Medical Flashcards
Hypothermia
Swiss grade 2-4 how defined
2 - 28-32 - impaired consciousness no shivering
3 - 24-28 no shivering, unconscious but vitals
4 - <24 no signs of life
Hypothermia SOP
May be prolonged resus
General assessment and grading
Management of those in Arrest/not arrest
- changes in ALS?
No drugs until >30 degrees
Consider doubling dose of drugs between 30-35 (6-8mins)
If still in VF after 3x shocks no more shocks until >30d
Use LUCAS asap use US instead of pulse check
If transporting in arrest need to go to centre for extra corporeal warning (top cover)
Magnesium sulphate
SOP indications
Contraindications
1g in 2mls
Refractory VF (2g 10 mins)
Torsades (2g 10’mins)
Af 4.5G IV 15 mins
Life threatening asthma (2g 20 mins or 40mg/kg child) or 150mg neb
Eclampsia (4g 20mins repeat 2g infusion)
Contraindicated in children <2
Allergy to MgSO4
Renal/hepatic failure
Thrombolysis- indications (4 criteria)
Suspected PE causing massive collapse/arrest
No contraindications to Tenectaplase (dissection or allergy) or ICH
Likely good outcome from therapy
Tenectaplase dose
See cheat card
Weight based
70-80kg = 8000 units
80-90kg = 9000 units
90-100 = 10000 units
Prolonged resus >100 mins
Sepsis
1)Definition
2)Abx carried and doses
1) life threatening organ dysfunction caused by dysregulated host response to infective agent (shock = sepsis with significant circulatory and cellular failure associated with increased mortality and hypotension)
2) CoAmoxiclav 1.2g adult - open fractures
BenzylPenicillin - meningitis - 1.2g Adult and > 10 (1-10 = 600mg < 1 = 300mg IM/IV/IO
Aciclovir - encephalitis - 10mg/kg adults and kids
Clindamycin - pen allergic open # 600mg or 5mg/kg paeds in 100ml 5% glucose
Arrhythmia and pacing
1) Indication for pacing
2) Pacing pads position
3) B blocker or Ca channel blocker over dose - try?
4) how to pace
5) Synch DCCV - why?
6) how?
7) refractory VF
1) Bradycardia <60 with insufficient CO to maintain organ perfusion eg syncope, shock, myocardial ischaemia or HF
2) AP preferentially
3) glucagon +\or calcium
4) pads on, sedate, ensure synched and pacing mode. Select rate 30 above current, set threshold for 70mA and increase until every spike capturing
5) tachyarrhythmia causing reduction in CO to maintain organ perfusion
6) AP pads on, ensure synch to peak of R wave, sedate, Narrow complex = 100j -> 200J -> 360J
B-road complex and AF -200-> 360 -> 360
Consider MgSO4 2g and Amiodarone 300mg (5mg/kg paed)
(Paeds shock 1J/kg -> 2 -> 3 - 4J/kg)
7) consider lidocaine 1.5mg/kg after 7th shock (amio 300 & 150 after 3rd and 5th shock)
ABD
1) Definition (3As)
2) precipitates
3) risks?
4) main points in Mx
1) Agitated
Autonomic dysfunction
Acute delirium
2) drugs (NMDA, cocaine, novel psychoactives, amphetamine) infections, electrolyte, exercise, intracranial pathology
3) sudden cv collapse, MOF, cardiac arrest, hyperthermia
4) Safety first
Minimal physics restraint
Deescalation
Capacity assessment
Chemical sedation - ketamine (3-5mg/kg IM or benzos IV)
PHEA
PHEA SOP indications (6)
- Airway compromise
- Ventilatory failure
- Low GCS
- Severe agitation
- Anticipated clinical course
- Humanitarian
Blood transfusion SOP
Nice major trauma guideline 39
Indications
Post transfusion
Audit
1) what does NOCE guideline NG39 say about patients with active bleedin?
