Medical Emergencies Flashcards
Describe meningitis, its features, and management
Features:
- Early: include headache, leg pains, cold hand and feet, abnormal skin colour, fever
- Late: include meningism (neck stiffness, photophobia, Kernig’s sign), decreased conscious level, seizures, petechial non blanching rash
Management:
- Take blood cultures, FBC, U+E, Coagulation screen
- If not contraindicated do LP.
- Start antibiotics if under 55yrs cefotaxime 2g/6h IV if older or less than 3 months add ampicillin 2g/4h IV as well. If suspected viral give aciclovir.
- IV dexamethasone 4/7 in pneumococcal meningitis with GCS 8-11
- ciprofloxacin for contacts if menignococcal (Pneumococcal no prophylaxis needed unless cluster of cases)
Describe Acute severe asthma, its assessment and treatment
Typically presents acute breathlessness and wheeze important to assess severity:
- Severe attack: unable to complete sentences, RR >25, PR >110, PEF 33-50% predicted
- Life-threatening attack: PEF less than 33% predicted, silent chest, cyanosis, feeble respiratory effort, bradycardia or hypotension, exhaustion, confusion, coma, ABG showing high PaCO2, low PaO2, acidosis
Treatment:
- consider triple burst therapy Salbutamol 5mg (2.5mg if less than 5yrs) nebulised with oxygen + Ipratropium 0.5mg (0.25 if les than 5yrs)
- Hydrocortisone 100mg IV or Prednisolone 40-50mg PO
- If PEF remains less than 75% repeat salbutamol
- If life-threatening features present inform ICU and seniors
- give salbutamol nebs every 15 minutes and add in ipratropium 0.5mg
- Give single dose magnesium sulfate 1.2-2g IV over 20min
- consider iv salbutamol.
- If not improvement refer to ICU for consideration for ventilatory support
Describe Acute limb ischaemia, its symptoms and signs and management
It is a surgical emergency requiring revascularisation within 4-6h to save the limb. May be due to thrombosis in situ (~40%), emboli (38%), graft/angioplasty occlusion (15%), or trauma.
Symptoms and signs: The 6 P’s Pale, Pulseless, Painful, Paralysed, Paraesthetic and Perishingly cold.
Management: This is an emergency and may require urgent open surgery or angioplasty.
- If diagnosis is in doubt do urgent angiography.
- Anticoagulate with heparin.
- Beware of post op reperfusion injury and subsequent compartment syndrome.
Describe Compartment syndrome its symptoms and treatment
Bleeding, oedema or inflammation/ infection may increase the pressure within one of the osteofacial compartments. Reduced capillary flow leads to muscle ischaemia further oedema and further increase in pressure a vicious cycle which after 12 hours leads to necrosis of nerve and muscle.
Signs and symptoms: the classic features are disproportionately high pain, bursting sensation, paresis, and intense pain on passive extension of distal limb.
Treatment: decompression of compartment, removal of casts and dressings and fasciotomy may be necessary
Describe Acute exacerbation of COPD its presentation, investigations and management
A common medical emergency especially in winter may be triggered by infection. Differentials include asthma, pulmonary oedema, upper airway obstruction, PE, anaphylaxis.
Presentation: increasing cough, SOB, wheeze, decreased exercise capacity
Tests: ABG, CXR, FBC, CRP, ECG, sputum culture and blood cultures if pyrexial
Management:
- ABCDE approach
- look for cause such as infection or pneumothorax.
- Give nebulised salbutamol and ipratropium driven by air and controlled oxygen therapy aim for O2 sats 88-92% (after ABG if no hypercapnia increased oxygen sats to 94-98%) via Venturi.
- Give IV hydrocortisone and oral prednisolone, antibiotics if infective exacerbation
- if no response consider aminophylline.
