Management Flashcards
Investigations for Severe Pulmonary Oedema
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)
Management of Severe Pulmonary Oedema/Acute Heart Failure
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
Investigations for Cardiogenic Shock
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
Management of Cardiogenic Shock
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
Beck’s Triad
Muffled heart sounds
Raised JVP
Hypotension with narrowed pulse pressure
Indicative of cardiac tamponade
Signs of Cardiac Tamponade
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
Management of Pericardial Effusion
Get a senior to come now
Pericardiocentesis
While you wait, monitor ECG and give O2
Take bloods, with cross-match
Pericardiocentesis
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
Management of Broad Complex Tachycardia
> 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
Dose of Amiodarone
300mg IV over >20 minutes
Then 900mg through central line
Dose of Adenosine
6mg IV bolus
Then 12mg
Second 12mg
Move onto verapamil
Warn about transient chest tightness, dyspnoea, headache and flushing
Dose of Verapamil
2.5-5mg
Over 2 minutes IV
Contraindicated in patients taking beta blockers
Management of Narrow Complex Tachycardia
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
Management of AF
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
Cushing’s Triad
Bradycardia
Hypertension
Irregular breathing
Indicative of raised ICP
Beta-blocker overdose antidote
Glucagon
Management of Bradycardia
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
Management of Acute Asthma
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
Management of Acute Exacerbation of COPD
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
When to seek surgical advice for pneumothorax
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
Management of tension pneumothorax
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
CURB-65
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
Pneumonia management by CURB-65
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%
Antibiotics for Mild/Moderate Pneumonia
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)
Antibiotics for Severe Pneumonia
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
Antibiotics for Atypical Pneumonia
Atypical
Legionella pneumophilia
Fluoroquinolone combined with clarithromycin, or rifampicin, if severe. See p[link]
Chlamydophila species
Tetracycline
Pneumocystis jirovecii
High-dose co-trimoxazole
Antibiotics for Aspiration Pneumonia
Aspiration
Streptococcus pneumoniae
Anaerobes
Cephalosporin iv + metronidazole iv
Antibiotics for Neutropenic Pneumonia
Neutropenic patients
Gram-positive cocci
Gram-negative bacilli
Aminoglycoside iv + antipseudomonal penicillin iv or 3rd-generation cephalosporin iv
Antibiotics for Hospital-Acquired Pneumonia
Hospital-acquired
Gram-negative bacilli
Pseudomonas
Anaerobes
Aminoglycoside iv + antipseudomonal penicillin iv or 3rd-generation cephalosporin iv (p[link])
Signs of PE on ECG
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’).
When to do a d-dimer?
Do a d-dimer in patients with low pre-test probability
Wells Score <4
Management of PE on Modified Two-Level Wells Score
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
Management of PE
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
Management of Upper GI Bleed
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.
Management of Meningitis
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).
Dose of Acivlovir in suspected viral meningitis
10mg/kg/8h iv over 1h
Dose of Ceftriaxone in suspected meningitis
Ceftriaxone 2g/12h IV
Encephalitis Management
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
CT/MRI signs of cerebral abscess
Ring-enhancing lesion
Management of Status Epilepticus
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.
When to perform an urgent CT head after trauma
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.
When to admit head injury
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).
When to perform a CT Spine
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.
Causes of Raised ICP
Primary or metastatic tumours
Head injury
Haemorrhage (subdural, extradural, subarachnoid, intracerebral, intraventricular)
Infection: meningitis, encephalitis, brain abscess
Hydrocephalus
Cerebral oedema
Status epilepticus
Management of Raised ICP
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
Sings of Uncal Herniation
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.
Sings of Cerebellar Tonsil Herniation
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.
Sings of Subfalcian Herniation
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).
Managment of Hyperkalaemia
(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 ☦
