Emergency Scenarios Flashcards
1
Q
dka
A
- fluid challenge and regular fluids
- bloods; vbg for ph, bicarbonate and lab glucose, ketones, u+es for sodium and potassium
- insulin; 50 units actrapid into 50ml normal saline and infuse continuously at 0.1units/kg/hour
- regular monitoring of ph, bicarbonate, glucose and potassium at 1 hour, 2 hour and every 2 hours
- assess need for potassium replacement
- consider catheter based on urine output
- when glucose less than 14, start 10% glucose at 125ml/hour
- treat precipitating cause
2
Q
upper gi bleed
A
- protect airway and keep nbm
- 2 wide bore cannulae
- urgent bloods; fbc, u+es, clotting, glucose, lfts, crossmatch 6 units
- rapid iv crystalloid infusion up to 1 litre
- if signs of grade 3/4 shock give o-ve blood
- otherwise slow crystalloid infusion
- transfuse as dictated by haematinics
- correct clotting abnormalities, vitamin k, ffp, platelet concentrate
- consider icu referral, cvp
- catherise
- regular obs
- surgeons
- endoscopy; varices?
3
Q
status epilepticus
A
- maintain airway
- 100% o2 and suction as required
- iv access and u&es, lfts, fbc, glucose, calcium, tox screen if indicated, anticonvulsant levels
- slow iv lorazepam 2-4mg, second dose at 10 minutes if no response
- thiamine 250mg iv over 30 minutes if malnourishment suspected
- glucose 50ml 50% unless glucose known to be normal
- treat acidosis if severe
- correct hypotension with fluids
- if seizures continue then start phenytoin infusion 15-20mg/kg at less than 50 mg/min, alternative is diazepam infusion
- if seizures continue seek expert help for rapid sequence induction and continuous eeg monitoring in icu
4
Q
anaphylaxis
A
- secure airway and 100% oxygen
- remove cause and raise feet
- adrenaline im 0.5mg ie 0.5ml of 1;1000, repeat every 5 minutes as guided by obs
- secure iv access
- chlorphenamine 10mg iv
- hydrocortisone 200mg iv
- fluid challenge
- treat other symptoms
- consider icu help early if deteriorating
- measure mast cell tryptase
- ecg
- chlorphenamine 4mg/6hours if still itching
- medic alert bracelet and epipen
- find cause - skin prick testing
5
Q
asthma exacerbation
A
- assess severity using peak flow, ability to speak and obs
- salbutamol 5mg nebulised with o2
- hydrocortisone 100mg iv or prednisolone 40-50mg po; both if very ill
- start o2 if saturations below 92, check abg
- if life threatening features; inform icu and seniors, give salbutamol nebs every 15 mins, monitor ecg, add in ipratropium 0.5mg to nebs, give single dose mgso4 1.2-2g iv over 20 minutes
if improving within 15-30 minutes
- nebulised salbutamol every 4 hours
- prednisolone 40-50mg po od for 5-7 days
- monitor peak flow and sats, aim 94-98
if not improving
- refer to icu for consideration of ventilatory support and more intense medical therapy
6
Q
copd exacerbation
A
- salbutamol 5mg/4 hours and ipratropium 500 micrograms/6 hours
- cxr and abg
- controlled o2 therapy
- iv hydrocortisone 200mg and oral prednisolone 30mg od, continue for 7-14 days
- antibiotics if evidence of infection
- physiotherapy to get rid of sputum
- consider iv aminophylline if no response to nebs and steroids
- non-invasive positive pressure ventilation
- intubation and ventilation
- respiratory stimulant drug; doxapram, short term measure only
7
Q
acs with st elevation
A
- mmonac
- 120min cut off for ppci; bivalirudin used to antocoagulate
- otherwise fibrinolysis and rescue pci/angiography if available
8
Q
hypoglycaemia
A
200-300ml of 10% dextrose iv
9
Q
narrow complex tachycardia
A
- get ecg and iv access, o2 if hypoxic
- if irregular, treat as af (beta-blocker, digoxin or cardioversion; amiodarone or dc shock)
- if regular start continuous ecg trace
- vagal maneouvres
- adenosine 6,12,12 or verapamil
- if adverse signs sedate and synchronised dc cardioversion 150, 360, 360, then amiodarone
- if no adverse signs beta-blockers (metoprolol), digoxin, amiodarone, overdrive pacing, seek cardiology advice
10
Q
broad complex tachycardia
A
- give 02 if sats less than 90
- get iv access and 12 lead ecg
adverse signs yes
- get help
- sedate
- up to 3 synchronised dc shocks (150-200J)
- amiodarone 300mg iv over greater than 20 minutes; then 900mg over 24 hours via central line
- check and correct potassium and magnesium
- further cardioversion if needed
for refractory cases consider; lidocaine, procainamide, fleicainide or overdrive pacing
adverse signs no
- correct electrolyte problems; esp low potassium
- assess rhythm; regular = vt therefore give amiodarone 300mg etc but consider adenosine as an alternative, irregular = af/pre-excited af/polymorphic vt - give magnesium on ivi
- get expert help if no success
- sedation
- synchronised dc shock
11
Q
pulmonary oedema/cardiogenic shock
A
- titrate o2 to maintain sats at 94-98
- diamorphine 1.25-5mg iv
- investigations and close monitoring
- correct arrhythmias, electrolytes and acid-base disturbances
- assess obs, jvp, cvp and consider toe
- alter fluid balance as appropriate
- look for and treat reversible causes (mi/pe/acute vsd/valvular disease)
12
Q
pneumothorax
A
primary pneumothorax
- aspirate if symptomatic and/or greater than 2cm rim on cxr
- chest drain if two inadequate aspirations
- discharge otherwise
secondary pneumothorax
- insert a chest drain if older than 50 and rim greater than 2cm on cxr
- otherwise attempt aspiration; if not successful insert chest drain
- otherwise admit for 24 hours observations
10-14 french tube, seldinger technique
13
Q
pulmonary embolism
A
- o2 if hypoxic
- morphine 5-15mg iv with antiemetic if pain or distress
- consider immediate thrombolysis with 50mg alteplase if periarrest
- iv access and start heparin
- assess bp
- bp greater than 90 systolic then start warfarin loading regimen eg 5-10mg po
bp less than 90 systolic, consider colloid infusion, noradrenaline infusion and thrombolysis unless aready given
investigations
- u+es, fbc, baseline clotting
- ecg
- cxr
- abg
- d-dimer
- ctpa or vq perfusion scan
14
Q
meningitis
A
- abcde
- ivi and fluid resus
- 2g cefotaxime iv plus others as per suscpicions
predominantly septicaemic
- no lp
- cefotaxime
- critical care team
predominantly meningitic
- dexamethasone 4-10mg/6 hours iv
- raised icp to icu
- no shock or raised icp then lp after cefotaxime
15
Q
acs without st elevation
A
- admit to ccu
- low flow o2 if sats below 90 or breathless
- morphine and metoclopramide
- gtn
- aspirin and clopidogrel/ticagrelor
- beta-blocker; metoprolol if hypertensive/tachycardic/low lv function
- verpamil/diltiazem if metoprolol contraindicated
- fondaparinux 2.5mg od sc or lmwh
- iv nitrate if pain continues
- risk stratify with grace score
- low risk; discharge and medically manage
- high risk; infusion of tirofiban (glycoprotein 2b/3a antagonist) and refer for angiography as inpatient
