Emergency medicine Flashcards
What are the causes of shock?
Pump failure: cardiogenic shock; shock secondary to PE, tension pneumothorax or cardiac tamponade
Peripheral circulation failure: hypovolaemia, anaphylaxis, septic shock, neurogenic shock, endocrine failure, iatrogenic
What is the general management of shock?
ABCDE Raise foot of bed unless cardiogenic IV access - wide bore x 2 IV fluids fast unless cardiogenic Identify and treat underlying cause Bloods: FBC, U&E, glucose, CRP, cross match and check clotting, blood cultures, lactate Urine cultures ECG, Echo CXR, abdo CT, USS Consider arterial line, central venous line and bladder catheter
What treatment do you give for anaphylaxis?
Secure airway and give 100% oxygen
Remove cause
IM adrenaline 0.5mg - repeat every 5 minutes until better
Secure IV access
Chlorphenamine 10mg IV and hydrocortisone 200mg IV
IV fluids - titrate against blood pressure
If wheeze, treat for asthma
If still hypotensive, treat on ICU
What are the features of cardiac tamponade?
Beck’s triad: hypotension, raised JVP and muffled heart sounds
CXR - globular heart
ECG - electrical alternans
How would you treat a cardiac tamponade?
Prompt pericardiocentesis. There may be a role for cardiothoracic surgery in some cases as a definitive solution.
Introduce needle at 45 degrees to skin just below and left of the xiphisternum, aiming for tip of the left scapula. Aspirate continuously and watch ECG.
What is the definition of status epilepticus?
Seizures lasting for >30 min or repeated seizures without intervening consciousness.
Aim to terminate seizures lasting more than a few minutes as soon as possible.
What is non-convulsive status epilepticus?
Absence status or continuous partial seizures with preservation of consciousness may be difficult to distinguish. Look for subtle eye or lid movement.
EEG –> rhythmic discharge
How do you manage status epilepticus?
Open and maintain airway - put into recovery position
100% oxygen and suction
IV access and bloods - FBC, U&E, LFT, glucose (BM and lab), calcium, ABG, toxicology screen if indicated. Consider anticonvulsant levels, LP and blood culture
Give thiamine 250mg IV if alcoholic/malnourished
Glucose 50ml 50% IV unless glucose known to be normal
Correct hypotension with fluids. Monitor ECG and BP
Lorazepam 2-4mg. Repeat if no response after 2 mins.
Phenytoin infusion
Diazepam infusion
General anaesthetic and ICU
How do you manage someone with raised ICP?
ABC
Correct hypotension and treat seizures
Brief hx and examination
Elevate head of bed to 30-40 degrees
If intubated, hyperventilate –> cerebral vasoconstriction
Osmotic diuretics e.g. mannitol can be considered
Dexamethasone for oedema around tumours
Fluid restriction.
Monitor ICP
Definitive treatment: neurosurgery for focal causes e.g. haematomas.
What investigations can you do for a suspected subarachnoid haemorrhage?
CT - detects >905 of SAH within first 48 hours
LP - if CT negative and no contraindication, perform >12 hours after headache onset. CSF in SAH is uniformly bloody early on and become xanthochromic after a few hours due to breakdown of Hb.
What is the management of SAH?
Refer all proven SAH to neurosurgery immediately.
Re-examine often and repeat CT if deteriorating
Maintain cerebral perfusion to keep well hydrated and systolic BP>160mmHg
Nimodipine - calcium antagonist that reduces vasospasm
Endovascular coiling is preferable to clipping
How do you manage DKA?
ABC
Restore circulating volume with normal saline - fluid challenge. If two boluses do not bring BP>90mmHg, seek senior medical advice
When systolic BP>90mmHg, give 1L normal saline over the next hour. Additional potassium is likely to be needed.
Start an IV insulin infusion at fixed rate 0.1 units/kg/hour. Established SC therapy should be continued.
Continue fluid replacement. once blood glucose 7.3 and patient is able to eat and drink.
