Medical Emergencies Flashcards
Signs and symptoms of meningitis
- Early features: headache, leg pains, cold hand and feet, abnormal skin colour, fever
- Later features: meningism (neck stiffness, photophobia, Kernig’s sign), decreased conscious level, seizures, petechial non blanching rash
Management of meningitis
- ABCDE
- High flow O2, IV and fluid resus (blood- FBC, U&E, LFT, glucose, Coagulation screen, culture)
If septicaemic - cefotaxime 2g IV; If shock - ITU
If meningitic - Dexamethasone 4-10mg/6hr IV. No signs of shock/increased ICP - do LP (MC&S, gram stain, protein, glucose, virology/PCR, lactate). Give cefotaxime 2mg. - Careful monitoring
- Cefotaxime 2-4mg/8hr IV
(>55yrs, + amipicillin 2mg/4hr IV)
Describe Compartment syndrome
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 of compartment syndrome
Disproportionately high pain, bursting sensation, paresis, and intense pain on passive extension of distal limb.
Treatment of compartment syndrome
decompression of compartment, removal of casts and dressings and fasciotomy may be necessary
Describe the management of STEMI
O2 2-4L aim SpO2 >95%
IV access (FBC, U+E, glucose, lipids, cardiac enzymes)
Brief assessment
Aspirin 300mg (+ clopidogrel 300mg)
Morphine 10mg IV + methoclopramide 10mg IV
GTN 2 puffs
Reperfusion therapy: Primary PCL or thrombolysis (if no PCI in 120mins - streptokinase/tenecteplase)
Beta-blocker e.g. atenolol 5mg IV
CXR
Consider DVT prophylaxis
Continuing therapy - 4As (aspirin, atorvastatin, ACEi, Atenolol)
Describe the management of NSTEMI
O2 2-4L aim SpO2 >95%
IV access (FBC, U+E, glucose, lipids, cardiac enzymes)
Brief assessment
Aspirin 300mg (+ clopidogrel 300mg/P2Y12 inhibitor)
Diamorphine 5mg IV + methoclopramide 10mg IV
(GTN 2 puffs)
PO beta-blocker e.g atenolol 50-100mg/24hr
Fondaparinux
IV nitrate if pain continues (GTN 50mg 0.9% saline at 2-10ml/h)
GRACE score to assess early coronary angiography
Management of paracetamol overdose
Activated charcoal if <1hr since ingestion
Bloods: paracetamol level 4 hr post ingestion, glucose, U+E, LFT, INR, ABG
N-acetylcysteine if levels above treatment line
Define status epilepticus
Seizures lasting for more than 30 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 of status epilepticus
-ABC, open and maintain airway, lay in recovery position, insert oral/nasal airway intubate if neccessary
-oxygen 100% + suction as required.
-IV access and take blood, U+E, LFT, Glucose, Ca2+, Mg, Toxicology screen, anticonvulsant levels, ABG
[thiamine 250mg IV over 10 ins if alcholism or malnourished;
Glucose 50ml 50% IV, unless glucose known normal]
Correct hypotension with fluids
-lorazepam IV 2-4mg over or buccal midazolam 10mg/rectal diazepam 10mg
-if no response within 2 mins - repeat lorazapam
- IV infusion phase
Phenytoin 18mg/kg IV at a rate of <50mg/min or diazepam infusion 100mg in 500ml of 50% dextrose (if on phenytoin tabs)
- General anaesthesia phase
Acute GI bleed causes
Causes: Peptic ulcer disease (35-50%), Gastroduodenal erosions (8-15%), Oesophagitis (5-15%), Mallory-Weiss tear (15%), Varices (5-10%), Other e.g. malignancy.
Acute GI bleed 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.
Acute GI bleed management
Blatchford bleeding score - to determine if patient needs to be admitted
ABCDE
Shocked
-Resuscitate patient and keep NBM
- insert 2 large bore cannulae (Blood: FBC, U&E, LFT, glucose, clotting, crossmatch 6 units)
- high flow oxygen
- rapid IV crystalloid infusion
- CVP line - aim for >5cmH2O
- catheterise and monitor UO
- notify all surgeons
- urgent endoscopy for diagnosis and control of bleeding
[ if suspect variceal bleeding - within 4 hrs; if shocked or significant co-morbidity - within 12/24hrs]
Haemostasis of vessels/ulcer: adrenaline injection, thermal/laser coagulation, fibrin glue, endoclips
Rockall score
Prior to gastroscopy - age - shock - comorbidity After gastroscopy - diagnosis - major stigmata of recent haemorrhage
Total of 11
If <3 good prognosis
>8 high risk of death
Signs and symptoms of tension pneumothorax
respiratory distress, tachycardia, hypotension, distended neck veins
trachea deviation away
increased percussion note
reduced air entry/breath sounds on the affected side.
Management of tension pneumothorax
ABCDE
Needle thoracostomy
- insert a large-bore venflon (14g/16g) in the 2nd intercostal space mid-clavicular line
- large bore (14-16g) needle with syringe, partially filled with 0.9% saline
- Insert intercostal chest drain
Describe Acute exacerbation of COPD (+Differentials)
A common medical emergency socially in winter may be triggered by infection.