- If no response consider non invasive ventilation BIPAP especially in patients with pH 7.25-7.35
- if still no response consider intubation and ventilation
Describe the management of STEMI
- Aspirin 300mg PO + Clopidogrel 300mg PO followed by 75mg/d
- Morphine 5-10mg IV + Anti-emetic (metoclopramide 10mg IV (1st line) or cyclizine 50mg IV)
- Nitrates if hypertensive or acute LVF
- Oxygen if SaO2 less than 95%, are breathless or in acute LVF
- Aim to restore coronary perfusion preferably by PCI or thrombolysis if unavailable.
- PCI should be offered to patients at a primary PCI centre or can be transferred to one within 120 minutes of first medical contact. If not available fibrinolysis may be give first and transferred after infusion.
- Fibrinolysis’ benefit steadily reduces from onset of chest pain target time is less than 30 minutes from admission and it is contraidicated 24h post onset of symptoms.
Describe the management of NSTEMI
- Aspirin 300mg PO + Clopidogrel 300mg PO follwed by 75mg/d
- Anticoagulation Fondaparinux (Factor Xa Inhibitor) or LMWH
- Nitrates
- Beta-blockers and ACE-i
- Assess risk with GRACE score
- High risk patients need angiography with 96h
- low risk continue assessment repeat troponin.
Describe tension pneumothorax, its signs and treatment
Air drawn into the pleural space with each inspiration has no route of escape during expiration. The mediastinum is pushed over into the contralateral hemithorax, kinking and compressing the great veins. Unless the air is rapidly removed, cardiorespiratory arrest will occur.
Signs: respiratory distress, tachycardia, hypotension, distended neck veins, trachea deviation away from side of pneumothorax (Late sign). Hyperresonant percussion note. reduced air entry/breath sounds on the affected side. Asymmetrical chest expansion. Surgical emphysema
Treatment: to remover the air, insert a large-bore (14-16G) needle with a syringe, partially filled with 0.9% saline, into the 2nd intercostal interspace in the midclavicular line on the side of the suspected pneumothorax. remove plunger to allow the trapped air to bubble through the syringe until a chest tube can be placed. alternatively insert a large-bore venflon in the same location.
Describe Acute Upper Gastrointestinal Bleeding, its causes, signs and symptoms, and management
Causes: Peptic ulcer disease (35-50%), Gastroduodenal erosions (8-15%), Oesophagitis (5-15%), Mallory-Weiss tear (15%), Varices (5-10%), Other e.g. malignancy.
Signs and symptoms: Haematemesis, or malaena, dizziness (especially postural hypotension), fainiting, abdominal pain, dysphagia, hypotension, tachycardia, decreased JVP, low urine output, cool and clammy peripheries, signs of chronic liver disease (variceal bleed) e.g. telangiectasia, purpura, jaundice, ascites.
Management:
- calculate Rockall score, glasgow-blatchford score
- is the patient shocked? e.g. cool, clammy, raised cap refill, pulse >100bpm, JVP not visible, systolic BP 20mmHg, urine output less than 30mL/h
- Resuscitate patient and in the case of variceal bleeding refer for urgent endoscopy (within 4 hours) for banding or sclerotherapy and give terlipressin 2mg SC QDS. (Octreotide can also be used in Variceal bleed but NICE 2016 Recommends Terlipressin)
- prophylactic antibiotic therapy
- For other bleeds endoscopy should be performed within 12-24hrs if patient was unstable on admission.
- if patient stable and scoring 0 on risk scores consider d/c and follow up OGD
- No need to stop aspirin/clopidogrel
Describe Status Epilepticus and its management.
Seizures lasting for more than 5 minutes or repeated seizures without intervening consciousness. Mortality and risk of brain damage increase with the length of attack so aim to terminate seizure.
Management:
- ABC, open and maintain airway, lay in recovery position, insert oral/nasal airway intubate if neccessary
- oxygen + suction as required.
