Emergency Medicine Flashcards
causes of shock?
CHOD
Cardiogenic:
MI, arrhythmia
hypovolaemic:
haemorrhage- internal/ external
endocrine- addisionian crisis, DKA
excess loss- burns, diarrhoea, vomiting
third-spacing- pancreatitis
obstructive:
PE, tension pneumothorax, cardiac tamponade
distributive:
sepsis, anaphylaxis, neurogenic
mx of shocked patient?
if ECG unrecordable, mx as a cardiac arrest
->
ABCDE approach
->
raise foot of bed (unless cardiogenic)
->
IV access: 2 wide bore cannula in each Antecubital fossa
->
fast infusion of crystalloid to raise BP (unless cardiogenic)
initial monitoring of a shocked patient?
catheter to measure urine output
(>30ml/hr)
arterial line- monitor blood pressure directly and in real-time
central venous pressure line-
blood pressure in the venae cavae, near the right atrium of the heart. CVP reflects the amount of blood returning to the heart and the ability of the heart to pump the blood back into the arterial system.
what is anaphylactic shock?
type 1 IgE mediated hypersensitivity reaction
TH2 driven IgE production following primary allergen exposure
re exposure -> biphasic inflammatory response
early phase: mast cell degranulation -> histamine release
late phase: amplify and sustain the initial response
presentation of anaphylactic shock?
skin: urticaria, itching, oedema
breathing: wheeze, laryngeal obstruction, cyanosis
GI: D+V, abdo pain
sweating
CVS: tachycardia, hypotension
mx of anaphylactic shock
secure airway: give 100% O2
- consider intubation if respiratory obstruction
elevate the feet
IM adrenaline 0.5ml of 1:1000 (0.5mg)
- repeat every 5 min if needed
Secure IV access: IV 0.9% saline (500ml over 15 min)
IV 10mg chlorphenamine
IV 200mg hydrocortisone
Salbutamol nebs if wheeze
- 5mg salbutamol + 0.5mg ipratropium
discharge advice for anaphylaxis patient
teach adrenaline self-injection and ensure pt has at least 2 epipens
advise wearing medic alert bracelet
advice re recognition and avoidance
arrange outpatient followup: skin prick tests, RAST to identify antigens
what is the definition of a supraventricular tachycardia?
rate > 100 beats/min
QRS width < 120 ms
start from atria/ AV node
types of SVT
Sinus tachycardia
Atrial:
AF, Atrial flutter, atrial tachycardia
AV nodal re-entry tachycardia (AVNRT)
AV re-entry tachycardia (AVRT): e.g. Wolff-Parkinson-White
What is AVRT?
Atrioventricular re-entrant tachycardia
a type of SVT
e.g. WPW
electrical signal passes in the normal manner from the AV node into the ventricles
the electrical impulse pathologically passes back into the atria via the accessory pathway (e.g. bundle of Kent), causing atrial contraction, and returns to the AV node to complete the reentrant circuit
-> may cause heart to beat faster
SVT Mx
if patient is compromised?
sedate + DC cardioversion
otherwise ID rhythm and treat accordingly
pt compromised
ie. MI, syncope, hypotension (shock), heart failure
SVT Mx?
ID rhythm ?
irregular -> treat as AF
regular?
SVT = Start with Vagal Treatment
(e.g. carotid sinus massage, valsalva)
if unsuccessful,
ABCD
adenosine while recording continuous rhythm strip
-> 6mg IV bolus, then 12mg, 12mg
then
choose from:
Beta Blockers: e.g. atenolol
CCB e.g. Verapamil
Digoxin
Amiodarone
SVT mx if all medical treatment fails?
DC cardioversion
SVT mx if adverse signs develop
ie. BP <90, heart failure, decreased consciousness, HR> 200?
Sedation
Synchronised Cardioversion
then
Amiodarone: 300 mg over 20-60 min
then 900mg over next 23 h
what are vagal manoeuvres meant to do in SVT mx?
decreases HR by stimulating vagus nerve
transiently increases AV block and may unmask underlying atrial rhythm
Giving adenosine in SVT mx?
what would it do
transient AV block -> unmasking atrial rhythm
cardioverts AVRT/AVNRT to sinus rhythm
Mode of action of adenosine?
temporary AV node block
Side effects of adenosine?
transient chest tightness, dyspnoea, flushing, headache
relative contraindications of adenosine?
asthma,
2nd/3rd degree heart block
in what type of SVT will you avoid the usual treatment pathway?
ie. Adenosine, CCB, BB
WPW
hx of WPW or AF/flutter with WPW
-> may lead to VF
Use amiodarone or flecainide
mx of AF?
onset <48h consider cardioversion w amiodarone or DC shock
Rate control: BB e.g. metoprolol or digoxin
Anticoagulation with heparin/ warfarin
prophylaxis of SVTs?
BB
AVRT: Flecainide
AVNRT: verapamil
Definition of broad complex tachycardias?
rate > 100bpm
QRS width >120 ms
types of broad complex tachycardias?
VT
Torsades de pointes
SVT w BBB
Causes of VT?
