Emergency medicine Flashcards
Airway signs of anaphylaxis
Swelling of the throat -> stridor and hoarse voice
Breathing signs of anaphylaxis
Respiratory wheeze, dyspnoea
Circulation signs of anaphylaxis
Tachycardia, hypotension
Adrenaline for anaphylaxis under 6 months
100-150 micrograms (0.1-0.15ml 1 in 1000)
Adrenaline for anaphylaxis 6 months to 6 years
150 micrograms (0.15ml 1 in 1000)
Adrenaline for anaphylaxis 6-12 years
300 micrograms (0.3 ml 1 in 1000)
Adrenaline for anaphylaxis over age 12
500 micrograms (0.5ml 1 in 1000)
After how many minutes can you repeat adrenaline in anaphylaxis?
5 minutes
Site IM adrenaline injection
Anterolateral aspect of middle third of the thigh
What is refractory anaphylaxis?
Respiratory or cardiovascular problems despite two doses of IM adrenaline
Management of refractory anaphylaxis
- IV fluids for shock
- consideration of IV adrenaline infusion
Management of anaphylaxis after stabilisation
- non sedating anti-histamines if continuing skin rash/urticaria
- serum tryptase to see if anaphylaxis
- if new episode of anaphylaxis refer to specialist allergy clinic
- prescribe and show patient how to use 2 adrenaline auto injectors
- WHO risk stratified approach to discharge
Who can be discharged after 2 hours from anaphylaxis?
- good response to a single dose of adrenaline
- complete resolution of symptoms
- given adrenaline auto-injector and trained how to use it
- adequate supervision following dishcarge
Discharge 6 hours after anaphylaxis
- 2 doses of IM adrenaline required
- or previous biphasic reaction
Discharge minimum of 12 hours from anaphylaxis
- severe reaction requiring >2 doses of IM adrenaline
- possibility of ongoing reaction e.g. modified slow release
- severe asthma
- difficult access to emergency care
- late at night
Rate of compressions to ventilation in an adult
30:2
What are the shockable rhythms?
- pulseless VT
- ventricular fibrillation
What are the non shockable rhythms
- asystole
- PEA
Shocks in a witnessed cardiac arrest of a monitored patient
stacked shocks: 3 successive quick shocks
Drugs in cardiac arrest for a non shockable rhythm
- give adrenaline 1mg as soon as possible
- repeat every 3-5 minutes
Drugs in cardiac arrest for a shockable rhythm
- give adrenaline 1mg after third shock
- give amiodarone 300mg after 3 shocks then 150mg after 5 shocks
When should thrombolytic drugs be given in the context of cardiac arrest
if pulmonary embolus is suspected
If thrombolytic drugs are given in cardiac arrest, how long should cpr be continued for?
60-90 minutes
Reversible causes of cardiac arrest
4H’s:
- hypoxia
- hyperkalaemia
- hypothermia
- hypovolaemia
4T’s:
- toxins
- thrombus
- tamponade
- tension pneumothorax
Definition of sepsis
life-threatening organ dysfunction caused by a dysregulated host response to infection
qSOFA score
- resp rate >22
- Altered mentation
- systolic BP <100mmHg
Heightened risk of mortality if score 2 or higher
Sepsis 6
- IV antibiotics
- oxygen
- IV fluids (fluid challenge)
- serum lactate
- blood cultures
- urine output
6 types of shock
- haemorrhagic
- septic
- cardiogenic
- neurogenic
- anaphylactic
- hypovolaemic
What is neurogenic shock?
Tends to occur in patients who have a transected spinal cord interrupting the autonomic nervous system resulting in decreased sympathetic tone or increased parasympathetic tone
What is status epilepticus?
