Emergency (NEW) Flashcards
1
Q
ACS definitions
A
STEMI
- Acute
- > persistent ST segment elevation (1 small square) in 2 contiguous leads (except V2/3)
- > new LBBB with symptoms
- does not require elevated troponins
- Consider posterior STEMI
- > ST depression in V1-3
- Old findings
- > ST segment at isoelectric
- > small R
- > pathologic Q (1/3 corresponding R)
- > inverted T wave
Non-STEMI
- > diffuse ST segment depression
- > depression in focal area likely STEMI with reciprocal changes
- > elevated troponins without ST elevation
UA
- > unstable/new/severe/frequent angina
- > no trops
- > only transient ECG changes
2
Q
ACS evaluation
A
Hx
- pain (OPQRST)
- > Onset is gradual
- > Precipitated by exercise/Palliated by rest/NO
- > Quality is discomfort/crushing/tightness etc
- > Radiates to epigastrium/scapula/jaw/throat/arms
- > Site is diffuse, should not be able to point with one finger
- > Time longer than 20 minutes
- associated symptoms
- > most commonly SOB
- > palpitations
- > nausea/vomiting
- > diaphoresis/clamming
- > syncope/presyncope
- absence of pain
- > older age
- > women
- > diabetics
Consider risk factors
- Non modifiable
- > male
- > old
- > family Hx men <55, women <65
- > established CAD
- Modifiable
- > overweight/obesity
- > metabolic syndrome
- > physical inactivity
- > dyslipidaemia
- > diabetes
- > hypertension
- > smoking
- > cocaine use (acute and chronic)
- > renal dysfunction
Exam
- evidence of hypoperfusion
- > hypotension
- > tachycardia
- > altered mental status
- > pale, cool, clammy skin
- evidence of heart failure
- > JVP elevated
- > crackles
- > S3 gallop
- > MR murmur
Immediate Tests (confirm ischaemia)
- ECG
- > confirms STEMI diagnosis
- > assessment for reperfusion immediately after
- High sensitivity troponin
- > baseline with repeat within 3 hours
- > confirms STEMI/non STEMI if symptomatic with rise/fall with one >99th centile
Consider non ischaemic chest pain (PPP GRAMMA)
- ddx
- > pneumothorax
- > pericarditis
- > PE
- > GORD
- > Ruptured viscus
- > Aortic dissection
- > Myocarditis
- > Musculoskeletal
- > Anxiety
- safe discharge
- > consider HEART score
Secondary tests
- Glucose
- > hyper/hypoglycaemia common
- FBC
- > anaemia (anti-platelet therapy)
- > leukocytosis (acute phase reactant)
- Electrolytes and CMP
- > arrhythmias
- Creatinine/eGFR
- > baseline for angiography contrast
- > baseline for medications
- CXR
- > rule out ddx
Consider
- ABG
- > signs of shock of pulmonary oedema
- Echo
- > MI complications
3
Q
ACS management
A
General management
- ACCU transfer/early cardio consult
- 2x IV canula
- O2
- Cardiac monitoring + serial ECGs
- Routine bloods
- CXR
- Pharmacological management (THROMBINS2)
- > Thionopyridines (clopidegrel)
- > Heparin/enoxaparin
- > RAS (ACEI/ARB)
- > O2
- > Morphine
- > Beta blocker (bisoprolol/metoprolol)
- > Invasive treatment (PCI) preferred
- > Nitoglycerine
- > Salicylate (aspirin)
- > Statin
- Balance ischaemic and bleeding risk
- > GRACE = ACS mortality
- > CRUSADE = bleeding risk in ACS
Common pathway
- Dual anti platelet
- > aspirin 300mg oral/dissolved
- > clopidegrel 300-600mg
- Anticoagulation
- > enoxaparin 1mg/kg SC
- > give initial 30mg IV bolus then SC if for fibrinolysis
- > additional dosing not required for PCI
- > use UFH if severe kidney disease (different pathway)
- Consider
- > abciximab (high risk/at time of PCI)
- > or bilalirudin (if high risk of bleeding)
STEMI
- Choice of reperfusion method
- > PCI if available within 90mins of presentation
- > if not, fibrinolysis within 30mins of presentation
- > if fibrinolysis contraindicated, transfer to PCI
- > unsuccessful thrombolysis
- Fibrinolysis contraindications
- > symptoms >12hrs
- > BP 180/110
- > recent trauma/surgery
- > GI bleeding in past month
- > Stroke/TIA in 3 months
- > Prior ICH
- > known malignancy/vascular lesion/coagulopathy
- Fibrinolysis treatment
- > tenectoplase preferred (bolus regime)
- > alteplase (bolus plus transfusion)
NSTEMI
- Approach
- > CA guided revascularisation (PCI or CABG)
- > no fibrinolysis
- Risk stratified treatment
- > very high risk = CA within 2hrs
- > high risk = CA within 24hrs
- > intermediate risk = CA within 72hrs
- > low risk/no symptoms = guided by provocative testing
4
Q
DKA evaluation
A
Triggers (Don’t PANIC)
- Drugs
- > corticosteroids
- > cocaine
- > simpathomimetics
- > SGLT-2
- > atypical anipsychotics
- Pregnancy
- Acute illness
- New diagnosis (common)
- Infarct
- Compliance
Symptoms
- polyuria/polydypsia
- fatigue/weakness
- nausea/vomiting
- abdo pain
Signs
- hypotension/tachycardia
- hypothermia
- kussmaul breathing
- fruity breath
- altered mental status (GSC)
- dry mucous membranes/slow cap refill
- pulmonary oedema may occur
- evidence of infection
5
Q
DKA labs
A
Investigations
- Glucose
- > greater than 11.1 for criteria
- > can be euglycaemic
- > usually above 45 in HHS
- VBG
- > high anion gap metabolic acidosis
- > K <3.5?