IM QVICK
Infarction (esp w ventricular aneurysm)
Myocarditis
QT interval prolonged
Valve abnormality: mitral prolapse, AS
Iatrogenic: digoxin, antiarrhythmics
Cardiomyopathy esp dilated
K low, low Mg, low O2, acidosis
Mx of broad complex tachycardia if pt is compromised?
ie. BP <90
Heart failure
chest pain (MI)
decreased consciousness / syncope
HR >150
Sedation
->
Synchronised cardioversion
(200->300->360)
->
Amiodarone:
300mg over 20-60 min
900 mg over next 23h
Mx of stable VT?
after O2 + IV access
Correct electrolyte problems:
ie. Low K+: max 60 mM KCl @ 20mmol/h
Low Mg2+: 4ml 50% MgSo4 in 30 min
mx of stable VT
if no electrolyte problems?
assess rhythm
regular ie. VT:
amiodarone
or lignocaine 50mg over 2min
irregular:
usually AF w BBB: flecainide/ amiodarone
or Torsades de pointes: MgSO4 2g IV over 10 min
mx of stable VT if medical treatment failed?
synchronised cardioversion
mx of Torsades de pointes?
MgSO4 2g IV over 10 min
Mx of recurrent/ paroxysmal VT?
Medical:
Amiodarone
BB
Implantable cardiac defibrillator
Acute Mx of STEMI?
12 lead ECG
O2 2-4L: aim for SpO2 94-98%
IV access: bloods for troponin, FBC, U+E, glucose, lipids
brief assessment: hx of CVD/ RFs, thrombolysis CIs, ABCDE
anti-platelets:
aspirin 300mg PO (then 75mg/d) + clopidogrel 300mg PO (then 75mg/d)
analgesia: morphine 5-10mg IV, metoclopramide 10mg IV
anti-ischaemia: GTN 2 puffs or 1 tablet sublingual, BB atenolol 5mg IV (CI asthma, LVF)
DVT prophylaxis: enoxaparin 40mg SC OD
admit to CCU for monitoring: arrhythmias, continue meds except CCBs
-> consider primary PCI / thrombolysis
when is Percutaneous coronary intervention inndicated in STEMI?
usually tx of choice if <12h
angioplasty and stenting
complications of primary PCI for STEMI?
bleeding
emboli
arrhythmia
if high risk patient
e.g. delayed PCI, Diabetes mellitus, complex procedure,
what medication is given alongside primary PCI for STEMI
GpIIb/IIIa antagonist
eg. tirofiban
DVT prophylaxis in STEMI mx
if pt is not receiving any reperfusion therapy?
if pt is receiving PCI?
not receiving any form of reperfusion therapy:
fondaparinux
otherwise:
enoxaparin
ECG criteria for thrombolysis?
ST elevation > 1mm in 2+ limbs or >2mm in 2+ chest leads
new LBBB
posterior: deep ST depression and tall R waves in V1- V3
when is thrombolysis for STEMI contraindicated?
beyond 24h of onset
AGAINST
aortic dissection
gi bleeding
allergic reaction previously
iatrogenic: major surgery <14d prior
neuro: cerebral neoplasm/ CVA hx
severe HTN (200/120)
trauma inc CPR
what are the agents used in thrombolysis in STEMI?
1st line:
streptokinase
alteplase
tenecteplase
complications of thrombolysis
bleeding
stroke
arrhythmia
allergic reaction
continuing therapy (long term) for STEMI?
lifestyle advice
Stop smoking
Diet: oily fish, fruit, veg, ↓ sat fats
Exercise: 30min OD
Work: return in 2mo
Sex: avoid for 1mo
Driving :avoid for 1mo
continuing therapy (long term) for STEMI?
medications
address risk factors
ACEi: start within 24h of MI (e.g. lisinopril 2.5mg)
BB: e.g. bisoprolol 1.25 mg OD (or CCB)
Cardiac rehabilitation: group exercise and info/ heart manual
DVT prophylaxis until fully mobile
(cont for 3 mo if large anterior MI)
Statin: regardless of basal lipids e.g. atorvastatin 80mg
Continue clopidogrel for 1mo following STEMI
Continue aspirin indefinitely.
NSTEMI mx?
exactly same as STEMI
assess CV risk
if low risk: no further pain, flat or inverted T waves or normal ECG, -ve troponins
may discharge + outpatient tests: angio, perfusion scan, stress echo
intermediate to high risk: persistent/ recurrent ischaemia, ST depression, + trops
GpIIb/IIIa antagonist - tirofiban
Angiography with PCI within 96 h
clopidogrel 75mg/d for one year + aspirin indefinitely
causes of severe pulmonary oedema?
cardiogenic:
MI, arrhythmia, fluid overload: renal/ iatrogenic
non-cardiogenic:
ARDS: sepsis, post op, trauma
upper airway obstruction
neurogenic- head injury
symptoms of severe pulmonary oedema
SOB
orthopnoea
pink frothy sputum
signs of severe pulmonary oedema
Distressed, pale, sweaty, cyanosed
↑HR, ↑RR
↑JVP
S3 / gallop rhythm
Bibasal creps
Pleural effusions
Wheeze (cardiac asthma)
monitoring of severe pulmonary oedema?
