Emergency Treatment Flashcards

1
Q

ECG changes for STEMI?

A

ST elevation
New LBBB

Tall T waves
normalisation on ST segments
T wave inversion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

STEMI acute treatment?

A
  1. ECG
  2. Aspirin 300mg
  3. Morphine (w/ metoclopramide), oxygen, GTN spray
  4. Angiography with PCI (ST elevation >2mm din 2 chefs leads or >1mm in limb leads) - if presenting within 12 hrs of symptoms and PCI can be delivered in 120 mins, offer prasurgrel with aspirin if not already on oral anticoagulant
  5. Fibrinolysis with alteplase/streptokinase - if presenting pithing 12 hours of symptoms and PCI not possible in 120 mins
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

STEMI secondary prevention?

A

Dual anti platelet - lifelong aspirin, ticagrelor (at least 12 months)
ACEi - indefinitely, titrated as high as possible eg. ramipril
BB - indefinitely, titrated a high as possible eg. atenolol or bisoprolol
Statin - atorvastatin 80mg OD
Lifestyle - stop smoking, cardiac rehab, no driving for 4 weeks, reduce alcohol, diet

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

ECG changes for NSTEMI?

A

No ECG changes
ST depression, T wave inversion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

NSTEMI acute treatment?

A

BATMAN:
Beta blocker
Aspirin 300mg stat
Ticagrelor 180mg stat dose OR Prasugrel (clopidogrel 300mg if high bleeding risk)
Morphine
Anticoagulant - Fondaparinux
Nitrates - GTN

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is the GRACE score?

A

Assess for PCI in NSTEMIs - 6 month risk of death or repeat MI
<3% low risk
>3% intermediate/high risk - angiography with PCI within 72 hours (if indicated)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is the definition of shock?

A

Acute circulatory failure with inadequate or inappropriately distributed tissue perfusion, resulting in generalised hypoxia and/or an inability of the cells to utilise oxygen

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are the different types of shock?

A

Hypovolaemic
Cardiogenic
Anaemic
Cytotoxic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What are the subgroups of hypovolaemic shock?

A

Haemorrhagic
Septic
Anaphylactic
Neurogenic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Clinical presentation: hypovolaemic shock

A

Skin - cold, clammy, pale
Drowsiness/confusion
Increased sympathetic tone
Tachycardia
Sweating

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are the 4 classes of hypovolaemic shock?

A

Blood loss:
I - 0-15%
II - 15-30%
III - 30-40%
IV - > 40%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Clinical presentation: cardiogenic shock

A

Signs of myocardial failure
Raised JVP
Gallop rhythm
Basal crackles and pulmonary oedema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Clinical presentation: septic shock

A

Pyrexia and rigors
Nausea and vomiting
Vasodilation and warm peripheries
Bounding pulse

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the sepsis 6?

A

High flow oxygen, maintain sats >94%
Blood cultures
Measure serial lactate levels
IV antibiotics
IV fluids
Monitor urine output

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Clinical presentation: anaphylactic shock

A

Profound vasoldilation
Warm peripheries
Low BP
Tachycardia
Bronchospasm
Pulmonary oedema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Treatment: neurogenic shock

A

Vasopressin and atropine

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

When is rhythm control 1st line treatment for AF?

A

Reversible cause
New onset < 48 hours
AF causing HF
Symptomatic despite rate control

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What is usually 1st line treatment for AF?

A

Rate control
BB or rate limiting CCB (diltiazem or verapamil) monotherapy
Digoxin if non paroxysmal AF (if does no or little exercise or other rate drugs ruled out)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is paroxysmal AF?

A

Intermittent episodes of AF that terminate within 7 days either spontaneously or with treatment

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What type of drug is digoxin?

A

Cardiac glycoside

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

When is cardioversion used for rhythm control in AF?

A

Immediate - if < 48 hours or haemodynamically unstable
Delayed - if > 48 hours and stable

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What medication needs to be given for delayed cardioversion?