- > plasma osmolality (>320mmol/L in HHS)
- Ketones
- > dipstick tests acetoacetate/capillary tests D-beta-hydroxybutarate level 3x higher
- > capillary ketones >3.0
- FBC
- leukocytosis is common (very high =?infection)
- EUCs
- > urea/creatinine high (dehydration)
- > Pseudohyponatraemia (minus 1.6mmol/L per 5.6mmol/L)
- > K normal despite total body depletion
- > Cl low
- CMP
- > low or normal
Consider testing for ddx’s
6
Q
management DKA
A
Goals
- restore circulating blood volume
- inhibit lipolysis, gluconeogenesis and ketogenesis
- address precipitating factors
- re-establish normal physiology and electrolyte balance
Issues
- acidosis
- dehydration
- hypokalaemia (hyper)
Monitoring
- continuous cardiac monitoring
- regular BP
- hourly
- > BG
- > ketones
- > VBG (particularly pH and K)
Fluids IV
-resuscitate, restore, maintain
Insulin IV
- goal
- > treat acidosis, not hyperglycaemia
- infusion
- > 0.1unit/kg/hr
- > don’t drop BG >5mmol/L/hr (cerebral oedema)
- target
- > glucose 10-15mmol/L
- maintain insulin infusion
- > start 5% glucose infusion
Potassium
- indication
- > serum level <5.5
- > once urinary flow is established
Resolution
- pH >7.3
- bicarb >15
- ketones <0.6
- patient alert
- tolerating oral fluids
Education
- review precipitating events
- discuss symptoms and triggers of DKA
- teach self management
- > during illness/reduced fluid intake
- advise when sick
- > check BG and ketones often
- > maintain hydration
- > present to medical attention early
7
Q
Upper GI bleed evaluation
A
DDx
- peptic ulcer
- malloryweis
- varices
- portal hyptersive gastropathy
- angiodysplasia
- neoplasia
- erosive
- > oesophagitis
- > gastritis
- > duodenitis
Hx
- Typical upper GI bleed
- > haematemesis
- > coffee ground
- > melena
- Typical features
- > epigastric pain = peptic ulcer
- > dysphagia/GORD = oesophageal ulcer
- > emesis/epigastric pain/hiatus hernia = MWT/BS
- > jaundice/distension = gastropathy/varices
- > dysphagia/cachexia = malignancy
- > melena w/o vomitting = distal to pylorus
- Severity screen
- > orthostatic presyncope
- > confusion
- > angina/palpitations
- Past hx
- > previous UGI bleed
- > varices
- > liver disease
- > peptic ulcer
- > malignancy
- > coagulopathy
- > renal disease/aortic stenosis/HHT (angiodysplasia)
- > AAA (aortoenteric fistula)
- Meds
- > NSAIDs
- > anticoagulants/antiplatelet
- > doxycycline
- > iron/bismuth
- Social
- > alcohol
- > smoking
- > IV drug use
Exam
- hypovolaemia
- > tachycardia
- > hypotension (orthostatic/supine)
- > pale/cool, clammy peripheries
- > delayed cap refil
- stigmata of chronic liver disease
- evidence of acute abdomen
- > perforation
- PR exam
- > melena/haematochezia
Investigations
- Blood group/cross match
- FBC
- > Hb normal early/lowered by fluid resusc
- > microcytic/iron deficiency = chronicity
- EUCs
- > urea:creatinine >30
- Coags
- LFTs
- Upper endoscopy once stable
- Consider CT abdo
Candidate for outpatient management?