BP
HR, RR
JVP
urine output
ABG
Mx of severe pulmonary oedema
Sit pt up
give O2 15L via non-rebreather mask for SpO2 to be 94-98%
IV access + monitor ECG
- take bloods for FBC, U+E, troponin, BNP, ABG
- tx any arrhythmias
IV furosemide 40-80mg (if pt on oral diuretics, use double dose)
IV GTN 0.5mg / hr (only if systolic BP >90)
Consider slow IV diamorphine 2.5-5mg + metoclopramide (for severe chest pain/ distress)
if SBP <100: tx as cardiogenic shock
(ie. consider inotropes)
indications for diamorphine in acute pulmonary oedema?
analgesia and sedation may be appropriate where the patient is in pain or distressed - eg, diamorphine 2.5-5 mg intravenously slowly
+ pulmonary venodilators -> decreases preload -> reduces SOB
opiates should not be given to patients with acute decompensated heart failure, or if drowsy, exhausted or hypotensive.
not used routinely
mx of acute pulmonary oedema if poor response to nitrates and furosemide?
Consider continuous positive airway pressure CPAP or NIV
if acidotic or poor response
! must discuss w senior
consider:
Referral to senior medical staff and intensive care for consideration of IV inotropes or invasive ventilation.
what is CPAP?
CPAP increases intrathoracic pressure, which reduces preload by decreasing venous return.
CPAP lowers afterload by increasing the pressure gradient between the left ventricle and the extrathoracic arteries, which may contribute to the associated increase in stroke volume.
Ix of severe acute pulmonary oedema?
ABG: to assess type and severity of resp failure + associated biochemical changes
CXR: ABCDE
ECG: MI, arrhythmias, pulsus alternans
consider echo
what CXR findings are assoc w Heart failure?
ABCDE
Alveolar oedema (bat’s wings)
kerley B lines (interstitial oedema)
Cardiomegaly
Dilated prominent upper lobe vessels
Effusion (pleural)
long-term mx of stable pt with pulmonary oedema?
daily weights
DVT prophylaxis
repeat CXR
change to oral furosemide/ bumetanide
ACEi + BB if heart failure
consider spironolactone
consider digoxin +/- warfarin (esp in AF)
definition of cardiogenic shock?
inadequate tissue perfusion (and oxygenation) to suit body’s metabolic needs primarily due to cardiac dysfunction
causes of cardiogenic shock?
MI
HyperK (+ other electrolytes)
Endocarditis
Aortic dissection
Rhythm disturbance
Tamponade
Obstructive: tension pneumothorax, massive PE
presentation of cardiogenic shock
unwell: cyanosed, pale, distressed
cold clammy peripheries
high RR, HR
pulmonary oedema
signs of cardiac tamponade?
Beck’s triad: low BP, raised JVP, muffled heart sounds
pulsus paradoxus: (pulse fades on inspiration)
Mx of cardiac tamponade?
pericardiocentesis
(preferably under US guidance)
what is Kussmaul’s sign?
assoc with constrictive pericarditis
raised JVP on inspiration
what is Beck’s triad?
assoc w Cardiac tamponade
low BP, raised JVP, muffled heart sounds
Ix of Cardiac tamponade?
echo: diagnostic
CXR: globular heart
mx of cardiogenic shock?
ABCDE approach
O2
monitor ECG
diamorphine + metoclopramide for pain/ anxiety
correct any arrhythmias, electrolyte disturbances, acid-base abnormalities
Ix: CXR, Echo, CT depending on cause
consider need for dobutamine (sympathomimetic)
tx underlying cause
what mx B1 receptor stimulant is used for HF and cardiogenic shock?
dobutamine
what is kernig’s sign?
flex both legs at hip to 90
-> pt will be unable to fully straighten one leg down
lumbar spine tenderness
what is Brudzinski’s sign?
neck flexion would cause flexion of legs at hip
discomfort at c spine
mx of meningitis in the community before transfer to hospital?
benzylpenicillin 1.2g IV/IM
tx of meningitis?
<50 yo: ceftriaxone 2g IVI/IM BD
>50 yo: ceftriaxone + ampicillin (to cover listeria)
if viral suspected: add aciclovir
ix of suspected meningitis pt?
Bloods: FBC, U+E, clotting, glucose, ABG
blood cultures
LP: MCS, glucose, virology/ PCR, lactate
contraindications to LP?
raised ICP
cardio/ resp instability
thrombocytopenia
coagulation disorder (DIC)
infection at LP site
focal neuro signs
acute mx of meningitis pt?
A to E approach
O2 15L - SpO2 94-98%
IVI fluid resus
if mainly meningitic: do LP if no CIs, dexamethasone + ceftriaxone
mainly septicaemic: ceftriaxone
+ maintenance fluids
what prophylaxis is available for household contacts of meningitic patients?
Rifampicin
mx of encephalitis?
aciclovir stat
supportive measures in HDU/ITU
phenytoin for seizures
risk factors for cerebral abscess?
infection: ear, sinus, dental
skull #
congenital heart disease
endocarditis
bronchiectasis
immunosuppression
ix of cerebral abscess?
CT/ MRI head- ring enhancing lesion
Bloods: high WCC, high ESR/CRP
tx of cerebral abscess?
neurosurgical referral
abx- e.g. ceftriaxone
treat the raised ICP
definition of status epilepticus?
seizure lasting > 5 min
or
repeated seizures w/o recovery of consciousness in between
ix in status epilepticus?
Blood glucose levels
Bloods: infection markers (WCC, CRP), U+E, Ca/Mg, FBC
ECG, EEG
Consider AED levels, tox screen, LP, CT head, BHCG
1st line mx of status epilepticus?