A

Antiocoagulate for min 3 weeks prior
Consider amiodarone 4 weeks prior and 12 weeks after

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What treatment is used for AF if monotherapy fails?

A

Combination therapy: any 2 of:
- BB
- diltiazem
- digoxin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What antiarrhythmic drug is contraindicated in patients with known IHD or structural HD?

A

Class 1c
eg. flecainide and propafenone

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

Long-term rhythm control:

A
  1. BB
  2. Dronedarone - 2nd line for rhythm control after successful cardioversion
  3. Amiodarone - LV impairment or HF
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

When is ‘pill-in-pocket used? and which drug?

A

Paroxysmal AF
Flecainide - take when episode starts

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

When is left atrial ablation considered in AF?

A

Drug treatment not tolerated/not suitable/unsuccessful in symptomatic paroxysmal or persistent AF
3 months of antiarrhythmic drugs after

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

What is CHA2DS2VASc?

A

Calculates stroke risk in patients with AF

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

Chadvasc score of 2 or more - action?

A

Anticoagulate with DOAC - apixaban, dabigatran, edoxaban, rivaroxaban
Men can have if score of 1 or more
Warfarin if DOAC contraindicated

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What is the ORBIT score?

A

Predicts risk of major bleeding in patients on anticoagulation for AF

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q

ORBIT score criteria:

A
  1. Haemoglobin - 2 points
    - Male - Hb < 13 or haematocrit < 40%
    - Female - Hb < 12 or haematocrit < 36%
  2. Age > 74 - 1 point
  3. Bleeding history - 2 points
    - GI, intracranial, haemorrhagic stroke -
  4. GFR < 60ml/min - 1 point
  5. Antiplatelet treatment - 1 point
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

ORBIT score outcomes:

A

Low risk - 0-2
Intermediate risk - 3
High risk - 4 or more

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

Acute management of stable SVT?

A

Valsalva manoeuvre
Carotid sinus massage
Adenosine 6mg IV bolus -> 12mg -> 12mg (verapamil as alternative)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

Acute management of unstable or unsuccessful management SVT?

A

Direct current cardio version with amiodarone 100J -> 200J -> 300J
Amiodarone loading dose of 300mg over 20 mins -> 900mg over next 23 hours

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Long term management of paroxysmal SVT?

A

Meds - BB. CCB, amiodarone
Radiofrequency ablation

36
Q

What is status epilepticus?

A

Seizure lasting longer than 5 minutes or 2 or more seizures without regaining consciousness

37
Q

Treatment of status epilepticus

A
  1. Benzodiazepine = IV lorazepam 0.1mg/kg, diazepam
  2. Further dose after 10 minutes
  3. No response still –> phenytoin/levetiracetam
  4. Intubation and GA
38
Q

Raised ICP presentation?

A

Headaches –> worse leaning forward/coughing
Vomiting
Papilloedema
Focal neurological deficit
Drowsiness
Seizures

39
Q

Management of raised ICP?

A

Treat underlying cause
Neuroprotective ventilation
Mannitol (1g/kg) or hypertonic saline
Radiotherapy
Dexamethasone - 8-16mg daily titrated down

40
Q

What is role of mannitol in raised ICP management?

A

Reduced ICP short term

41
Q

What score is used to diagnose PE?

A

Wells Score

42
Q

Well’s score <4 next steps?

A

PE unlikely
D-dimer (1), proximal leg US (2/3)
Interim therapeutic anticoagulation

43
Q

Well’s score > 5 next steps?

A

PE likely
CTPA and interim therapeutic anticoagulation

44
Q

Investigations for PE

A

FBC, U&Es, LFTs, PT, APTT
Can have raised troponin
ECG can look like MI

45
Q

What is the PESI score?

A

Risk of mortality and severity of complications in PE

46
Q

Management of PE - haemodynamically unstable?

A

Thrombolysis with streptokinase/alteplase

47
Q

Management of PE - haemodynamically stable?