- glasgow blatchford score
- > mortality risk increases with every point
8
Q
Upper GI bleed management
A
Unstable
- Secure airway
- > nasal cannula
- > low threshold for intubation
- Gain IV access
- Fluid resuscitation
- > start immediately
- Transfusion
- > may be required despite high Hb
- > avoid overtransfusion in variceal bleeding
- > FFP/platelets after 4 PRBCs
- Monitor
- > telemetry/ECG’s
- > pulse ox
- > serial BPs
General management of stable patient
- Keep NBM
- Fluid rescus
- PRBs
- > restrictive (<7) approach preferred
- > lower mortality compared to liberal (<9)
- > no difference in MI (including past MI)/CVA/AKI
- FFP
- > give before endoscopy if INR >2
- Platelets
- > consider before endoscopy if thrombocytopaenic
- Medications
- > IV esomeprazole 80mg
- > consider IV octreotide or vasopressin
- > IV erythromycin 30mins prior to endoscopy
- > IV ceftriaxone 1g if cirrhotic
- > consider with-holding anticoagulants/antiplatelets
- Upper endoscopy
- > interventions depend on pathology
Variceal bleeding
- Natural hx
- > mortality rate approx 15%
- > 50% spontaneous resolution
- > 1/3 rebleed in short term
- > 2/3 rebleed in long term
- Initial therapy
- > IV octreotide 50mcg bolus then 50mcg/hr transfusion
- > consider vasopressin
- > balloon tamponade after intubation
- Urgent endoscopy
- > after resuss/within 12hrs
- > band ligation/sclerotherapy
- > successful in approx 90%
- Consider alcoholism complications
- > monitor serum electrolytes
- > check thiamine
- Consider cirrhosis complications
- > hepatic encephalopathy
- > secondary infection
- > electrolyte abnormalities
- > renal failure
Mallory Weiss
- Natural hx
- > mortality rate approx 5%
- > rebleeding in <10%
- Initial therapy
- > IV ondansetron 10mg once daily
- > consider IV ocreotide 25-50cg bolus and transfusion
- Urgent endoscopy
- > after resuss/within 12hrs
- > haemoclip
- > adrenaline + haemoclip/sclerotherapy/band ligation
- > successful >90%
9
Q
thunderclap headache ddx
A
Always Remembering Several Critical Differentials is A Painful Thorn In My Side
- Aneurysm rupture
- > thunderclap headache after trigger/maybe sentinel bleed
- > vomiting/nuchal rigidity/LOC/seizures
- Reversible cerebral vasoconstriction syndrome
- > recurrent TCH over days to weeks
- > similar triggers to aneurysmal rupture
- > may develop neurological deficits due to stroke
- Spontaneous intracranial hypotension
- > postural headache after trauma/CSF drain
- > nuchal rigidity/nausea/vomiting sometimes
- Cluster headache
- > eye/temple pain lasting up to 3 hours
- > red eyes/ipsilateral lacrimation/rhinorrhea/horners
- Dissection (cervical artery)
- > stroke/TIA/neck or head pain
- > partial horners (no anhidrosis)/tinitus/bruit
- > trauma/connective tissue disorder
- Acute angle glaucoma
- > blurred vision/halos/red eye/dilated pupil
- Posterior reversible encephalopathy syndrome
- > HTN/seizure/visual symptoms/insidious headaches
- > white matter oedema
- > sometimes UMN signs and focal deficits
- Thrombus (venous)
- > VTE risk factors/neuro deficits across arterial territories
- Ischaemic stroke
-Meningitis
- Spontaneous intracerebral haemorrhage
- > HTN/anticoagulated/older
- > gradual focal neuro signs (putamen/post int capsule)
- > headache/vomiting/meningism/stupour
10
Q
Headache evaluation
A
Red flags on history
- sudden and severe onset
- precipitated by exertion or trauma
- altered mental status
- seizure
- visual disturbance
- pain down into neck or around eye
- systemic symptoms
- > fever
- > vomiting
- > dizziness
- concurrent head infection
- no past hx
- family hx of SAH
- medications
- > anticoagulants/NSAIDs
- > COCP
- > simpathomimetics
Red flags on exam
- Cushings triad
- Fever
- > inflammation or bleeding
- HTN
- Toxic appearance
- Altered mental status
- Focal neuro signs
- Meningismus
- Eye
- > papilloedema
- > red eye
- > visual deficits
- > CN IV/VI palsy
Investigations
- CT or MRI
- > non con
- > neck/cerebral angiography
- LP (if imaging negative)
- > high opening pressure = pathology
- > RBC dilution across 4 tubes/xanthochromia
- > biochemical analysis
- FBC
- > anaemia?
- > thrombocytopaenia?