Lorazepam IV 2-4mg bolus over 30s
2nd dose if no response within 2 min
alternatives:
buccal midazolam 10mg
rectal diazepam 10mg
mx of status epilepticus after 1st line tx (e.g. lorazepam) has failed?
phenytoin 18mg/kg IVI @ 50mg/ min
monitor ECG and BP
CI: bradycardia or heart block
alternative: diazepam infusion
what medication will be considered if cerebral oedema may be the cause of status epilepticus?
dexamethasone
Important things to remember in status epilepticus?
Get anaesthetist early - may need to intubate
treat early with 100ml 20% glucose unless glucose known to be normal
GCS eyes criteria?
4 – Spontaneous eye opening
3 – Open to voice
2 – Open to pain
1 – No opening
GCS verbal criteria?
5 – Orientated conversation
4 – Confused conversation
3 – Inappropriate speech
2 – Incomprehensible sounds
1 – No speech
GCS motor criteria?
6 – Obeys commands
5 – Localises pain
4 – Withdraws to pain
3 – Decorticate posturing to pain (flexor)
2 – Decerebrate posturing to pain (extensor)
1 – No movement
initial primary survey of head injury pt?
A: ? intubation, immobilise C-spine
B: 100%O2, RR
C: IV access, BP, HR
D: GCS, pupils
Treat seizures
E: expose pt and look for other obvious injuries
secondary survey of head injury patient?
Look for:
Lacerations
Obvious facial/skull deformity
CSF leak from nose or ears
Battle’s sign, Racoon eyes
Blood behind TM
C-spine tenderness ± deformity
Head-to-toe examination for other injuries
ix of head injury patient?
CT head + c spine
Bloods: FBC, U+E, glucose, clotting, ABG, EtOH level
mx of head injury patient?
Neurosurgical opinion if signs of ↑ICP, CT evidence of intracranial bleed significant skull #
Admit if:
Abnormalities on imaging
Difficult to assess: EtOH, post-ictal
Not returned to GCS 15 after imaging
CNS signs: vomiting, severe headache
Neuro-obs half-hrly until GCS 15:
GCS, pupils, HR, BP, RR, SpO2, temp
discharge advice for someone who had received a head injury?
Stay with someone for first 48hrs
Give advice card advising return on:
Confusion, drowsiness, unconsciousness
Visual problems
Weakness
Deafness
V. painful headache that won’t go away
Vomiting
Fits
when to intubate after head injury?
GCS ≤ 8
Respiratory irregularity
Spontaneous hyperventilation: PCO2 <4KPa
PaO2 <9KPa on air / <13KPa on O2 or PCO2 >6KPa
cerebral oedema may cause which false localising sign?
6th CN palsy
what is Cushing’s reflex?
raised BP
bradycardia
irregular breathing
Acute Mx of cerebral oedema?
A-> E approach
treat seizures and correct hypotension
elevate bed to 40 degrees
neuroprotective ventilation: PaO2: > 13kPa, PCO2: 4.5 kPa, good sedation
Mannitol or hypertonic saline -> can decrease ICP in the short term but may cause rebound raised ICP later
ix of acute severe asthma
PEFR
ABG: Co2 should be low, if normal or rising: send to ITU for ventilation
FBC, U+E, CRP, blood cultures
what is severe asthma?
presentation
PEFR <50%
RR>25
HR>110
cant complete sentence in one breath
what is life threatening asthma?
PEFR< 33%
SpO2 <92%
PCO2> 4.6 kPa
cyanosis
exhaustion
silent chest, poor respiratory effort
mx of acute severe asthma?
- sit up
- 100% O2 via non-rebreathe mask (aim for 94-98%)
- Nebulised salbutamol (5mg) and ipratropium bromide(0.5mg)
- Hydrocortisone 100mg IV or pred 50mg PO (or both)
- Write “no sedation” on drug chart
mx of life threatening asthma attack
same as severe: O2, nebs, steroids
Inform ITU
MgSO4 2g IVI over 20 min
back to back nebulised salbutamol with cardiac monitoring
Salbutamol 2g IVI
Consider Aminophylline
monitoring of patient experiencing severe acute asthma?
PEFR every 15-30 min
pre and post B agonist
SpO2: keep > 92%
ABG if initial PaCO2 normal or high
medications upon discharge after severe asthma attack?
PO steroids for 5d
management of acute exacerbation of COPD?
controlled O2 therapy:
sit up, Target SpO2 88-92%, 24% O2 via venturi mask
nebulised bronchodilators:
salbutamol, ipratropium
steroids:
hydrocortisone IV, prednisolone PO 40mg for 7-14d
ABx:
if evidence of infection. doxycycline
NIV if no response:
BiPAP if pH<7.35 / RR>30
consider invasive ventilation if pH <7.26
Mx of PE
Sit up
O2
Analgesia: Morphine + metoclopramide
if massive PE: consider thrombolysis with alteplase or surgical/interventional embolectomy
LMWH heparin - enoxaparin SC
if BP low: consider fluids
long term mx after PE?