- single seizure lasting over 5 minutes
- 2 seizures within 5 minutes, without the person returning to normal in between them
Management of status epilepticus
- ABC: airway adjunct, oxygen, check blood glucose
- PR diazapam or buccal midazolam if not in hospital
- IV lorazepam if in hospital, can be repeated after 5-10 minutes
- If ongoing give levetiricetam
- if no resolution after 45 minutes then consider general anaesthesia or phenobarbital
Pre renal causes of AKI
- hypovolaemia
- renal artery stenosis
Renal causes of AKI
- glomerulonephritis
- Acute tubular necrosis
- acute interstitial necrosis
- rhabdomyolysis
- tumour lysis syndrome
Post renal causes of AKI
- kidney stone in ureter or bladder
- BPH
- external compression of the ureter
Nephrotoxic drugs
- NAIDs
- aminoglycosides
- ACEi
- ARB
- diuretics
Definition of AKI
- <0.5ml per kg per hour urine output
- rise in creatinine of 26mmol in the past 48 hours
- 50% or greater rise in serum creatinine over the past 7 days
Which drugs may have to be stopped in AKI because of risk of toxicity
- metformin
- lithium
- digoxin
Signs of lower GI bleed
- bright red blood or dark red per rectum
Causes of lower GI bleed
- colitis
- divertiucular disease
- haemorrhoids
- cancer
- angiodysplasia
Management of lower GI bleed
- history, abdo exam, PR, proctoscopy
- consider admisson if over 60, hameodynamic instability, aspirin/NSAID, significant co-morbidity
- outpatient colonoscopy if stable
- if unstable then angiogram
Features of upper GI bleed
- haematemesis (coffee ground)
- melena
- raised urea
oesophageal causes of upper GI bleed
- oesophagitis
- oesophageal cancer
- mallory-weiss tear
- oesophageal varices
Gastric causes of upper GI bleed
- gastric ulcer
- gastric cancer
Duodenal causes of upper GI bleed?
- duodenal ulcer
- aorto-enteric fistula
When do you use the glasgow blatchford score vs rockall score
Rockall score is used after endoscopy
What is the glasgow score used to calculate?
If the patient can be treated as an outpatient
What is the rockall score used to calculate?
Percentage risk of rebleeding and mortality
Management of variceal bleed
- terlipressin and antibiotics at presentation (before endoscopy)
- band ligation for oesophageal varices
- N-butyl- 2-cyanoacrylate for gastric varices
- transjugular intrahepatic portosystemic shunts if bleeding not controlled after above measures
immediate first aid for burns
- ABCDE
- Heat: remove the person from the source, within 20 minutes irrigate with cool water for 10-30 minutes, cover with clingfilm (layered not wrapped)
- electric: switch off power supply, remove person
- chemical: brush off any powder, irrigate with water
3 ways to assess extent of burn
- Wallace rule of 9s : Head and neck=9%, each arm=9%, each anterior part of leg=9%, each posterior part of leg = 9%, anterior chest=9, posterior chest=9, anterior abdomen=9, posterior abdomen=9
- Lund and browder chart
- palmar surface is roughly 1%
categories of depths of burn
- superficial epidermal
- partial thickness (superficial dermal)
- partial thickness (deep dermal)
- full thickness
Superficial epidermal burn
- red and painful
- dry
- no blister
Partial thickness superficial dermal
- pale pink
- painful
- blistered
- slow capillary refill
Partial thickness deep dermal
- typically white
- patches of non blanching erythema
- reduced sensation
- painful to deep pressure
Full thickness burn
- white (waxy), brown/black
- no blisters
- no pain
Who should be referred to secondary care for a burn
- any deep dermal or full thickness burn
- superficial dermal affecting over 3% adult or 2% child
- superficial dermal burn affecting the face, perineum, hands, feet, genitalia, any flexure, or circumferential burns on limb or torso or neck
- inhalation injury
- chemical or electrical burn
- suspected non accidental injury
management of superficial dermal burn
- clean wound
- leave the blister intact
- non-adherent dressing
- avoid topical creams
- review in 24 hours
For burns, who requires IV fluids?
