Medicine Flashcards
Anaphylaxis acute management (4)
- Adrenaline - IM dose of 300-500 mcg (0.3-0.5mL of 1:1000) while trying to gain IV access.
- Nebulised salbutamol (5mg) with high flow oxygen
- Fluid resuscitation with normal saline to treat hypotension
- If no response to initial dose of adrenaline further doses can be given IV (either in 20-50mcg boluses or as a continuous infusion)
What adjuvant treatment can be given in an anaphylaxis reaction? (3)
Anti-histamine (e.g. promethazine)
Histamine-2 receptor blockade (e.g. ranitidine)
Corticosteroid (e.g. 250mg IV hydrocortisone)
What blood test can be used to help diagnose anaphylaxis?
Mast cell tryptase - serum protease specific to mast cells which reaches a peak one hour after an anaphylactic reaction and remains elevated for approx. 6 hours.
A NORMAL SERUM TRYPTASE DOES NOT EXCLUDE A POSSIBLE ANAPHYLACTIC REACTION
What is the exception to serum tryptase elevation in anaphylaxis?
Elevation very rarely associated with food-induced prophylaxis
Post-acute management of severe first-time anaphylaxis (4)
- Requires observation in ED or in a short-stay ward for at least 10 hours
- On discharge, should be prescribed and carefully educated in the use of an ‘EpiPen’ and referred to allergist for further testing (skin testing or serum antibody tests) and follow-up
- Education regarding allergen advice
- Place alert in medical record outlining suspected trigger and features of the reaction
What is the dose of adrenaline in children with severe anaphylaxis?
0.1 mL/kg of 1:10000 IV (0.01 mg/kg)
What is the risk of hyponatraemia vs rapid correction?
Hyponatraemia - cerebral oedema
Rapid correction can cause central pontine myelinolysis
Define anaphylaxis.
Severe, life-threatening, generalised or systemic hypersensitivity reaction
Characterised by rapidly developing life-threatening airway (pharyngeal or laryngeal edema) and/or breathing (bronchospasm and tachypnea) and/or circulation (hypotension and tachycardia) problems usually associated with skin and mucosal changes (but not always!)
Warfarin: What needs to happen if INR is greater than therapeutic range but less than 5.0 (no bleeding)? (2)
- Lower dose or omit the next dose of warfarin
2. Resume therapy at lower dose when INR approaches therapeutic range
Warfarin: what needs to happen if INR 5.0 - 9.0 with no bleeding? (5)
- Cease warfarin
- Consider reasons for elevated INR
- If bleeding risk high, give vitamin K1 (1mg oral or IV)
- repeat INR within 24 hours
- Resume warfarin at lower dose once INR in therapeutic range
Warfarin: what needs to happen if INR greater than 9.0 with no bleeding? (4)
- cease warfarin
- if low risk bleeding: vitamin K1 (2.5-5.0mg oral or 1mg IV)
- if high risk: vitamin k1 1mg IV, consider prothrombinex-HT and FFP
- Measure INR 6-12h and resume warfarin at lower dose once INR less than 5
Warfarin: what needs to happen if there is any clinically significant bleeding with warfarin-induced coagulopathy? (3)
- cease warfarin
- give vit K1, prothrombinex, FFP
- Assess patient continuously until INR less than 5 and bleeding stops
What can anaphylaxis present as in those with known allergies?
Isolated hypotension
What is contained in prothrombinex?
Vit K dependent factors - II, VII (small amounts only), IX and X
What are the diagnostic criteria for DKA? (3)
- BGL > 11.1
- Venous pH less than 7.3 or bicarbonate less than 15
- Presence of blood or urinary ketones
What is the treatment of DKA? (5)
See BHS guidelines!
- O2 if necessary, and IV access
- Fluid resuscitation - 1L of 0.9% saline stat
- Insulin - amount dependent on initial BGL - roughly 0.1u/kg/hr - aim to lower glucose by 1-2 mmol/l/hr
- Once glucose below 15 provide 5% dextrose 100 mL/hr
- Monitor for electrolyte abnormalities + may require ICU admission
What happens in DKA?
No insulin = no glucose uptake = lipolysis = FFAs broken down into ketone bodies = metabolic acidosis = respiratory compensation leads to hyperventilation
When should adults who have a wound get a booster dose of tetanus?
If it has been more than 5 years since the last one, and if the wound is ‘tetanus prone’
When shoud IM tetanus immunoglobulin (TIG) be given?
TIG only used if wound is tetanus-prone and if person has had less than three doses or is uncertain of how many doses they’ve had.