TEDS stocking
graduated compression stockings for 2 years if DVT: prevent post-phlebitic syndrome
continue LMWH until INR>2
Target INR 2-3
for 3 mo if remedial cause, 6 mo if no identifiable cause
Warfarin
definition of pneumothorax?
accumulation of air in the pleural space with secondary lung collapse
causes of primary pneumothorax?
no underlying lung disease
usually young, thin men with ruptured subpleural bulla
smokers
causes of secondary spontaneous pneumothorax?
underlying lung disease present
- COPD
- Marfan’s, Ehler-Danlos
- Pulmonary fibrosis, sarcoidosis
iatrogenic causes of pneumothorax?
subclavian CVP line insertion
positive pressure ventilation
transbronchial biopsy
liver biopsy
what sorts of trauma can cause pneumothorax?
penetrating chest wound
blunt trauma +/- rib #s
signs of pneumothorax?
reduced expansion,
hyperresonant percussion
decreased breath sounds
decreased vocal resonance
surgical emphysema
signs of tension pneumothorax?
mediastinal shift
raised JVP
raised HR, low BP
mx of tension pneumothorax?
large bore cannula into 2nd ICS, mid clavicular line
then chest drain
mx of traumatic pneumothorax with open wound?
3-sided wet dressing if sucking
chest drain
what is the Rockall score for?
prediction of re-bleeding and mortality
final score post endoscopy
(initial score >3) >6 indication for surgery
causes of cardiogenic shock?
MI
arrhythmia
causes of hypovolaemic shock?
haemorrhage: internal and external
Diarrhoea and vomiting, burns
Third spacing: pancreatitis
Endocrine: addisonian crisis, DKA
causes of obstructive shock?
PE
Tension pneumothorax
causes of distributive shock
sepsis
anaphylaxis
neurogenic
specific mx of anaphylactic shock?
adrenaline IM 0.5mg
Hydrocortisone IV 200mg
Chlorphenamine 10 mg
Salbutamol
Specific Mx of cardiogenic shock?
Dobutamine (B1 agonist)
or
dopamine (B1 agonist)
to increase heart contractility
specific mx of septic shock?
IV ABx
Fluids
Vasopressors e.g. norad
specific mx of hypovolaemic shock?
Fluid replacement: crystalloid, colloid, blood
titrate to: urine output, CVP, BP
haemodialysis if ATN
use of noradrenaline in septic shock?
potently stimulates alpha and b1 receptors
main effect = peripheral vasoconstriction to non essential organs e.g. gut
useful in septic shock to maintain BP
if pt doesnt get better after tx for septic shock?
Get culture results back -> may be organism resistant to abx used
Prep for possible ITU transfer
specific mx of upper GI bleed?
due to varices
IV terlipressin (splanchnic vasopressor)
Prophylactic Abx e.g. ciprofloxacin 1g/ 24h
Fluids/ blood
correct coagulopathy: Vit K, FFP, platelets
Thiamine if alcohol cause
notify surgeons of severe bleeds
specific mx of upper GI bleed due to ulcer?
O2, Large bore cannulae: fluids, blood resus
Correct coagulopathy: Vit K, FFP, platelets
Notify surgeons of severe bleeds
URGENT endoscopy:
haemostasis of vessel or ulcer-
adrenaline injection, thermal/ laser coagulation, fibrin glue, endoclips
Endoscopic mx of upper GI bleed due to varices?
urgent endoscopy:
1st line: Banding, sclerotherapy, adrenaline
2nd: balloon tamponade w Sengstaken-Blakemore tube
(only used if exsanguinating haemorrhage or failure of endoscopic tx)
2nd: TIPSS if bleeding cant be stopped endoscopically (to decrease portal pressure)
indications for surgery in upper GI bleeding?
rebleeding
bleeding despite transfusing 6u
uncontrollable bleeding at endoscopy
initial rockall score ≥3, or final >6.
open stomach, find bleeder and underrun vessel.
causes of acute renal failure?
pre renal:
shock e.g. sepsis, hypovolaemia
renal:
ATN, GN
Post renal:
stone, catheter, neoplasm
presentation of acute renal failure?
usually presents in the context of critical illness
uraemia
hyperK
acidosis
oedema and raised BP
Ix of acute renal failure?
Bloods: FBC, U+E, LFT, Glucose, Clotting, Ca, ESR
ABG: hypoxia (oedema), acidosis, raised K+
GN screen: if cause unclear
Urine: Dip, MCS, chemistry (e.g. osmolality)
ECG: HyperK
CXR: pulmonary oedema
Renal US: renal size, hydronephrosis
ECG features of Hyper K?
peaked T waves
flattened P waves
increased PR interval
widened QRS
Sine wave pattern -> VF
Mx of HyperK?
10ml 10% calcium gluconate
100ml 20% glucose + 10 u insulin (Actrapid)
Salbutamol 5mg nebulizer
Calcium Resonium 15g PO or 30g PR or Haemofiltration
indications for acute dialysis?
AEIOU
Acidosis:
Severe metabolic acidosis (pH <7.2)
Electrolytes:
Persistent hyperK (>7 mM)
Intoxicants:
Poisons e.g. aspirin
Oedema:
refractory pulmonary oedema
Uraemia:
Symptomatic- encephalopathy, pericarditis
Mx of pulmonary oedema?
Sit up and give high flow O2
morphine 2.5mg IV + metoclopramide 10mg IV
Frusemide IV 120-250mg over 1h
GTN spray +/- ISMN IVI (unless SBP <90)
if no response consider:
CPAP
haemofiltration/ haemodialysis +/- venesection
Mx of Acute Renal Failure?