Differentials include asthma, pulmonary oedema, upper airway obstruction, PE, anaphylaxis.
Signs and symptoms of Acute exacerbation of COPD
increasing cough, breathlessness, wheeze, decreased exercise capacity
Investigations in acute exacerbation of COPD
PEFR, ABG, CXR, FBC, CRP, ECG, sputum culture and blood cultures if pyrexial
Management of acute exacerbation of COPD
look for cause such as infection or pneumothorax.
- Sit patient up
-Give nebulised salbutamol 5mg/4hr and ipratropium 500microg/6hr driven by air and controlled oxygen therapy aim for O2 sats 88-92% (aim PaO2 >8 and PaCO2 increase of <1.5) via Venturi.
-Give IV hydrocortisone 200mg and oral prednisolone 30-40mg, antibiotics if infective exacerbation (amoxicillin 500mg/8hr PO or clarithro)
-if no response,
Repeat nebs + consider aminophylline.
consider non invasive ventilation BIPAP
consider intubation and ventilation
consider a respiratory stimulant drug
Describe acute limb ischaemia
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 of acute limb ischaemia
The 6 P’s
Pale, Pulseless, Painful, Paralysed, Paraesthetic and Perishingly cold.
Management of acute limb ischaemia
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.
Define acute asthma and severity
- moderate attack: incerasing symptoms PEF >50-75%
- Severe attack: unable to complete sentences, RR >25, HR >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 of acute asthma
- Sit patient up
- 100% O2 via non-rebreathe mask
- Nebulised Salbutamol 5mg + Ipratropium 0.5mg with oxygen
-Hydrocortisone 100mg IV or Prednisolone 40-50mg PO (for at least 5 days or until recovery)
[CXR to exclude pneumothorax]
-If not improving, continue treatment and nebs salbutamol every 15 mins or 10mg continuously + ipratropium 0.5mg every 4-6hrs
- If life-threatening/still not improving, inform ICU and seniors
- add MgSO4 1.2-2g IV over 20 mins
- give salbutamol nebs every 15 minutes or 10mg continuously/hour
- consider aminophylline
- ITU and ventilation
Severe pulmonary oedema - Causes
CVS - LVF, valvular heart disease, arrhythmias, malignant hypertension
ARDS
Fluid overload
Neurogenic head injury
Severe pulmonary oedema - presentation
Dyspnoea, orthopnoea, pink frothy sputum
Pulsus alternans, fine lung crackles
Severe pulmonary oedema - management
Sit patient upright
O2
IV access (bloods: FBC, U+E, Troponin, BNP, ABG) + monitor ECG (treat any arrhythmias)
Diamorphine 5mg IV + metoclopramide 10mg IV
Furosemide 80mg IV slowly
GTN spray 2 puffs
Hx + exam + Ix
Call ITU if
If systolic BP >110mmHg - start isosorbide dinitrate IVI (but keep systolic >90mmHg)
IF worsening more furosemide, consider ventilation or increasing nitrate infusion
Define cardiogenic shock
Heart failure so severe that there is not enough pressure to perfuse even the heart muscle and brain alone
Causes of cardiogenic shock
MI HEART MI Hyperkalaemia Endocarditis Aortic dissection Rhythm disturbances Tamponade
Management of cardiogenic shock
O2
IV access (FBC, U+E, Troponin, ABG) and monitor ECG
Correct arrhythmias, electrolyte distubance and acid-base abnormalities
Optimise filling pressure
if PCWP <15 - plasma expander 100ml every 15mins IV until PCWP 15-20
if PCWP >15 - inotropic support - dobutamine aim systolic >80mmHg
Consider renal dose dopamine IV
consider intra-aortic balloon pump
Treat/look for any reversible cause
Cardiac tamponade - causes
Trauma, lung/breast cancer, pericarditis, MI
Cardiac tamponade - presentation
Beck’s triad - Hypotension, increased JVP/distended neck veins, muffled heart sounds
Kussmaul’s sign - increase JVP on inspiration
Pulsus paradoxus
Cardiac tamponade - investigations
Echo
CXR
ECG - electrical alternans
Cardiac tamponade - management
O2, ECG, IV access
Bed rest with leg elevation
Volume expansion for adequate intravascular volume
Echo guided Pericardiocentesis
Narrow complex tachycardia/ SVT - management
O2 and IV access
Start continuous ECG trace
Vagal manoeuvres (carotid sinus massage, valsalva manoeuvre)
Adenosine 6/12/12mg bolus
Adverse signs–> sedate and DC cardioversion–> amiodarone 300mg over 30mins then 900mg over 24 hours
If patients relatively stable - choose from esmolol, digoxin, verapamil, amiodarone, overdrive pacing
Variceal bleeding - management
Medical: Terlipressin IV and prophylactic antibiotics
Surgical:
-2 of banding, sclerotherapy, adrenaline, coagulation
-balloon tamponade with sengstaken-blakemore tube
-Transjugular intrahepatic porto-systemic shunt
Contraindications to LP
Increased ICP Thrombocytopaenia Coagulation disorder Infection at site Cardio/Resp distress Focal neurological signs