- Coags
- EUCs
- > hyponatraemia (SIADH)
11
Q
Aneurysmal SAH management
A
Consider complications (Bloody Hot CHIPS)
- > Bleeding (mortality increased to approx 70%)
- > Hydrocephalus
- > Cardiac (arrythmia/trops/takasubo)
- > Hyponatraemia
- > Ischaemia (delayed due to vasospasm)
- > Pressure (increased ICP)
- > Seizures
Transfer
- > to ICU
- > tertiary institute
- Grading
- > Hunt and Hess
Core supportive measures
- Blood pressure
- > withold management unless severe/stuporous
- Vasospasm
- > Nimodipine 60mg oral immediately
- Analgesia
- > paracetamol
- > opioids
- Monitor
- > neurological status every 1-2hrs
- > transcranial doppler daily
Additional measures
- Anti-thrombotic reversal
- > antiplatelet = desmopressin
- > warfarin = IV vit K + FFP
- > UHF = protamine
- > DOACs= some have direct inhibitors
- Euvolaemia
- > prevent hypovolaemia and stroke
- > avoid raising BP
- > correct hyponatraemia
- Definitive treatment
- > surgical clip/coiling
12
Q
Meningitis evaluation and management
A
ddx (MASES PTSD)
- Meningitis
- > bacterial
- > aseptic
- Abscess
- Subdural empyema
- Encephalitis
- SAH
- Petechial ddx’s
- Trauma
- Septicaemia
- > meningococcus
- > varicella
- > pneumococcal
- Drugs
- > sulfur containing
- > antibiotics
- > anticonvulsants
Initial evaluation
- concurrent primary survey + history to confirm
- key issues
- > shock
- > hypoxia
- > hypoglycaemia
- > hyponatraemia
- > seizures
Investigations
- Consider CT before LP if signs of raised ICP
- Lumbar puncture
- Blood cultures
- > useful if LP is delaying treatment
- Glucose
- FBC
- EUCs
- CMP
- CRP
- Coags
Initial management
- dexamethasone 10mg (0.15mg/kg) IV before antibiotics
- > ideally before antibiotics
- cefotaxime/ceftriaxone 2g (child 50mg/kg) IV
- > as soon as possible
- > should not be delayed by investigations
- Maintenance fluids for euvolaemia
- ICP
- > sit bed at 45 degrees
- > if raised = consider monitoring/osmotherapy/sedation
13
Q
Anaphylaxis evaluation and management
A
ASAP Fluids, Ventilation, Adrenaline
- anaphylaxis
- shock
- asthma attack
- panic attack
- foreign body aspiration
- vasovagal reaction
- acute exacerbation COPD
Immediate response
- remove allergen
- lay flat
- call for help
- prepare IM adrenaline
- collapsed
- > assess pulse and breathing
- > ALS pathway
A -examine lips, tongue, pharynx -assess for obstruction ->stridor/angioedema = upper ->wheeze = lower -ladder of interventions ->low threshold for intubation ->oxygenation is priority -ask patient to speak ->change to voice with angioedema B -high flow O2 via hudson/non rebreather C -IM adrenaline >10mcg/kg (up to 0.5mg) ->min dose = 0.1mg (<1yr old) ->outer thigh ->repeat every 5 mins -not responding after approx 2 doses ->prepare adrenaline infusion ->contact ICU ->fluid boluses ->consider IV glucagon in beta blocker patient -any signs of shock ->1-2L boluses adult ->20mL/kg bolus child -D ->serially assess -E ->any more allergens?
Resistant to treatment
- transfer to ICU
- adrenaline infusion
- fluid boluses
- upper airway obstruction
- > nebulised adrenaline
- lower airway obstruction
- > nebulised salbutamol
14
Q
anaphylaxis post acute care
A
Treatment
- consider H2 antihistamines (ranitidine/cimitadine)
- > itch
- consider corticosteroids (methyprednisone)
- > biphasic
- > limited evidence
Observation
- at least 4 hours
- longer if
- > severe
- > hx of biphasic
- > risk factors for fatal anaphylaxis
- > remote or isolated
- biphasic reaction
- > overal risk approx 5% (higher in kids)
- > up to 3 days later
- consider tryptase for follow up
Discharge (SAFE)
- Safety net
- > recurrence in 20%
- > patient education
- > provide anaphylaxis action plan (ASCIA)
- Allergen avoidance
- Follow up with immunologist
- > diagnosis revised in up to a third
- > confirm allergen
- > immunotherapy for stinging insects
- > address co-morbidities
- Epinephrine
- > prescribe 2x auto injectors
- > urge patient to fill immediately
- > education on proper use
15
Q
Undifferentiated shock
A
When to suspect (Red flags)
- hypotension
- > SBP <90/MAP <65/orthostatic
- > not always present (compensated shock)
- tachycardia
- oliguria
- abnormal mental status
- cool, clammy, cyanosed skin
- cap refill >3 seconds
- metabolic acidosis