Resus and assess fluid status
ABC
A: ↓GCS may need airway Mx
B: Pulmonary oedema. - sit up, high flow O2
C: assess fluid status: CRT, urine output, BP
tx any lifethreatening complications: hyperK, pulmonary oedema, consider need for rapid dialysis
monitoring in acute renal failure?
cardiac monitor: hyperK
urinary catheter
consider CVP
start fluid balance chart
features of benzodiazepine poisoning?
reduced GCS
respiratory depression
mx of benzodiazepine overdose?
Flumazenil
features of BB overdose?
Severe bradycardia or hypotension
mx of Beta Blocker overdose?
Atropine
Cyanide overdose features?
inhibits the cytochrome system
almond smell
phase 1: anxiety +/- confusion
phase 2: increased/ decreased pulse
phase 3: fits, coma
mx of cyanide overdose?
Dicobalt edentate
Carbon monoxide overdose features?
headache, dizziness, nausea
hypoxaemia (SpO2 may be normal)
metabolic acidosis
Mx of Carbon Monoxide overdose?
Hyperbaric O2
Features of digoxin overdose?
reduced GCS
yellow green visual haloes
arrhythmias
mx of digoxin overdose?
Anti-digoxin antibodies (Digibind)
Features of ethanol overdose?
reduced GCS
respiratory depression
Features of ethylene glycol poisoning?
Found in antifreeze
High anion gap metabolic acidosis with high osmolar gap
Intoxication with no visual disturbance
mx of ethylene glycol poisoning?
Ethanol
Haemodialysis
Features of heparin overdose?
bleeding
Mx of heparin overdose?
Protamine sulphate
features of iron overload?
n+v
abdo pain
mx of iron overload?
desferrioxamine
Features of methanol overdose?
high anion gap metabolic acidosis with high osmolar gap
intoxication with visual disturbance
mx of methanol overdose?
ethanol
haemodialysis
features of Lithium overdose?
N+V
ataxia, coarse tremor
Confusion
polyuria and renal failure
mx of lithium ovferdose?
IV fluids, haemodialysis
features of opiate overdose?
respiratory depression
reduced GCS
pin point pupils
mx of opiate overdose?
Naloxone
mx of warfarin overdose?
Vit K
Prothrombin complex
features of warfarin overdose?
major bleed
features of tricyclic antidepressant overdose?
Prolonged QT interval -> Torsade de pointes
Metabolic acidosis
anticholinergic effects
mx of tricyclic antidepressants overdose?
activated charcoal
NaHCO3 IV
mx of organophosphate overdose?
atropine + pralidoxime
effects of aspirin overdose?
respiratory stimulant -> respiratory alkalosis
uncouples oxidative phosphorylation -> met acidosis
vomiting and dehydration
hyperventilation
tinnitus, vertigo
hyper/ hypoglycaemia
respiratory alkalosis initially then lactic acidosis
mx of aspirin overdose?
activated charcoal if <1h since ingestion
Bloods: paracetamol and salicylate levels, Glucose, U+E, LFTs, INR,
ABG: met acidosis
alkalinise urine: NaHCO3 +/- KCl
haemodialysis may be needed
pathophysiology of paracetamol overdose?
normal metabolism overloaded and paracetamol -> highly toxic NAPQI by cytP450
NAPQI can be detoxified by glutathione conjugation (overwhelmed in Overdose)
presentation of Paracetamol overdose?
vomiting, RUQ pain
jaundice and encephalopathy +/- liver failure
cerebral oedema -> raised ICP
mx of paracetamol overdose?
activated charcoal if <1 h since ingestion
Bloods: paracetamol level 4h post ingestion
Glucose, U+E, LFTs, INR, ABG
N-acetyl cysteine: if levels are above treatment line on graph
pathophysiology of diabetic ketoacidosis?
Ketogenesis:
↓ insulin → ↑ stress hormones and ↑ glucagon
→ ↓ glucose utilisation + ↑ fat β-oxidation
↑ fatty acids → ↑ ATP + generation of ketone bodies
Dehydration:
↓ insulin → ↓ glucose utilisation + ↑ gluconeogenesis →severe hyperglycaemia
→ osmotic diuresis → dehydration
Also, ↑ ketones → vomiting
Acidosis:
Dehydration -> renal perfusion
HyperK
presentation of DKA?
abdo pain, vomiting
gradual drowsiness
Dehydration
sighing “kussmaul” hyperventilation
ketotic breath
diagnosis of diabetic ketoacidosis?
Acidosis (high anion gap): pH < 7.3
Hyperglycaemia: ≥11.1mM
Ketonaemia: ≥3mM (≥2+ on dipstix)
Ix of diabetic ketoacidosis?
Urine: dip for ketones and glucose, MCS
Capillary glucose and ketones
VBG: acidosis + high K
Bloods: U+E, FBC, glucose, cultures
CXR: ?infection
complications of diabetic ketoacidosis?
cerebral oedema: excess fluid administration
aspiration pneumonia (vomiting)
hypoK
Hypophosphataemia -> resp and skeletal muscle weakness
Thromboembolism
Mx of Diabetic Ketoacidosis?
