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Acute Station > Management > Flashcards

Management Flashcards

1
Q

Investigations for Severe Pulmonary Oedema

A

Chest x-ray: Cardiomegaly, Signs of pulmonary oedema: bilateral shadowing, small effusions at costophrenic angles, fluid in fissures, kerly b lines (septal linear opacities)

ECG: signs of MI, dysrhythmia

Bloods: Troponin, U&Es
BNP
ABG

Echo

Signs on examination: distressed, pale, sweaty, tachycardia, tachypnoea, pink frothy sputum, pulsus alterans, increased JVP, fine crackles, triple gallop, wheeze (cardiac)

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2
Q

Management of Severe Pulmonary Oedema/Acute Heart Failure

A

A through to E approach

Sit the payment up

High-flow O2

IV access and ECG
Treat any arrhythmias

Diamorphine 1.25-5mg IV slowly

Furosemide 40-80mg IV slowly
Increase dose in renal failure

GTN spray or sublingual (2 x 0.3mg)
Only if SBP >90mmHg

If SBP >100mmHg start nitrate infusion

If worsening
Repeat dose of furosemide
Consider CPAP
Increase nitrate infusion whilst maintaining SBP

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3
Q

Investigations for Cardiogenic Shock

A

Investigations: ecg, u&e, troponin, abg, cxr, echocardiogram. If indicated, ct thorax (speak with radiologists, this can be protocolled for both aortic dissection and pe)

Monitor: cvp, bp, abg, ecg, urine output. Keep on cardiac monitor/telemetry. Record a 12-lead ecg every hour until the diagnosis is made. Consider a cvp line and an arterial line to monitor pressure, if these are in situ consider measuring cardiac output and volume status. Catheterize for accurate urine

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4
Q

Management of Cardiogenic Shock

A

Oxygen - maintain O2 at 94-98%

Diamorphine 1.25-5mg IV slowly (1mg/minute)

Investigations and monitoring

Correct arrhythmias, abnormalities and acid-base disturbance

Optimise filling pressure
Under filled –> plasma expander every 15 minutes

Over filled –> dobutamine 2.5-10 micrograms/kg/min

Aim for MAP 70mmHg

Treat reversible causes: pulmonary embolism, MI, valve failures

Manage in acute coronary care unit

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5
Q

Beck’s Triad

A

Muffled heart sounds

Raised JVP

Hypotension with narrowed pulse pressure

Indicative of cardiac tamponade

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6
Q

Signs of Cardiac Tamponade

A

Beck’s Triad
Hypotension with narrowed pulse pressure
Raised JVP
Muffled heart sounds

Increased JVP on inspiration (Kussmauls)

Pulsus paradoxus (pulse fades on inspiration)

Echo

CXR: globular heart, left heart border convex or straight, right costophrenic angle >90%

ECG: electrical alterans

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7
Q

Management of Pericardial Effusion

A

Get a senior to come now

Pericardiocentesis

While you wait, monitor ECG and give O2

Take bloods, with cross-match

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8
Q

Pericardiocentesis

A

Subxiphoid approach

Long 18-22 G needle attached to syringe

Insertion: between xiphisterum and left costal margin direct towards the left shoulder at 40 degree angle to skin continual aspiration as needle approaches RV once pericardial fluid aspirated, can insert cannula into pericardial space attach a 3 way tap and remove fluid with improvement in haemodynamics

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9
Q

Management of Broad Complex Tachycardia

A

> 100bpm QRS >120ms

Pulse? No —> arrest protocol

Yes

Give O2 if data <90%
IV access
12-lead ECG

Check for adverse signs?
Shock SBP <90mmHg
Chest pain/ ischaemia on ECG
Heart failure
Syncope

No
Correct electrolyte abnormalities
Assess rhythm
300mg IV amiodorone

Yes
Get expert help
Sedation
3 synchronised DC shocks
Check and correct electrolyte abnormalities
300mg IV amiodorone (>20 minutes)

Give amiodarone through central line

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10
Q

Dose of Amiodarone

A

300mg IV over >20 minutes

Then 900mg through central line

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11
Q

Dose of Adenosine

A

6mg IV bolus

Then 12mg

Second 12mg

Move onto verapamil

Warn about transient chest tightness, dyspnoea, headache and flushing

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12
Q

Dose of Verapamil

A

2.5-5mg

Over 2 minutes IV

Contraindicated in patients taking beta blockers

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13
Q

Management of Narrow Complex Tachycardia

A

QRS <120ms
Rate >100

O2 if SaO2 <90%
Achieve IV access
12-lead ECG

Adverse signs?