A

Apixaban or rivaroxaban for 3 months (6 if unprovoked and active cancer)
If unsuitable - LMWH 5 days then dabigatran/edoxaban for at least 3 months
Renal impairment (eGFR < 15ml) - LMWH then UFH/VKA

48
Q

Long term PE management?

A

Compression stockings
IVC filters an option if repeat DVT/PE despite anticoagulation

49
Q

Pneumothorax: No SOB and <2cm rim of air on CXR. Treatment?

A

None - resolves spontaneously
Follow up 2-4 weals

50
Q

Pneumothorax: SOB and/or >2cm rim of air on CXR. Treatment?

A

Aspiration
Chest drain
Surgery if drain fails - abrasive pleurodesis, chemical pleurodesis, pleurectomy

51
Q

Tension pneumothorax. Treatment?

A

Large bore cannula into 2nd intercostal space in mid-clavicular line

52
Q

Upper GI bleed presentation

A

Haematemesis -> coffee ground vomit
Malaena
Hameodynamic instability

53
Q

What is the Blatchford score?

A

Likelihood of having upper GI bleed

54
Q

What is the Rockall score?

A

Risk of rebreeding or death after upper GI bleed

(do after endoscopy)

55
Q

Management of upper GI bleed?

A

ABCDE resuscitation
Bloods -> Hb (FBC), urea (U&Es), coagulation, LFTs, crossmatch
Transfuse
Endoscopy
Depends on source of bleeding
After endoscopy - PPI, repeat endoscopy if rebelled
stop NSAIDs, anticoagulants

56
Q

When is an endoscopy needed for upper GI bleed?

A

Immediately after resuscitation in unstable patient with severe acute upper GI bleed
Within 24 hours otherwise

57
Q

Upper GI bleed management: non variceal bleed

A

Mechanical method (clips) +/- adrenaline
Thermal coagulation with adrenaline
Fibrin or thrombin with adrenaline

58
Q

Upper GI bleed: variceal bleed

A

Terlipressin at presentation
Prophylactic abx
Band ligation
Transjugular intrahepatic portosystemic shunts (TIPS) if bleed not controlled by band ligation

59
Q

What transfusions are required for massive upper GI bleed?

A

Blood
Platelets - if actively bleeding and count < 50
Clotting factors - FFP if actively bleeding and PT or APTT > 1.5x normal
Prothrombin complex concentrate - if on warfarin and actively bleeding

60
Q

What is the definition of an AKI?

A

Acute drop in kidney function, diagnosed by measuring serum creatinine

61
Q

What is the criteria for AKI diagnosis?

A
  1. Rise in creatinine > 25 micromol/L in 48 hours
  2. Rise in creatinine > 50% in 7 days
  3. Urine output < 0.5ml/kg/hour for 6 hours
  4. eGFR fallen by >25% in children and young people in 7 days
62
Q

Risk factors for AKI:

A

CKD, HF, DM, liver disease, old age, cognitive impairments, nephrotoxic medications (NSAIDs, ACEI), contrast medium use

63
Q

3 types of causes of AKI?

A

Pre renal, renal, post-renal

64
Q

Pre renal causes of AKI

A

Inadequate blood supply - dehydration, hypotension (shock), HF

65
Q

Renal causes of AKI

A

Intrinsic disease - glomerulonephritis, interstitial nephritis, acute tubular necrosis

66
Q

Post renal causes of AKI

A

Obstruction to outflow - kidney stones, masses/cancers, ureter/ureteral strictures, enlarged prostate

67
Q

Investigations for AKI

A

Urinalysis:
- leucocytes and nitrates - infection
- protein and blood - acute nephritis
- glucose - diabetes

US - look for obstruction

68
Q

Management of AKI?

A

Stop nephrotoxic meds
Pre-renal - fluid rehydration
Renal - biopsy and specialist treatment
Post-renal - obstruction relief with nephrostomy to stunting within 12 hours of diagnosis

69
Q

When is dialysis needed for AKI management?