- Adults with greater than 15% BS
- children with greater than 10%
Management of more severe burns
- IV fluids
- urinary catheter
- if circumferential may need escharotomy
- early intubation should be considered if deep burns to face or neck, or blisters, or oedema of oropharynx
Which head injury patients should get a head CT within an hour?
- GCS<13
- GCS<15 after 2 hours post injury
- suspected open or depressed skull fracture
- post injury seizure
- 2 or more episodes of vomiting
- focal neurological deficit
- any sign of basal skull fracture
What are the signs of a basal skull fracture?
- panda eyes
- battle sign
Which head injury patients should receive a head CT within 8 hours
For adults who have experienced some kind of loss of consciousness or amnesia since the injury
- anyone aged 65 or older
- on anticoagulants or history of a bleeding disorder
- dangerous mechanism of injury
- more than 30 minutes of retrograde amnesia of events preceding the injury
Presentation of extra dural haematoma
- lucid interval
- raised ICP
What type of injury classically causes extra dural haematoma
- acceleration deceleration injury
- blow to the side of the head
Which artery is most commonly associated with an extra dural head injury?
Middle meningeal
Risk factors for subdural haemorrhage
- older age
- alcoholism
Shape extra dural haematoma
lemon
Shape subdural haematoma
Crescent
What type of head bleed sudden collapse and loss of consciousness?
Sub arachnoid haemorrhage
Which scans are most sensitive to diffuse axonal injury?
MRI
Sub dural haematoma vessels
Bridging veins
Management of mass effect in head injury
IV mannitol
Signs of opiate overdose
- pin point pupils
- respiratory depression
- drowsy
- hypotensive
Signs of anti-cholinergic overdose
- blind as a bat, pupils dilated
- mad as a hatter, confused and agitated
- dry as a bone, dry mouth and urinary retention
- red as a beet
- hot as hell
- tachycardia
Management of amitriptyline overdose causing broad complex tachycardia or hypotension
NaHCO3 8.4%
Benzodiazepine overdose
- decreased heart rate
- decreased resp rate
- decreased bowel sounds
- decreased temp
When should you start NAC immediately?
- staggered overdose
- if presenting 8-24 hours after single ingestion and over 150mg/kg
- if presenting over 24 hours since ingestion and showing signs of jaundice or hepatic tenderness
In the context of paracetamol overdose, when should you check the paracetamol levels?
4 hours after ingestion
Adverse NAC reaction
- nausea/vomiting
- flushing/pruritis
- hypotension/bronchospasm
- angioedema
Management of adverse NAC reaction
- stop NAC
- antihistamine
- bronchodilators
- adrenaline
- once treated can re-start NAC
How do you calculate anion gap?
(Na+K) - (HCO3 + CL)
Causes of high anion gap
- Methanol
- Uraemia
- DKA
- Paraldehyde
- Iron, Isoniazid
- Lactic acidosis
- Ethanol
- Salicylate
- Carbon monoxide
- Aminoglycosides
- Theophylline
Signs of cholinergic overdose
- constricted pupils
- increased bowel sounds
- increased secretions
Blood gas salicylate
- respiratory alkalosis due to stimulation of the respiratory centre
- then acidosis
paracetamol overdose ingested less than an hour ago
activated charcoal
Management of benzo overdose
Can use flumazenil but this can cause seizures which you then wouldnt be bale to treat with benzos so mainly just supportive management
Lithium overdose management
- IV saline
- haemodialysis in severe toxicity
heparin reversal agent
protamine sulphate
management of beta blocker overdose
- if bradycardic then atropine
- in resistant cases can try glucagon
Iron poisoning
desferrioxamine
Lead poisoning
Dimercaprol, calcium edetate
Criteria for liver transplant following paracetamol overdose
- arterial pH less than 7.3 24 hours after ingestion
OR ALL of the following:
- PT>100 seconds
- creatinine >300
- grade III or IV encephalopathy
