Key Management Issues

Question 1

Anaphylaxis

Answer 1

1. DRABCD (lie flat or sit up straight, no standing)
2. IM adrenaline 300-500microg (repeat every 5 mins as needed
3. IV saline bolus (20ml/kg) if hypotensive
4. Adrenaline infusion if unresponsive (1mg in 1L normal saline at 5ml/kg/hr)
5. If ongoing upper airway obstruction: nebulised adrenaline (5mL) –> intubation
6. If ongoing hypotension: normal saline fluid resus
7. If ongoing wheeze: salbutamol (puffer or nebs), oral pred (1mg/kg max 50mg) or IV hydrocortisone (5mg/kg max 200mg)
8. Observe for minimum 4hrs after last dose of adrenaline overnight if more severe/complicated)
9. Discharge meds: epipen + education, oral pred (1mg/kg max 50mg for 2 days), referral to allergy specialist, antihistamines if urticaria

Question 2

Oculogyric crisis

Answer 2

Benztropine 1-2mg IV or IM

Question 3

Seizures

Answer 3

1. Benzodiazepine (Midazolam/diazepam 10mg IV over 2mins - 0.2mg/kg in kids)
2. If ongoing: phenytoin 20mg/kg IV or sodium valproate 40mg/kg
3. If ongoing: consider transfer to ICU

Question 4

Opiate excess/overdose

Answer 4

1. DRABCD (beware QRS/QT prolongation & Torsades)

2. Naloxone 50-200microg IV bolus (every 2-3mins, max 2mg)

Question 5

Hypoglycaemic (severe)

Answer 5

1. IV glucose 20mL IV (50% in adults, 10% in kids)
   - -> consider IM/SC glucagon 1mg if IV not available
2. Monitor glucose levels every 1-2hours for 4hours

Question 6

Acute pulmonary oedema

Answer 6

1. Furosemide 20-80mg IV (repeat in 20mins if required)
2. GTN 10microg/min IV (double rate every 5 mins based on clinical response, monitoring BP so >90 systolic)
3. CPAP (100% O2)
4. Morphine 1-2.5mg IV single dose
5. If also AF –> amiodarone 300mg infusion over 60mins, then dobutamine

Question 7

Constipation

Answer 7

1. Psyllium (metamucil) or sterculia (normafibe)
2. Macrogol 3350 (movicol or osmolax)
3. Coloxyl & senna 1-2 tabs nocte

Question 8

Nausea & vomitting

Answer 8

Metoclopramide PO/IM/IV 10mg Q8h

Ondansetron PO/IV 4-8mg 8-12hrly