- lactic acidosis
- tachypnea
Initial response
- secure airway
- support breathing
- gain IV/IO access (x2)
- > fluid bolus (adults=500mL, paeds=10mL/kg)
- > draw blood for lab
- risk stratify
- > brief hx and exam
Risk stratified response
- life threatening condition suspected
- > begin empiric life saving therapies
- > do not delay for results lab studies
- patient stable but undifferentiated
- > focused hx and exam
- > ECG
- > CXR
- > ultrasound (RUSH) or echo
- > lab studies
Lab studies for undifferentiated
- ABG
- FBC
- EUC
- LFTs
- Coags and D dimer
- Troponin and BNP
- Lactate
Empiric treatment
- IV fluid boluses
- > adults = 20mL/kg up to 1L then ICU
- > paediatrics = 10mL/kg up to 40mL/kg then ICU
- > smaller if cardiogenic suspected
- Inotropes/pressors
- > only use when fluid resus has failed (can worsen hypovolaemic shock)
- > norad or metaraminol (pressor choice doesn’t matter)
16
Q
Septic arthritis evaluation
A
Clinical manifestations
- acute onset
- single joint (polyarticular does occur)
- > red
- > hot
- > swollen
- > painful (any amount of active/passive movement)
- > tender
- > loss of ROM
- large joint
- > usually lower limb (including sacroiliac)
- > knee and hip most common
- systemically unwell
- fever
- neonate
- > intolerance of handling/posture changes
- > pseudoparalysis of limb
- children
- > refusal to walk
- > consider referred pain
- consider
- > hx of trauma
- > rashes
- > recent antibiotic use
- > recent or concurrent illness (haematogenous/reactive)
- > immunisation status
- > family hx of rheumatological disease/IBD
Investigations
- FBC
- > leukocytosis common
- CRP/ESR
- > elevated
- aspiration before abx (into blood culture bottle)
- > cell count = high WCC with neutrophils
- > culture = moderate sensitivity
- > gram stain = increased sensitivity/rapid results
- > polarised microscopy = crystals may co-occur
- xray
- > usually normal
- > excludes ddx’s (fracture/osteomyelitis)
- ultrasound
- > very high sensitivity
- > used to guide aspiration
17
Q
Septic arthritis management
A
Supportive
- analgesia
- > opioids inpatient
- > NSAIDs and paracetamol on discharge
- physiotherapy
- > prevent contractures
Antibiotics (guided by gram stain)
- gram +ive cocci in clusters (s. aureus)
- > flucloxacilin 2g (50mg/kg child) IV
- gram +ive cocci in chains (strep) or gram -ive
- > cefotaxime 2g (50mg/kg child) IV
- no gram stain results
- > assume staph aureus
Drainage
- needle aspiration
- arthoscopic or arthrotomy
- > allows irrigation
- > preferred for hips and shoulders
- repeat drainage may be necessary
Monitor
- clinical condition
- WCC and ESR/CRP
- consider repeat synovial fluid analysis
18
Q
Chest pain ddx
A
Life threatening (ED TRAP) Embolism Dissection Tamponade Ruptured viscus ACS Pericarditis Other/Common (GIMP) Gastrointestinal Gastritis/peptic ulcer Pancreatitis Cholecystitis Infective respiratory conditions Pneumonia Asthma/COPD exacerbation Musculoskeletal Intercostals/ribs Psychiatric Panic/anxiety
19
Q
Hyperkalaemia evaluation
A
missed dialysis prolonged fasting chest pain/palpitations abdo pain weakness/paresthesias
Hx
- Acidosis
- > infection/shock/ingestion of toxins
- Diabetes
- > insulin dosing/hyperglycaemia/fasting
- Hyporeninaemic hypoaldosteronism
- > medication hx
- Catabolism
- > trauma/seizures/cancer
- RTA
- > chronic diseases
- > urine output
- Aldosterone resistance
- > medication hx
- Sodium delivery
- > hypovolaemia
- > AKI
Exam
- ascending muscle weakness
- > beginning with legs, moving to trunk and arms
- > progresses to flaccid paralysis
- > presence = immediate treatment
Immediate ECG
- Morphology
- > flattened P waves
- > prolonged PR interval
- > broad QRS
- > short QT
- > peak T waves
- > tall peaked T waves
- shortened QT
- Arrhythmias
- > sinus brady
- > AV block
- > RBB/LBB
- > VT/VF
- > asystole
Glucose -hyerglycaemia/hypoinsulinaemia VBG -pH -electrolytes Repeat electrolytes -pseudohyperkalaemia -hyponatraemia? Calcium FBC -haemolysis -infective Urea/creatinine -AKI -GFR
20
Q
Hyperkalaemia management
A
Primary survey
- weakness, supporting airway
- c - cardiac complications
Remove aetiology
Stabilise myocardium
- calcium (chloride or gluconate) IV
- effects immediate but last 30-60 mins