Fluids:
0.9% Normal saline infusion
(SBP > 90 -> 1L over 1h)
(SBP < 90 -> IL stat + more until SBP >90)
Start K replacement in 2nd bag of fluids
3.5-5.5 mM -> 40 mM/L
Add 10% dextrose 1L/ 8h when glucose <14mM
Insulin infusion
0.1u/kg/h Actrapid
find an treat precipitating factors
monitoring during tx of diabetic ketoacidosis?
Hourly cap glucose and ketones
VBG @ 60 min, 2h then 2 hrly
Plasma electrolytes 4 hrly
When to restart Subcut insulin in DKA?
when pt is biochemically resolved, eating and drinking
start long acting insulin night before and short acting insulin before breakfast
metabolic derangement in hyperosmolar non ketotic coma?
marked dehydration and glucose > 35mM
no acidosis (no ketogenesis)
osmolality > 340 mosmol/kg
complications of hyperosmolar non-ketotic coma?
occlusive events are common: DVT, stroke
give LMWH
mx of hyperosmolar non ketotic coma?
Rehydrate with 0.9% NS over 48h
- may need ~9L
wait 1 h before starting insulin
(may not be needed) - start low to avoid rapid changes in osmolality
Look for precipitant
e.g. MI, infection, bowel infarct
LMWH
cause of hypoglycaemia?
usually exogenous: insulin, gliclazide
pituitary insufficiency
Liver failure
Addison’s
Insulinomas
Symptoms of hypoglycaemia?
Autonomic:
sweating, anxiety, hunger, tremor, palpitations
neuroglycopaenic:
confusion, drowsiness, seizures, coma, personality change
Mx of hypoglycaemia?
if pt still able to swallow
oral carbs
rapid acting: lucozade
long acting: sandwich
Mx of hypoglycaemia
if pt is unconscious/ unsafe swallow?
IV dextrose 100ml 20%
mx of hypoglycaemia if pt is drowsy / confused but swallow still intact?
Buccal glucogel/ hypostop
consider gaining IV access
Mx of hypoglycaemia with no IV access?
1mg Glucagon IM
(insulin release may cause rebound hypoglycaemia)
presentation of thyroid storm?
high temp
agitation, confusion, coma
tachycardia, AF
acute abdomen
heart failure
precipitants of thyroid storm?
Recent thyroid surgery or radioiodine
infection
MI
trauma
Mx of thyroid storm?
Fluid resus + NGT
Bloods: TFTs + cultures if infection suspected
Propranolol (symptomatic control)
Digoxin may be needed
Carbimazole then Lugol’s iodine 4h later to inhibit thyroid
Hydrocortisone
Tx cause
Presentation of myxoedema coma?
looks hypothyroid
hypothermia
hypoglycaemia
heart failure: bradycardia and low BP
coma and seizures
mx of myxoedema coma?
Bloods: TFTs, FBC, U+E, glucose, cortisol
correct any hypoglycaemia
T3/T4 IV slowly (may precipitate MI)
hydrocortisone 100mg IV
tx hypothermia and heart failure
precipitants of myxoedema coma?
radioiodine
thyroidectomy
Pituitary surgery
Infection, trauma, MI, stroke
presentation of addisonian crisis?
shocked: high HR, postural drop, oliguria, confused
hypoglycaemia
usually known addisonian or chronic steroid user
precipitants of addisonian crisis?
infection
trauma
surgery
stopping long-term steroids
Mx of addisonian crisis?
Check cap glugose: glucose may be needed
Hydrocortisone 100mg IV 6hrly
IV crystalloid
septic screen
tx underlying cause
cause of hypertensive crisis?
phaeochromocytoma
presentation of hypertensive crisis?
pallor
pulsating headache
feeling of impending doom
raised BP
Cardiogenic shock
mx of hypertensive crisis?
alpha blocker
e.g. phentolamine or labetalol
phenoxybenzamine when BP controlled
BBs AFTER to control tachycardia/ arrhythmia
elective surgery after 4-6 wks to allow full a-blockade and volume expansion
risk factors for burns
age: children + elderly
comorbidities: epilepsy, CVA, dementia, mental illness
occupation
classification of burns?
superficial:
erythema, painful e.g. sunburn
partial thickness:
heal within 2-3 wks if not complicated
superficial: no loss of dermis, painful, blisters
deep: loss of dermis but adnexae remain
healing from adnexae e.g. follicles
v painful
full thickness:
complete loss of dermis
charred, waxy, white skin
anaesthetic
heal from the edges -> scar
early complications of burns?
- Infection: loss of barrier function, necrotic tissue, SIRS, hospital
- Hypovolaemia: loss of fluid in skin + ↑ cap permeability
- Metabolic disturbance: ↑↑K, ↑↑myoglobin, ↑Hb → AKI
- Compartment syndrome: circumferential burns
- Peptic ulcers: Curling’s ulcers
- Pulmonary: CO poisoning, ARDS
what metabolic disturbances may result from burns?
High K+
high myoglobin
raised Hb -> AKI
What peptic ulcers results from burns?
Curling’s Ulcers
late complications of burns?
scarring
contractures
psychological problems
intermediate complications of burns?
VTE
pressure sores
assessment of % body surface area burnt?