  • shock
  • chest pain
  • heart failure
  • syncope
--->yes
Seek expert help
Sedation
Three synchronised DC
Check electrolytes and correct
 300mg Amiodarone
DC cardio version
900mg Amiodarone via central line

—>no
Continuous ECG
Vagal manoeuvres

Then
Adenosine 6mg IV bolus
Then Adenosine 12mg
Then Verapamil 2.5-5mg

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14
Q

Management of AF

A

Metoprolol 1-10mg IV
Give small increments to slow rate

Rate-limiting Ca2+ channel blocker e.g. verapamil 5-10mg IV

If heart failure, can use digoxin as alternative
Load dose with 500micrograms

Amiodarone can be used to control rhythm

Anticoagulant therapy to reduce risk of stroke
DOAC: Apixabam 5mg BD

If onset <48 hours —> DC cardioversion
Anti coagulated for 3 weeks —> DC cardioversion

Chemical cardioversion
Flecanide 2mg/kg IV slow over 10-30 minutes with ECG monitoring

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15
Q

Cushing’s Triad

A

Bradycardia
Hypertension
Irregular breathing

Indicative of raised ICP

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16
Q

Beta-blocker overdose antidote

A

Glucagon

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17
Q

Management of Bradycardia

A

Give O2 if SaO2 <90%
Manual BP
IV access
ECG

Identify reversible causes (e.g. Hypothermia, electrolyte abnormalities)

Adverse signs?
Shock
Heart failure 
Syncope
Myocardial ischaemia

Yes adverse signs present
Atropine 500micograms IV every 3-5 minutes
Maximum of 3mg (6 doses)
If fails, Transcutaneous pacing (under sedation)

Isoprenaline 
Adrenaline
Dopamine
Aminophylline 
Glucagon

If no adverse signs, assess risk of asystole
Recent asystole
Mobitz II AV block
Complete heart block
Ventricular pauses >3s
If risk –> commence management above of atropine

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18
Q

Management of Acute Asthma

A

Assessment - Severity
If severe/life-threatening notify ICU

Supplement O2 to achieve sats of 94-98%

Salbutamol 5mg in oxygen-driven nebuliser

If severe, add in ipratropium bromide 0.5mg/6 hours to nebuliser

Prednisolone 40-50mg PO OR. Hydrocortisone 100mg IV

Reassess every 15 minutes
If PEF<75%, repeat salbutamol nebuliser every 15-30 minutes
Monitor ECGs, watch for arrhythmias

Consider single dose of IV magnesium sulphate 1.2-2g over 20 minutes in those with severe/life-threatening features without good response to initial therapy

If not improving ---> ICU
Normocapnia
Worsening acidosis
Low pO2
Exhaustion, feeble respiration
Drowsiness, confusion 
Respiratory arrest
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19
Q

Management of Acute Exacerbation of COPD

A

A—>E

Nebulised bronchodilators
Salbutamol 5mg /4h
Ipratropium bromide 500micrograms /6h

Controlled oxygen therapy
Indicated if SaO2<88% or PaO2 <7 kP
Start using Venturi mask 24-28% FiO2
Aim for PaO2 >8 with a rise in PaCO2 <1.5

Steroids
IV hydrocortisone 200mg
And
Oral Prednisone 30mg OD

Antibiotics
Amoxicillin 500mg QDS
Clarithromycin or Doxycycline

Physiotherapy to aid clearance

If no response to nebulisers or steroids —> IV aminophylline

No response —> consider Non-invasive positive pressure ventilation (NIPPV)
If RR>30, pH<7.35, or rising PaCO2

Doxaparam in those not suitable for mechanical ventilation (1.5-4mg/min)

Consider intubation and ventilation

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20
Q

When to seek surgical advice for pneumothorax

A

Bilateral pneumothoraces
Lung fails to expand within 48hours of intercostal drain insertion
Persistent air leak
2 or more previous pneumothoraces on same side
History of pneumothorax on opposite side

21
Q

Management of tension pneumothorax

A

Large bore needle with saline in syringe as water seal
Or cannula
2nd intercostal spade mid-clavicle line

Once aspirated

Chest X-ray

Then chest drain

22
Q

CURB-65

A

Confusion (abbreviated mental test score < or equal to 8)

Urea (>/7mmol/L)

Respiratory rate (>/30/min)

Blood pressure <90/60mmHg

Age >\ 65 years

Curb score
1- treatment at home
2- treatment in hospital
3- severe pneumonia and consider ICU 
4
5
23
Q