A

Persistent hyperkalaemia, refractory pulmonary oedema, symptomatic uraemia (encephalopathy, pericarditis), severe metabolic acidosis, poisoning (aspirin)

70
Q

Presentation of DKA?

A

Recent diabetic symptoms -> polyuria, polydipsia, WL
Abdominal pain, N+V
Dehydration
Lethargy, drowsiness
Kassmaul sign -> tachypnoea, acidotic breathing

71
Q

What is Kassmaul sign?

A

Increased JVP on inspiration

72
Q

Precipitating factors for DKA?

A

Infection
Inadequate insulin or non-adherence with insulin treatment
New onset DM or other psychological stress -> trauma, surgery
Other conditions -> hypothyroidism, pancreatitis
Drugs -> steroids, diuretics, atypical antipsychotics, salbutamol

73
Q

Diagnosis of DKA:

A

Acidosis = pH < 7.3 (+/- HCO3 < 15mM)
Hyperglycaemia = > 11.1
Ketonuria = urinary > 2mM, capillary blood > 3mM

74
Q

Management of DKA:

A

Resuscitation, IV access, catheter

Fluids:
- avoid fluid boluses
- 0.9% normal saline = 1l stat
- add potassium in 2nd bag if K < 5.5mM = 4L over 12 hours

Insulin infusion:
- actrapid at 0.1 units/kg/hour
- started after 1st hour

Monitor glucose to prevent hypoglycaemia:
- swap fluid to IV dextrose once blood glucose < 14mmol/L

Treat underlying triggers, monitor for signs of cerebral oedema, monitor glucose, monitor ketones, monitor pH

75
Q

Most likely patient for hyperosmolar hyperglycaemic state?

A

Often T2DM and elderly

76
Q

Diagnosis of hyperosmolar hyperglycaemic state

A
  • Hypervolaemia/marked dehydration
  • Marked hyperglycaemia (>30mmol/L) without significant hyperketonuria or acidosis
  • Osmolality >320mosmol/kg
77
Q

Management of HHS:

A

0.9% normal saline –> replace 50% of loss in first 12 hours, remained in next 12 hours

Low dose IV insulin (0.05units/kg/hr) - only when blood glucose no longer falling

Treat precipitant

Prophylactic anticoagulant in most patients –> LMWH during admission at least

78
Q

Hypoglycaemia definition?

A

Blood glucose levels < 3.5mmol/L

79
Q

Presentation of mild hypoglycaemia:

A

Hunger, anxiety, irritable, palpitations, tremor, sweating, tingling lips

80
Q

Presentation of moderate hypoglycaemia:

A

Headache, drowsiness, difficulty concentrating, impaired vision, confusion, impaired cognitive function (<3.0)

81
Q

Presentation of severe hypoglycaemia:

A

severe cognitive impairment, convulsions, LOC, coma

82
Q

Precipitating factors for hypoglycaemia?

A

Insulin regime
Sulfonylurea SE

83
Q

Management of hypoglycaemia:

A

10-20g fast acting carbohydrate - fresh fruit juice, glucose tablets, dextrose tablets, jelly babies, glucose gel (0.3g/kg children)

Recheck blood sugars after 10-15 mins
Repeat oral intake
Recheck sugars after 10-15 mins

If restored - long-acting carbs eg, bread, potatoes, pasta

If unconscious/unable to swallow:
- IM glucagon 1mg (child <8 years or <25kg = 500micrograms)
- if no response within 10 mins or no glucagon available call 999
- if restored -> oral carb
- IV dextrose if access

84
Q

Anaphylaxis management - hospital:

A

IM adrenaline, repeat after 5 mins
If respondents/cardio problems persisting - IV fluid bolus + IV adrenaline (expert guidance)

After stabilisation:
- non-sedating oral antihistamine
- serum tryptase levels

85
Q

Where is IM adrenaline administered?

A

anterolateral aspect of middle third of thigh

86
Q

Anaphylaxis management - home:

A
87
Q

What is the most common ECG change in PE?

A

Sinus tachycardia