- > can repeat after 5 mins
- > monitoring serum calcium level
- > doesn’t drop K level
- don’t give calcium in digitalis (cardiotoxicity)
Drive K intracellularly
- Give fluid before insulin
- > reverse dehydration effect
- Insulin and glucose IV or nebulised salbutamol
- effect within 15 mins
- > can drop K by 1mmoL
- > lasts 2 hrs
Increase K excretion
- IV furosemide
- > not as monotherapy/avoid with poor renal function
- Gastrointestinal cation exchangers
- > bind K and exchange for Na or Ca (zirconium)
- > use in acute hyperkalaemia debatable
- Haemodialysis
- > preferred method/particular with poor renal function
- > can be delayed when no vascular access
21
Q
Seizure evaluation and management
A
Epileptic vs non epileptic Non epileptic ->provoked ->non provoked ->psychogenic
Primary survey
Hx
- Prior
- > triggers
- > aura
- During
- > duration
- > awareness
- > movements
- > injuries
- Post
- > hemiparesis/aphasia
- > post ictal confusion
- Past hx
- > previous episodes
- > medication compliance
- > triggers
- Family hx
- Psychosocial
- > work/ADLs
- > driving
Exam
- alertness and orientation
- speech
- upper/lower/CN neurological exam
- > symptoms = underlying lesion
- assess for injuries and infection
- look for meningism
Blood glucose
ECG
FBC Electrolytes and CMP Urea and creatinine Toxicology screen (if indicated) bHCG if female (treatment)
MRI brain -structural lesion EEG ->relatively low sensitivity ->if still confused = as inpatient ->otherwise can be done as outpatient Lumbar puncture ->if infection suspected
Consider serum prolactin
- needs to be performed within 20 mins of seizure
- > repeat later as baseline
- > distinguishing psychogenic from real
No specific management needed
focus on safety
ECI website for seizures
22
Q
Dizziness evaluation
A
sit down
anti-emetic
veg for electrolytes
Hx
- What do they mean by dizzy?
- Time course
- > acute prolonged = stroke/vestibular neuritis
- > constant for months = psychogenic
- > recurrent attacks = meniers/vestibular migraine
- Provoking factors
- > postural = presyncope or vertigo
- > positional without posture = vertigo
- > moving head makes it worse = vertigo
- > occurs only with walking = balance
- Association symptoms
- > tilt/drop attack/oscillopsia = vertigo
- > hearing loss = peripheral vertigo
- > brainstem symptoms (D’s) = central vertigo
- > warm/diaphoretic/nausea = presyncope
- > palpitations/chest pain/dyspnoea = cardiac presyncope
- Prior hx
- > cardiac disease/stroke or risk factors
- > migraine
- > trauma
- Medications
Exam
- BP + orthostatic
- Gait
- > peripheral = fall towards lesion
- > central = can’t walk/variable lean
- Rombergs
- > proprioception
- Cardiovascular exam
- Upper/lower/CN exam
- > focal lesion supports central
HINTS+ (not for BPPV suspected)
- Head impulse
- > eye deviation to side of peripheral lesion
- > normal in central lesion
- Nystagmus
- > beat = away in peripheral/towards in central
- > central = at rest/with fixation/reversible direction
- Test of skew
- > vertical misalignment = supranuclear lesion
- Hearing test
- > loss = central
- Otoscope
- Dix halpike (canalithiasis of posterior SCC)
- > do not use when nystagmus at rest
- > nystagmus when lesion in lower ear
- > beat superiorly and torsion of upper pole downwards
- > opposite direction when sat up
- > horizontal with no torsion = probably horizontal BPPV
ECG
glucose
MRI/MRA
->if central lesion cannot be ruled out
23
Q
ddx hyperkalaemia
A
ADH CRAPS
- Acidosis (metabolic)
- Diabetes
- > insulin deficiency
- > hyperglycaemia
- > fasting on dialysis
- Hyporeninaemic hypoaldosteronism
- > ACEI/ARB
- > NSAIDs
- > heparin
- Catabolism
- > trauma
- > rhabdo
- > tumour lysis
- RTA (voltage dependent)
- > UTO
- > lupus
- > sickle cell
- Aldosterone resistance
- > spironolactone
- Pseudohyperkalaemia
- Sodium delivery to distal nephron
- > hypovolaemia
- > AKI
24
Q
Initial clinical assessment stroke
A
DDX (Thinking About Stroke Mimics Helps Me Consider Everything They Missed) -Todds paralysis -Abscess -Syncope -Migraine with aura -Hypertensive encephalopathy -MS -Conversion disorder -Encephalitis -Tumour -Metabolic encephalopathy (hypoglycaemia)
- Time is brain
- > concurrent primary survey/history/beside investigations