Pneumonia management by CURB-65

A

1- treat at home
2- treat in hospital
3- severe, consider ICU

2- Blood cultures
2-Sputum cultures (has not yet commenced antibiotics)
2- urine pneumococcal antigen
2- Consider pleural fluid aspiration
3-Sputum cultures (irrespective of commencement of antibiotics)
3- legionella antigen

Everyone gets chest X-ray and ABG if SaO2<92%

24
Q

Antibiotics for Mild/Moderate Pneumonia

A

Mild not previously ℞ (curb 0–1)
Streptococcus pneumoniae
Haemophilus influenzae

—>
Oral amoxicillin 500mg–1g/8h or clarithromycin 500mg/12h or doxycycline 200mg loading then 100mg/day (initially 5-day course)

Moderate (curb 2)
Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae

—>
Oral amoxicillin 500mg–1g/8h + clarithromycin 500mg/12h or doxycycline 200mg loading then 100mg/12h If iv required: amoxicillin 500mg/8h + clarithromycin 500mg/12h (7-day course)

25
Q

Antibiotics for Severe Pneumonia

A

Severe (curb >3)

Co-amoxiclav 1.2g/8h iv or cephalosporin iv (eg cefuroxime 1.5g/8h iv) and clarithromycin 500mg/12h iv (7 days)

Add flucloxacillin ± rifampicin if Staph suspected; vancomycin (or teicoplanin) if mrsa suspected. Treat for 10d (14–21d if Staph, Legionella, or Gram −ve enteric bacteria suspected)

Panton-Valentine Leukocidin-producing Staph. aureus (pvl-sa)

Seek urgent help. Consider adding iv linezolid, clindamycin, and rifampicin

26
Q

Antibiotics for Atypical Pneumonia

A

Atypical
Legionella pneumophilia
Fluoroquinolone combined with clarithromycin, or rifampicin, if severe. See p[link]

Chlamydophila species
Tetracycline

Pneumocystis jirovecii
High-dose co-trimoxazole

27
Q

Antibiotics for Aspiration Pneumonia

A

Aspiration
Streptococcus pneumoniae
Anaerobes

Cephalosporin iv + metronidazole iv

28
Q

Antibiotics for Neutropenic Pneumonia

A

Neutropenic patients
Gram-positive cocci
Gram-negative bacilli

Aminoglycoside iv + antipseudomonal penicillin iv or 3rd-generation cephalosporin iv

29
Q

Antibiotics for Hospital-Acquired Pneumonia

A

Hospital-acquired
Gram-negative bacilli
Pseudomonas
Anaerobes

Aminoglycoside iv + antipseudomonal penicillin iv or 3rd-generation cephalosporin iv (p[link])

30
Q

Signs of PE on ECG

A

Commonly normal
Or sinus tachycardia

Can have:
Right ventricular strain pattern v1–v3 
Right axis deviation
RBBB
AF
May be deep s waves in I, q waves in III, inverted t waves in III (‘sI qIII tIII’).
31
Q

When to do a d-dimer?

A

Do a d-dimer in patients with low pre-test probability

Wells Score <4

32
Q

Management of PE on Modified Two-Level Wells Score

A

Wells Score

<4 –> D-dimer
Positive D-dimer —> CTPA or treatment with LMWH
Negative D-dimer –> consider something else

> 4
CTPA
OR treatment with LMWH if delay

33
Q

Management of PE

A

A—>E

O2 if hypoxic

Morphine 5-10mg IV + anti-emetic if patient distressed

IV access and start Fonaparinux (dose on weight)
~7.5mg / 24 hours

Bridge with Warfarin or switch to apixabam

If hypotensive –> 500ml over 15 minutes of crystalloid

If haemodynamically unstable –> thrombolysis with alteplase

Find underlying cause
If obvious remedial cause 3 months of anticoagulation
If not, continue for ≥3–6 months
Long term if recurrent emboli, or underlying malignancy

34
Q

Management of Upper GI Bleed

A

Is the patient shocked?

Peripherally cool/clammy; capillary refill time >2s; urine output <0.5mL/kg/h.
↓gcs or encephalopathy (p[link]).
Tachycardic (pulse >100bpm).
Systolic bp <100mmHg; postural drop >20mmHg.

If shocked –> treat for shock

If haemodynamically stable:
Insert two large-bore (14–16g) iv cannulae and take blood for fbc, u&e, lft, clotting, and group & save.

Give iv fluids) to restore intravascular volume; avoid saline if cirrhotic/varices; consider a cvp line to monitor and guide fluid replacement.