Wallace rule of 9s
Head and neck: 9%
arms: 9% each
torso: 18% front and back
legs: 18% each
perineum: 1%
palm: 1%
Mx of Burns?
specific concerns w burns: secure airway, manage fluid loss, prevent infection
Airway: examine for respiratory burns, consider early intubation + dexamethasone (to decrease inflammation)
Breathing: 100% O2, look for signs of CO poisoning,
ABG: COHb level, SpO2 unreliable if CO poisoning
Circulation: 2 large bore cannulae, take bloods, start 2L warmed Hartmann’s immediately
+ Analgesia: morphine + metoclopramide
what signs may suggest respiratory burns?
soot in oral or nasal cavity
burnt nasal hairs
hoarse voice, stridor
signs of CO poisoning?
headache
n/v
confusion
cherry red appearance
What are some formulas to guide fluid replacement in burns?
parkland formula in 1st 24h
4 x weight (Kg) x % burn = mL of Hartmanns in 24h
give half in 1st 8h
Muir and Barclay formula
(weight x % burn) /2 = mL of Colloid per unit time
time units: 4, 4, 4, 6, 6, 12 = 36 hrs total
definition of hypothermia?
core (rectal) temperature < 35
pathophysiology of hypothermia?
- Radiation: 60%
Infra-red emissions
- Conduction: 15%
Direct contact
1O means in cold water immersion
- Convection: 15%
Removes warmed air from around the body
↑d in windy environments
- Evaporation: 10%
Removal of warmed water
↑ in dry, windy environments
primary vs secondary causes of hypothermia?
primary: environmental exposure
secondary: change in temp set point
e. g. age related, hypothyroidism, autonomic neuropathy
presentation of mild hypotension?
32.2-35
shivering
tachycardia
vasoconstriction
apathy
presentation of moderate hypothermia?
28-32.2
dysrhythmia, bradycardia, hypotension
J waves
decreased reflexes, dilated pupils, reduced GCS
presentation of severe hypotension??
<28 degrees
VT -> VF -> cardiogenic shock
apnoea
non reactive pupils
coagulopathy
oliguria
pulmonary oedema
Ix of hypothermia?
rectal temperature
FBC, U+E, glucose
TFTs, blood gas
ECG: J waves (between QRS and T wave) , arrhythmias
mx of hypothermia?
slowly rewarm (0.5 degrees/ hr)
(reheating too quickly -> peripheral vasodilation -> shock)
passive external: blankets, warm drinks
active external: warm water or warmed air
active internal: mediastinal lavage and CPB
(severe hypothermia only)
warm IVI 0.9% NS
consider abx for prevention of pneumonia (routine if temp < 32 and age > 65)
complications of hypothermia?
arrhythmias
pneumonia
coagulopathy
acute renal failure
what is the rate of Chest compressions to breaths in adult CPR?
30:2
If non shockable rhythm is identified on defibrillator?
PEA/ Asystole.
Immediately resume CPR for 2 min then assess rhythm again
adrenaline 1 mg as soon as IV access obtained
repeat adrenaline every other cycle
if shockable rhythm is identified on defibrillator?
VF/ pulseless VT
1 shock
then immediately resume CPR for 2 min
+ adrenaline 1 mg
amiodarone 300mg after 3rd shock
repeat adrenaline every other cycle
reversible causes of cardiac arrest?
Hypoxia
Hypovolaemia
Hypo/HyperK/ metabolic
Hypothermia
Thrombosis - coronary or pulmonary
Tamponade - cardiac
Toxins
Tension pneumothorax
Adrenaline given how often in cardiac arrest?
every 3- 5 min
what adverse features would suggest pt is unstable and requires synchronised DC shock?
tachycardia/ arrhythmia
+
shock
syncope
myocardial ischaemia
heart failure
How to carry out synchronised DC shock?
up to 3 attempts
then
amiodarone 300mg IV o ver 10-20. min and repeat shock
followed by amiodarone 900 mg over 24h
narrow complex tachycardia mx?
vagal manoeuvres
then
adenosine 6mg rapid IV bolus (then 12, 12 mg)
monitor ECG continuously
if sinus rhythm not restored -> seek expert help
if restored -> probable re entry paroxysmal SVT
- record 12 lead ECG in sinus rhythm
AF Mx?
rate control
- BB or diltiazem
- consider digoxin or amiodarone if evidence of heart failure
VT mx?
amiodarone 300mg IV over 20-60 min
then 900 mg over 24h
Torsades de pointes mx?
Mg 2g over 10 min
SVT w BBB mx?
give adenosine as for regular narrow complex tachycardia
Bradycardia general mx?
ABCDE approach
O2, IV access
Monitor ECG, BP, SpO2
identify and treat reversible causes (e.g. electrolytes)
bradycardia with no adverse features (shock, syncope, MI, HF) + no risk of asystole
Mx?
Observe
what suggests increased risk of asystole in bradycardia pt?
recent asystole
mobitz II AV block
Complete Heart block w broad QRS
ventricular pause > 3s
mx of bradycardia w adverse features (e.g. shock, syncope, HF, MI)?
atropine 500mcg IV
mx of bradycardia if no satisfactory response to atropine or risk of asystole?
Atropine 500mcg IV repeat to max 3mg
Isoprenaline 5 mcg/ min IV
Adrenaline 2 -10 mcg/ min IV
OR
Transcutaneous pacing