Hx
- Before/during/after
- > illness/seizures/aura/trauma
- Onset
- > determine time of onset/last seen well (management)
- > acute = ischaemic/gradual = haemorrhagic
- Ischaemic factors
- > CVD risk factors
- Haemorrhagic risk factors
- > HTN
- > anticoagulation
- > sympathomimetics
- Haemorrhagic vs ischaemic
- > haemorrhagic = nausea/vom/LOC/meningism/seizure
A -LOC loses protection -NBM until swallowing assessed B -brainstem involvement = lose respiratory drive ->hypoventilation/hypercapnia/cerebral vasodilation/ICP -risk of aspiration -monitor SpO2 and supplement if <94 (not higher) -listen to lungs for stridor/abnormal breath sounds C -ECG and telemetry ->AF ->demand ischaemia -BP -palpate carotid/peripheral pulses -listen to heart for murmur D -serial GCS -NIHSS score E -temperature -signs of anticoagulation -hypercholesterolaemia/PVD -recent surgery -head trauma -fundoscopic exam ->papilloedema ->terson ->cotton wool/roth spots/cholesterol F -often volume deplete -IV normal saline resuss and maintenance -avoid hypotonic solutions G -measure glucose ->hypoglycaemia as ddx ->secondary hyperglycaemia worsens outcome
25
Q
Initial investigations and management stroke
A
Immediate empiric management
- Positioning
- > however comfortable
- > flat for ischaemic/45 degrees if aspirating/ICP
- > avoid cervical collars etc
- O2
- > supplement if <94%
- > liberal use increases mortality
- BP
- > management determined by aetiology
- Correct hyperglycaemia
- > doesn’t improve outcome
- Fever
- > 1g paracetamol may improve outcome
- Transfer to stroke unit
- > improves outcome
- VTE prophylaxis
- > cause of 10% mortality
- > compression stockings
- > early mobilisation
- > UFH/enoxaparin if no haemorrhagic change
Immediate tests -FBC -EUCs -Trops -Coags -VBG -CT non con ->haemorrhagic/ischaemia/intracerebral lesion ->haemorrhagic = midline shift/bleed volume/subarachnoid -CT perfusion ->ischaemic = estimate penumbra expansion -CT angio (intracranial + aortic arch) ->ischaemic = thrombus ->haemorrhagic = aneurysms/vascular malformations
Haemorrhagic management
- BP
- > treat if hypertensive = labetalol
- > aggressive treatment favoured if SBP>220
- ICP
- > maintain head at 45 degrees
- > mild sedation
- > consider monitoring/mannitol/CSF drainage
- Anticoag/antiplatelet ceased and reversal
- > warfarin = FFP + vitamin K
- > UFH = protamine
- > aspirin = desmopressin
- Surgery
- > haematoma excavation for cerebellar or hydrocephalus
- > craniotomy for supratentorial bleed is controversial
Ischaemic management
- BP
- > avoid lowering
- Endovascular interventions
- > stent retrievers (first line)/thrombectomy/thrombolysis
- > if evidence of thrombus and within 6hrs
- Thrombolysis
- > effective within 4.5hrs (aim for <1hr)
- > consent (5% haemorrhage -> 50% fatal)
- > consult local guidelines for indications/contraindications
- > consider severity/goal of treatment/likely outcome
- Aspirin 300mg once daily
- > indicated for all if non-haemorrhagic confirmed on CT
- > delay 24hrs if for thrombolysis
- > immediate if not for thrombolysis
- Anticoagulation (UFH for 3 months)
- > start immediately if venous (even if haemorrhagic change)
- > if AF, use 1,3,6,12 rule (TIA/small/moderate/large)
26
Q
DDx palpitations
A
DDX (AV POEMS)
- Arrhythmias
- > structural defect (cardiomyopathy/prior MI)
- > congenital (long QT/WPF)
- Valvular
- > mitral valve prolapse
- Psychiatric
- > anxiety/panic/somatization
- Output high
- > anaemia/fever/pregnancy
- Excessive catecholamines
- > stress
- > excercise
- > pheochromocytoma
- Metabolic
- > hyperthyroid/hypoglycaemia
- Substances
- > caffeine
- > cocaine/amphetamines/nicotine
- > anticholinergics/vasodilators
Sepsis
Shock
27
Q
Evaluation arrhythmias
A
Immediately
- ECG
- BP
- pulse oximetry
- glucose
Hx
- Patient’s age
- > younger = AVRT or AVNRT
- Regularity
- > irregular = most common AF
- > regular = most common sinus tachy
- Duration
- > brief/faded after an instant = PVC/PAC
- > minutes or longer = more concerning
- Character
- > skipped beat/pounding = PVC/PAC
- Additional features
- > pounding in neck = AVRT/AVNRT
- > worse when lying down/bending = AVRNT
- > syncope/presyncope = VT
- Precipitating factors