Organize a cxr, ecg, and check abg.

Consider a urinary catheter and monitor hourly urine output.
Transfuse if significant Hb drop (<70g/L).

Correct clotting abnormalities (vitamin K, FFP, platelets)

If suspicion of varices (eg known history of liver disease or alcohol excess) then give terlipressin iv (1–2mg/6h for ≤3d) and initiate broad-spectrum iv antibiotics (eg piperacillin/tazobactam iv 4.5g/8h).

Monitor pulse, bp, and cvp (keep >5cmH20) at least hourly until stable.

Arrange an urgent endoscopy

If endoscopic control fails, surgery or emergency mesenteric angiography/embolization may be needed

For uncontrolled oesophageal variceal bleeding, a Sengstaken–Blakemore tube may compress the varices, but should only be placed by someone with experience.

35
Q

Management of Meningitis

A

If ↑ICP, summon help immediately and inform icu.

Initiate early antibiotics. Take blood cultures first. Then perform lp prior to antibiotics only in patients where no evidence of shock, petechial rash or ↑icp and where able to obtain lp within 1h

Consult local policies and seek advice
Empirical options include ceftriaxone 2g/12h IV
Add eg amoxicillin 2g/4h iv if >60yrs age or immunocompromised.

Acivlovir if suspected viral - 10mg/kg/8h iv over 1h

If features of menigism give dexamethasone 10mg/6h iv

Other investigations, u&e, fbc (↓wbc ≈ immunocompromise: get help), lft, glucose, coagulation.

Throat swabs (1 for bacteria, 1 for virology)

CXR

Consider hiv, tb tests.

Prophylaxis (discuss with public health/id):
Household contacts in droplet range.
Those who have kissed the patient’s mouth. Give ciprofloxacin (500mg po, 1 dose; child 5–12yrs: 250mg; child <5yrs: 30mg/kg to max 125mg).

36
Q

Dose of Acivlovir in suspected viral meningitis

A

10mg/kg/8h iv over 1h

37
Q

Dose of Ceftriaxone in suspected meningitis

A

Ceftriaxone 2g/12h IV

38
Q

Encephalitis Management

A

Bloods: Blood cultures; serum for viral pcr (also throat swab and msu); toxoplasma IgM titre; malaria film.

Contrast-enhanced ct: Focal bilateral temporal lobe involvement is suggestive of hsv encephalitis.
Meningeal enhancement suggests meningoencephalitis.
Do before LP

MRIis alternative if allergic to contrast.

LP: Typically moderately ↑csf protein and lymphocytes, and ↓glucose

Send CSFfor viral PCR including HSV

EEG: Urgent EEG showing diffuse abnormalities may help confirm a diagnosis of encephalitis, but does not indicate a cause

Management
Mortality in untreated viral encephalitis is ~70%

Aim to start aciclovir within 30min of the patient arriving (10mg/kg/8h iv over 1h) for 14d as empirical treatment for HSV
(21d if immunosuppressed)

Specific therapies also exist for cmv and toxoplasmosis

Supportive therapy, in high-dependency unit or icu environment if necessary.

Symptomatic treatment: eg phenytoin for seizures

39
Q

CT/MRI signs of cerebral abscess

A

Ring-enhancing lesion

40
Q

Management of Status Epilepticus

A

Lorazepam: 0.1mg/kg (usually 4mg) as a slow bolus into a large vein.
If no response after 10–20min give a second dose.

Beware respiratory arrest during the last part of the injection. Have full resuscitation facilities to hand for all IV benzodiazepine use. The rectal route is an alternative for diazepam if IV access is difficult. Buccal midazolam is an easier to use oral alternative where no IV access (eg in a community setting); dose for those 10yrs old and older 10mg; squirt half the volume between the lower gum and the cheek on each side.

Phenytoin infusion: 15–18mg/kg IVI (1.5g if 80kg; max 2g), at a maximum rate of 50mg/min (don’t put diazepam in same line: they don’t mix).
Beware ↓BP and do not use if bradycardic or heart block.
Requires BP and ECG monitoring. 100mg/6–8h is a maintenance dose (check levels)

Seek ICU help: Paralysis and anaesthesia with eg propofol is required. Close monitoring, especially respiratory function, is vital. Consider whether this could be pseudoseizures - particularly if there are odd features (pelvic thrusts; resisting attempts to open lids and your attempts to do passive movements; arms and legs flailing around).

Dexamethasone: 10mg iv if vasculitis/cerebral oedema (tumour) possible.

