhythmia
Management of acute asthma attack
- Admit all with life-threatening asthma and severe asthma that persists after initial bronchodilator Tx
- Supplementary O2 if required
- Abx if bacterial cause
- Moderate to severe cases in stepwise approach
1. Salbutamol inhalers via spacer device (10 puffs every 2 hrs)
2. Nebulisers with salbutamol/ipratropium bromide
3. Oral prednisolone
4. IV hydrocortisone
5. IV magnesium sulfate
6. IV salbutamol
7. IV aminophylline - Then step down ladder as control is reached
Causes of DKA
- Interruption of insulin therapy
- Stress of intercurrent illness (surgery/infection)
- Patient reduces/omits insulin because unable to eat (nausea/vomiting)
- Undiagnosed diabetes
Presentation of DKA
- Gradual drowsiness
- Nausea and vomiting
- Abdominal pain
- Deep breathing
- Polyuria and polydipsia
- Breath smells of pear drops
- Dehydration and hypotension
- Acidotic
- Coma
Investigations of DKA
- Hyperglycaemia = blood glucose > 11mmol/L
- Raised plasma ketones = >3mmol/L
- ABG/VBG = low pH, K+ low, O2 low, bicarbonate <15mmol/l
- FBC, U&E, LFT, clotting, CRP
- CXR
- ECG
- Urine C+S
Management of DKA
FIGPICK
- Fluid resuscitation (Saline bolus)
- IV Insulin continuous infusion rapid acting 0.1 unit/kg/hr
- Glucose once blood glucose <14mmol/l 10% dextrose infusion added
- Potassium = monitor and correct
- Infection = treat underlying triggers
- Chart fluid balance
- Ketones = monitor blood ketones or bicarbonate
- Anticoagulation
Complications of DKA
- AKI
- Gastric stasis
- Thromboembolism (DVT)
- Acute respiratory distress syndrome
- Cerebral + pulmonary oedema
Causes of hyperosmolar hyperglycaemic state
- Infection = most common precipitating cause (pneumonia)
- Consumption of glucose rich fluids
- Concurrent mediation = thiazide diuretics or steroids
Presentation of hyperosmolar hyperglycaemic state
- Longer history = 1 week
- Decreased level of consciousness = due to elevated plasma osmolality
- Clinical signs of dehydration
- Polyuria and polydipsia
- Lethargy
- N+V
- Focal neurological deficits
- Stupor or coma
Investigations of HHS
- Marked hyperglycaemia (>30mmol/L)
- Urine stick test = heavy glycosuria
- Mild or no ketosis = No ketones in blood or urine
- Bicarbonate not lowered
- Plasma osmolality = extremely high
- Total body K+ is low = Due to osmotic diuresis
o Serum K+ is raised absence of insulin K+ shift out of cells
Management of HHS
- Fluid replacement with IV 0.9% saline slowly
o 0.5-1L per hour
o Aim for +ve fluid balance of 3-6L by 12 hrs
o Encourage food and drink ASAP - Patients more sensitive to insulin = lower rate of infusion
o Only use if glucose not falling or ketonemia - VTE prophylaxis Low molecular weight heparin
- Monitor K+ and give when urine starts to flow
Complications of HHS
- Risk of cerebral and pulmonary oedema
o Rapid lowering of blood glucose and osmolality of blood - Severe dehydration (hyperviscosity) DVT, stroke, MI, arterial insufficiency of lower limbs
- Foot ulcers
Causes of hypoglycaemia
- Insulinoma
- Self-administration of insulin/sulphonylureas
- Liver failure
- Addisons’s
- Alcohol
- Nesidioblastosis
Presentation of hypoglycaemia
- Autonomic symptoms
o Sweating
o Shaking
o Hunger
o Anxiety
o Nausea - Neuroglycopenic symptoms
o Weakness
o Vision changes
o Confusion
o Dizziness - Severe convulsion, coma
Management of hypoglycaemia
- Oral glucose 10-20g in liquid, gel or tablet form
- Quick-acting carbohydrate GlucoGel or Dextrogel
- SC or IM glucagon
- IV 100ml 20% glucose
Risk factors for paracetamol overdose
rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St John’s Wort, anorexia nervosa, malnourished, HIV, P450 inducers
Management of paracetamol overdose
o Activated charcoal within 1 hr
o Acetylcysteine if
conc over line after 4 hrs, or
staggered overdose or
Present 8-24 hrs of ingestion >150mg/kg
Present >24 hrs if jaundiced or hepatic tenderness or ALT above upper limit
o Liver transplant
Arterial pH <7.3, 24 hrs after ingestion
PT >100s and creat >300 and grade III or IV encephalopathy
Features of salicylate overdose
hyperventilation, tinnitus, lethargy, sweating, pyrexia, N+V, hyper/hypoglycaemia, seizures, coma (mixed respiratory alkalosis and metabolic acidosis)
Management of salicylate overdose
o Mx: charcoal, IV sodium bicarbonate,
o Indications for haemodialysis
Serum conc >700
Metabolic acidosis resistant to Tx
Acute renal failure
Pulmonary oedema
Seizures
Coma
Management of opioid overdose
IV naloxone give in smaller increments. May need an infusion. Careful in palliative care setting.
Features of TCA overdose
arrhythmias (wide QRS and prolonged QT), seizures, metabolic acidosis, coma
Management of TCA overdose
IV bicarbonate
Features of lithium overdose
coarse tremor, hyperreflexia, confusion, polyuria, seizure, coma
Management of lithium overdose
o Mild – mod normal saline
o Severe Haemodialysis
Management of BB overdose
atropine (if resistant glucagon)
Management of iron overdose
o <40mg/kg + asymptomatic observed at home
o >40mg/kg or symptomatic measure iron levels 2-4 hrs post ingestion and AXR
o Whole bowel irrigation for all patient within 4 hrs of ingesting >60mg/kg
o Desferrioxamine
Iron level >90
Iron level 60-90 + symptomatic or persistent iron on AXR despite whole bowel irrigation
Shock, coma, metabolic acidosis
Over fluids/fasting before surgery
- Clear fluids until 2 hrs before surgery
o Helps reduce headaches, nausea and vomiting
o E.g. water, fruit juice, coffee/ tea without milk, ice lollies - Fast for 6 hrs before surgery
Complications of diabetes and surgery
o Undetected hypoglycaemia
o Increased risk of wound and resp infections
o Increased risk of post-op AKI
o Increased length of hospital stay
Insulin and surgery
o Good glycaemic control (HbA1c <69) and minor procedure managed by adjustment of usual insulin regimen
o Variable rate IV insulin infusion if long fasting period and poorly controlled diabetes
o Reduce once daily insulin by 20%
o Half morning dose of biphasic or ultra-long acting insulins
Causes of malignant hyperthermia
Anaesthetic agents halothane, suxamethonium, antipsychotics
Management of malignant hyperthermia
Dantrolene
Presentation of postoperative ileus
- Abdo distention/bloating
- Abdo pain
- N+V
- Inability to pass flatus
- Inability to tolerate oral diet
Management of postoperative ileus
- NBM
- NG tube if vomiting
- IV fluids + correct electrolytes
- TPN for severe/prolonged cases