- > stress/emotions = anxiety/long QT/inappropriate sinus tachy/sinus tachy
- > feeling of panic = anxiety or arrhythmias
- > exercise = long QT/AF/sinus tachy
- > awakening = POSA + AF
- Past cardiac hx
- > previous MI
- > congenital heart disease
- Non cardiac ddx
- > hyperthyroid symptoms
- > diabetes/fasting
- > psychiatric disorder
- > substance use
- Strong family hx
- > cardiomyopathy
- > long QT syndrome
Exam
- primary survey
- > unstable? cardiogenic shock/pulmonary oedema
- General appearance
- > signs of hyperthyroidism
- > fever or anaemia with high output
- Pulse
- > rate and rhythm
- > bradycardia = heart block + PVC
- BP
- > high = catecholamine excess
- JVP
- > AV dissociation
- Praecordium
- > displaced apex beat = dilated cardiomyopathy
- Auscultation
- > valvular lesion
Consider
- ambulatory monitoring
- > if cause unknown/high risk of arrhythmia
- TSH
- FBC
- Electrolytes and CMP
- Echo/cardia MRI
- > if structural lesion suspected
28
Q
Arrhythmia management
A
Regular and Narrow Tachy
- ddx
- > sinus tachy/SVT/atrial tachycardia/atrial flutter
- Sinus tachy
- > treat underlying cause
- SVT
- > DC cardioversion if unstable
- > consider vagal maneuvers then adenosine if stable
- Atrial tachycardia
- > DC cardioversion if unstable
- > if stable, beta blockers/non dihyrdropyridine CCB
- Atrial flutter
- > treated liked AF
Irregular and Narrow Tachy
- ddx
- > AF/multifocal atrial tachy/atrial flutter variable conduction
- AF
- > unstable = DC cardioversion
- > stable = beta blockers/non dihydropyridine CCB
- > consider need for anticoagulation
- multifocal atrial tachy/atrial flutter variable conduction
- > usually underlying cardiac/pulmonary path
- > usually stable
- > treatment focused at addressing cause
Regular and Wide Tachy
- ddx
- > VT (until proven otherwise)
- VT
- > unstable = DC cardioversion
- > stable = amiodarone or lidocaine
Irregular and Wide Tachy
- ddx
- > polymorphic VT/VF
- Polymorphic VT
- > unconscious = DC cardioversion
- > baseline long QT (torsades) = magnesium sulfate
- > normal baseline QT (post MI) = beta blockers
- VF
- > ALS
Bradycardia
- only treat if shocked
- > temporary pacing
- > atropine given prior
- > consider dopamine/adrenaline
adenosine
- half life in seconds
- with flush
- raise arm
cardioversion
-usually with propofol
29
Q
Fall with postural hypotension evaluation
A
DDX orthostasis (HAND)
- hypovolaemia
- age (decreased baroreceptor sensitivity)
- neurological
- > synucleinopathies (parkinson’s/lewy body dementia)
- > peripheral neuropathies
- drugs
- > vasodilators/anti HTN
- > tri-cyclics
- > diuretics
- > antipsychotics
- Before
- > early morning/heat/meal/prolonged standing
- > orthostasis (dizziness/dimming vision/weak)
- > mechanical/palpitations/vision/substances
- During
- > injury/LOC
- > length of lie
- After
- > pain/power/sensation
- > confusion/drowsiness
- Falls past medical ddx (BADASS FAN)
- > balance/dizziness/vertigo
- > arrhythmias and heart disease
- > diabetes
- > arthritis/immobility/de-conditioning/injury
- > seizures/strokes
- > sight
- > fluids/vomiting/diarrhoea
- > alzheimers
- > neuropathies (burning/tingling/loss of sensation/incontinence)
- Medications, medications, medications
- > BP altering
- > anticoagulant/antiplatelet
Exam
- Postural BP
- > SBP <20, DBP <10
- Autonomic failure
- > HR increase <20
- Pulse
- > absent sinus arrhythmia
- Exposure
- > injuries (head/long bones)
- Gait
- Peripheral neuro exam
- > power/sensation/proprioception
ECG
Glucose
FBC
EUC
30
Q
Management falls and orthostatic hypotension
A
Review medications
- reduce dose/cease where possible
- consider alternative anti-HTN
Advice
- sit before standing
- no straining on toilet/valsava while exercising
- > may need to treat constipation
- eat smaller, more frequent meals
- toe standing/crossing legs/muscle tensing
- stockings to increase venous return
Volume expansion
- increase salt supplementation
- > sleeping head up reduces overnight salt loss
- 2L water per day
- consider fludocortisone
Pharmacological intervention
- midodrine
- > alpha 1 agonist
- > urinary retention/supine HTN/pruritus
- pyridostigmine
- > AcH inhibitor
- droxidopa
- > noadrenaline pro-drug
- > indicated in neurogenic orthostatic