How do you manage HHS?
ABC
Rehydrate with 9L of 0.9% saline over 48 hours (half the rate used in DKA). Replace potassium when urine starts to flow.
Wait for 1hr before using insulin (it may not be needed)
Fully heparinise as occlusive events are a danger
Look for a cause
How do you manage hypoglycaemia?
If patient is conscious: glucose 10-20g given by mouth, either in liquid form (glucogel), lucozade or jelly babies (5)
If unable to take things orally:
200-300ml of 10% dextrose IV
Glucagon IM 1mg (will not work on drunk patients)
Once able, give sugary drinks and a meal.
How do you manage hypothermia?
ABC
Warm IV fluids
Cardiac monitor (VF or AF can arise without warning)
Consider antibiotics to prevent pneumonia
Consider urinary catheter to monitor renal function
Slowly rewarm - reheating too quickly causes peripheral vasodilation, shock and death. Aim for a rise of 0.5 degrees/hour. The first sign of too rapid warming is falling BP
Check rectal temperature, BP, pulse and RR every half hour.
How do you treat a paracetamol overdose?
Gastric lavage if >12g or >150mg/kg taken within 1 hour. activated charcoal if within 1 hour of ingestion.
Bloods - glucose, U&E, LFT, clotting, FBC, bicarbonate, ABG, blood paracetamol levels at 4 hours post ingestion and toxicology (do not assume that this is a single overdose)
Check revised paracetamol overdose treatment graph. If treatment needed, start N-acetylcysteine.
If staggered overdose, get expert help.
What are the signs and symptoms of a paracetamol overdose?
None initially, or vomiting and RUQ pain.
Later: jaundice and encephalopathy from liver or renal damage.
What are the signs and symptoms of an aspirin overdose?
Vomiting, dehydration, hyperventilation, tinnitus, vertigo, sweating
Rarely: lethargy, coma, seizures, hypotension and heart block, pulmonary oedema
How does an aspirin overdose cause an acid base disturbance?
Salicylates stimulate the respiratory centre and cause a respiratory alkalosis. Compensatory mechanisms including excretion of bicarbonate and potassium result in metabolic acidosis. Salicylates also interfere with carbhoydrate, fat and protein metabolism and disrupt oxidative phosphorylation, producing increased concentrations of lactate, pyruvate and ketones.
This causes a mixed acid-base disturbance.
How do you treat a salicylate overdose?
Correct dehydration. Gastric lavage and activated charcoal with within 1 hour.
Monitor urine output and blood glucose
Correct any metabolic acidosis with bicarbonate.
If plasma salicylate level >500mg/h, consider alkalinisation of the urine e.g. 1.5L 1.26% bicarbohnate with 40mmol KCl over 3 hours (nb monitor serum K)
Dialysis may be needed if salicylate level >700mg/L or if renal or heart failure, seizures, severe acidsis or persistently raised plasma salicylate.
What are the symptoms of carbon monoxide poisoning?
Headache Vomiting Tachycardia Tachypnoea Cherry red lips If COHb >50%, fits, coma and cardiac arrest may occur.
How do you treat carbon monoxide poisoning?
Remove source
Give 100% oxygen
Metabolic acidosis usually responds to correction of hypoxia.
If severe, anticipate cerebral oedema and give mannitol.
How do you treat a TCA overdose?
Supportive: give oxygen, control of convulsions and correct acidosis. A small number of overdoses will require ventilation.
Onset of SVT and VT should be treated with sodium bicarbonate, even if no acidosis present. If VT is compromising cardiac output, amiodarone should be given.
What are the signs and symptoms of TCA toxicity?
Mild:
- Antimuscarinic: sinus tachycardia, dry mouth, dilated pupils, urinary retention
- increased reflexes
- extensor plantar responses
- drowsiness
Severe:
- coma
- divergent strabismus
- convulsions
- plantar, oculocephalic and oculovestibular reflexes may be abolished completely
- metabolic acidosis
- cardiorespiratory depression