41
Q

When to perform an urgent CT head after trauma

A

gcs <13 on initial assessment, or gcs <15 at 2h following injury.

Focal neurological deficit

Suspected open or depressed skull fracture, or signs of basal skull fracture: periobital ecchymoses (‘panda’ eyes/racoon sign), postauricular ecchymosis (Battle’s sign), CSF leak through nose/ears, haemotympanum.

Post-traumatic seizure.

Vomiting more than once

Perform a ct head <8h if:
Any loss of consciousness or amnesia and any of:
Age ≥65
Coagulopathy
High-impact injury, eg struck by or ejected from motor vehicle; fall >1m or >5 stairs
Retrograde amnesia of >30min.

42
Q

When to admit head injury

A

New, clinically significant abnormalities on ct

GCS<15 after ct, regardless of result or continuing worrying signs (eg vomiting)

When ct indications met but ct unavailable

Other concerns (eg drugs or alcohol, other injuries, csf leak, shock, suspected non-accidental injury, meningism).

43
Q

When to perform a CT Spine

A

Perform a ct cervical spine <1h if:

GCS <13 on initial assessment.

The patient has been intubated.

Definitive diagnosis of cervical spine injury is needed urgently (eg before surgery).

The patient is having other body areas scanned, eg multi-region trauma.

Clinical suspicion of cervical spine injury and any of:
Age 65 years or older
High-impact injury
Focal neurological deficit
Paraesthesia in the upper or lower limbs.

If above-listed criteria are not met and if any of the following low-risk features are present, then assess neck movement:

* simple rear-end motor vehicle collision
* comfortable in a sitting position
* ambulatory since injury
* no midline cervical spine tenderness
* delayed onset of neck pain. If patient unable actively to rotate neck 45° to left and right or if a low-risk feature not present, then obtain plain x-rays of cervical spine <1h. If x-rays technically inadequate, suspicious, or definitely abnormal, proceed to ct.
44
Q

Causes of Raised ICP

A

Primary or metastatic tumours

Head injury

Haemorrhage (subdural, extradural, subarachnoid, intracerebral, intraventricular)

Infection: meningitis, encephalitis, brain abscess

Hydrocephalus

Cerebral oedema

Status epilepticus

45
Q

Management of Raised ICP

A

ABC

Correct hypotension, aim for MAP >90mmHg

Treat any seizures

Brief Ex + Hx, seek clues to cause

Elevate head to 30-40 degrees

If intubated, hyperventilate aim for PaCO2 3.5-4.0kPa

Osmotic agents, mannitol 20% solution 0.25-5mg/kg over 10-20 minutes

If tumour as cause –> dexamethasone 10mg IV followed by 4mg/6h

Restrict fluid to <1.5L per day

Find cause

ICP monitor

46
Q

Sings of Uncal Herniation

A

IIIrd nerve compression
Dilated ipsilateral pupil, then ophthalmoplegia (a fixed pupil localizes a lesion poorly but is ‘ipsilateralizing’)

This may be followed (quickly) by contralateral hemiparesis (pressure on the cerebral peduncle)

Coma from pressure on the ascending reticular activating system (aras) in the midbrain.

47
Q

Sings of Cerebellar Tonsil Herniation

A

Ataxi

VIth nerve palsies,

Upgoing plantar reflexes occur first

Then loss of consciousness, irregular breathing, and apnoea

This syndrome may proceed very rapidly given the small size of, and poor compliance in, the posterior fossa.

48
Q

Sings of Subfalcian Herniation

A

Cingulate gyrus (medial frontal lobe) is forced under the rigid falx cerebri

It may be silent unless the anterior cerebral artery is compressed and causes a stroke—eg contralateral leg weakness ± abulia (lack of decision-making).

49
Q

Managment of Hyperkalaemia

A

(K+ ≥7mmol/l or >5.3mmol/l with ECG changes)

ECG changes: arrhythmias, flat P waves, wide QRS, tall/tented T waves

15l/min O2 in all patients

Monitor defibrillator’s ECG leads, BP, pulse oximeter

Venous access, take bloods for urgent repeat U+E

If ECG changes seen or K+ ≥7mmol/l (arrhythmias, Fluids and renals

10ml of 10% calcium gluconate IV over 2min, repeat every 15min up to 50ml (five doses) until K+corrected

10 units Actrapid® in 50ml of 50% glucose over 10min

Salbutamol 5mg nebuliser

ABG to exclude severe acidosis

Consider Calcium Resonium® 15g PO or 30g PR

Call for senior help

Reassess, starting with A, B, C ☦

Acute Station (7 decks)

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