- IV access and take blood, U+E, LFT, Glucose, Ca2+, ABG and BM
- check temperature if raised give rectal paracetamol may be febrile convulsion in young, consider eclampsia in pregnancy (give IV magnesium sulphate)
- Check Calcium, Mg and Glucose and if hypoglycaemic give glucose (in children 5ml/kg IV of 10% dextrose), if Hx of alcohol abuse give slow IVI thiamine (Pabrinex 2 pairs of ampoules TDS)
- 4mg lorazepam IV slowly (can be repeated once after 10mins) or 10mg buccal midazolam (can be repeated once), or 10-20mg Rectal Diazepam (Maximum of 30mg)
- get help PICU + Anaesthetist
- If above fails consider IVI Phenytoin 20mg/kg with ECG + BP monitoring (phenobarbitone if phenytoin already used /contraindicated)
- Consider Rapid sequence induction (ideally with thiopental), intubation and continuation of anticonvulsant medication in ITU setting
Describe the management of paracetamol overdose
ABCDE
Find out how much was taken, how it was taken I.e. Staggered dose
(More than 1 hour between first and last dose, all at once. When it was taken. Anything else taken. Any other medications (rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St. John’s wort)
If ingested less than an hour ago activated charcoal may have a role.
Acetylcysteine should be given if there is a staggered overdose especially if more than 75mg/kg was taken or if there is doubt over the time and exact amount of paracetamol ingestion, regardless of plasma paracetamol concentration.
Otherwise plot using treatment line by taking paracetamol levels with a minimum of 4 hours after ingestion. Depending on the plasma level the BNF has a treatment line for patients that need N-acetylcisteine.
N-acetylcysteine is given as three infusions:
-150mg/kg in 200ml of 5% dextrose over 1 hour
-50mg/kg in 500ml of 5% dextrose over 4 hours
-100mg/kg in 1L of 5% dextrose over 20 hours
N-acetylcysteine can cause an anaphylactoid like reaction with urticaria rash, nausea, tachycardia and wheeze, but it does not have an allergic basis. If occurs stop infusion and give chlorphenamin 10mg IV and then estate acetylcysteine treatment using the next infusion on improvement of symptoms.
Kings college hospital criteria for liver transplantation:
Arterial pH less than 7.3 24hrs after ingestion or all of the following: prothrombin time over 100s
creatinine over 300
grade 3 or 4 encephalopathy.
Describe the classification of shock and the estimated blood loss for each.
Class I: Up to 15% 0.75L blood loss, HR less than 100, SBP over 100mmHg, RR 14-20
Class II: 15-30% 0.75-1.5L blood loss, HR 100-120 and SBP over 100mmHg, RR 20-30
Class III: 30-40% 1.5-2L blood loss, HR 120-140 and SBP less than 100mmHg or confusion, RR 30-40
Class IV: over 40%, massive haemorrhage, critical SBP < 90 HR over 140 and confusion, RR over 35
Describe Tricyclics Overdose, its symptoms, investigations, and management
Complications of tricyclic overdose include prolonged hypotension, cardiac arrhythmias and seizure.
Symptoms: Confusion, tachycardia, hypotension, mydriasis, urinary retention, features of serotonin syndrome (restlessness, dilated pupils, rigidity, sweating, diarrhoea, fasciculations)
Investigations: ECG, Sodium bicarbonate therapeutic trial, ABG, serum TCA concentration, Paracetamol concentration, salicylate concentration, urine drug screen
Management:
- Supportive care and monitoring
- if within 2hours of ingestion activated charcoal
- if broadened QRS or pH less than 7.45 sodium bolus followed by infusion
- treat any arrhythmias
- IV fluids for hypotension
- Sodium bicarbonate
What is the management of salicylate overdose?
Management:
-Supportive, haemodialysis if Salicylate level over 700mg/L
What is the management of beta-blocker overdose?
Management:
- Atropine if bradycardia
- in resistant cases glucagon may be used