2) LNAA indications for blood transfusion? (3)
3) what temp does the tinytag have in range?
4) what steps must you take before administration?
5) what should you do after transfusion?
1) Patients with suspected active bleeding should be managed with a restrictive approach to fluid resuscitation. Titrate to Maintain a central pulse (femoral/carotid)
If TBI predominates have less restrictive approach
- Traumatic patient with suspected bleeding and signs of life-threatening hypovolaemic shock (Hateful 8)
Patients with non traumatic conditions with signs of life-threatening shock (eg AAA, UGI bleed, obstetric)
Patients in TCA where bleeding is thought to have played a major role and has been addressed (TQ etc) and ROSC/good outcome likely
3) 2-6 degrees - if green and flashing ok to use. If red then not ok (unless green and flashing within last hour)
4) consent if able
Stop bleeding either TQ, splinting, reduction, compression etc
TXA prior
If NCH rapid transfer to hospital
5) PRF and blood transfusion report form
Photos of blood bags
Then in clear bag with cable tie and then orange bag.
HEMSBASE entry and then print out form and put in credo box for blood bank
Datix any problems or
6) audit KPIs
Every 6/12
100% must get TXA
100% of those getting 2or more should get calcium
100% through a warmer
Ventilation SOP
What is general policy?
Starting vent settings? Targets?
Asthma changes?
Open lung policy reducing alveolar collapse
Peep 5 vt 6-8 I:e 1:2 Fio2 1.0 rr 15
Aim SpO2 94-98, etco2 3.5-4.5 kpa
Asthma slow and low
Reduce rr and increase I:e, p max cautious increase, pressure control bipap, peep 5 max
Be ready to decompress or stop breath stacking
CO2 clearance less important than oxygenation
PHEA SOP - indications, optimisation, delivery
optimisation
Position - 360 degree access, environmental, trolley height, sat up? Ear to sternal notch
Patient - dsi ketamine 0.5mg/kg
Volume - FFP:blood
Squeeze if septic or spinal
Oxygenation - tight fitting NRM or BVM and nasal oxygen 4L-> 15L/min
Medical cardiac arrest
Definition
Key points
Adrenaline infusion
A sudden loss in blood flow due to inability of heart to maintain CO for end organ perfusion
30% LNAA work
Key points
Good history (why has this patient arrested?) and examination. Clarify times of arrest, no flow, low flow and CPR quality
Ensure safe configuration ie good cpr, oxyg menation and etco2.
Early defib
Consider reversible causes Inc thrombolysis
May need increased RR if acidotic and likely need long CPR to improve cardiac mileu
PLE as required
ROSC - neuro protection, full exam and sedation etc as required (midaz +- roc)
Triage?
Adrenaline
Adrenaline
2mg (2 x 1:1000 amps) into 18mp NaCl 0.9% 20 ml total = 100mcg/ml
Run 1-6ml/h (100-600mcg/h)
Acute mental health issues SOP
General approach
Legal frameworks - Mental Capacity Act 2005
Mental Health act 1987
Safe (rooms with >1 exit, radios on, with crew mate, check with patient if any dangerous items on them etc)
Care and compassion
Thorough hx and exam
Get people to leave if making scene worse
Capacity assessment documented
Least restrictive option
Capacity - if non in MCA (2005) then act in best interests. Least restrictive option.
Understand info, retain, weigh up and communicate.
Only >16 (invalid if Advanced directive)
Assume capacity until proven otherwise. Allowed to make unwise decisions.
MHA 1987 - section 136 police can detain those in mental health crisis in public places.
135 - warrant to enter private residence to detain
Consider top cover call for advice
JRCALC diagnosis of death unequivocal
Incineration
Decapitation
Cerebral or cranial destruction
Hemicorporectomy or similar
Putrefaction
Hypostasis
Rigor mortis
Decomposing
Asystole 30 mins
