Medicine: AcuteMed Flashcards
Three components of assessing ACS
Hx
ECG
Troponin
Classic cardiac chest pain hx
Retrosternal heaviness, radiates to jaw +/- arm, exertion exacerbates sx, GTN may help, a/w autonomic features
ACS RFs
HTN, hyperlipidaemia, diabetes, FHx, smoking
Unstable Angina (inc both at rest + crescendo angina)
Hx is vital, no acute ECG findings, normal troponin -> admit for ACS tx + cardio review
What is crescendo angina?
Chest pain comes on after shorter and shorter distances of exertion
NSTEMI vs STEMI
NSTEMI - mismatch of O2 demand/consumption w some myocardial damage
STEMI - complete blockage of blood flow and transmural damage
There’s an elevated troponin in both
NSTEMI
ECG: normal, subtle ST abnormalities, ST depression, inverted T waves
Mx: A-E, cardiac monitor, serial ECGs, admit for ACS tx +/- angiography
What is the ACS tx?
- Load w Dual AntiPl (300mg Aspirin + 300mg Clopidogrel / 180mg Ticagrelol)
- 2-8d AntiCoag (2.5mg Fundaparinox OD)
- 1y Dual AntiPl (75mg Aspirin OD + 75mg Clopidogrel OD / 90mg Ticagrelol BD)
- If they had PCI then after 1y stop the clopidogrel/ticagrelol and persist w lifelong aspirin
When should angiography be performed?
Fit individuals within 72hrs
STEMI
ECG: ST elevation of 2mm in chest leads/1mm in two consecutive inferior leads, new LBBB, hyperacute T waves
Mx: A-E, PCI <90mins if in capable hospital, PCI <120mins if requires transfer, thrombolysis <30mins if PCI unavailable, plus MONA w/o high flow O2 due to free radicals unless sats are low
Which antiemetic doesn’t cause tachycardia?
Metoclopramide
The classification of stroke
Ischaemic - lacunar, atherosclerotic, cardiogenic emboli, cryptogenic
Haemorrhagic - SAH + intracerebral
The different types of a lacunar stroke
Pure motor, pure sensory, mixed sensorimotor, ataxic hemiparesis, clumsy hand, silent
The vasc territories of the brain
Ant Circulation - ACA, MCA, internal carotid
Post Circulation - PCA, basilar, vertebral
Cerebellum - SCA, AICA, PICA
ACA Stroke Syndrome
Contralateral leg > arm paresis or bilateral if both ACAs involved + mild sensory defect, disinhibition, executive dysfunction
MCA Stroke Syndromes
Face -> Arm -> Leg Weakness
Left Hemisphere ie dominant - right hemiparesis, sensory loss, homonymous hemianopia + dysarthria, aphasia, apraxia
Right Hemisphere ie non-dominant - left hemiparesis, sensory loss, homonymous hemianopia + dysarthria, neglect of left side, flat affect
PCA Stroke Syndromes
Occipital Lobe - contralateral homonymous hemianopia or quadrantanopia + cortical blindness if bilateral lesions
Medial Temp Lobe - deficits in long and short term memory + behaviour alteration
Thalamic - contralateral sensory loss, executive dysfunction, aphasia, memory impairment, dec level of consciousness
Where must the infarct be if the patient has a quadrantanopia?
The occipital lobe
Which strokes can cause a dec level of consciousness?
Large MCA, thalamic, brainstem
Cerebellar Stroke
Dysdiadochokinesis Ataxia Nystagmus Intention Tremor Scanning Dysarthria Hypotonia
+/- nausea, vomiting, headache
What else can AICA ischaemia present with?
Deafness
What are you worried about if a pt following a cerebellar stroke becomes drowsy?
Hydrocephalus, repeat CT head, may require surgery
What simple test should you always do for a pt w collapse and neurology?
Glucose
Tx of ischaemic stroke following CT head
IV alteplase within 4.5hrs unless absolute CI of intracerebral or active bleeding
If you miss the timeframe or there’s a CI then IV thrombectomy within 6-24hrs
Plus two wks 200mg aspirin then switch to long term 75mg clopidogrel, statin, lifestyle advice
What further ix do you do for a pt <65yrs following a stroke?
Prolonged heart recorder looking for AF, bubble echo looking for patent foramen ovale, homocysteine, thrombophilia screen, vasculitic screen, LP, HIV, FHx
How do you dx TIA?
They’re having a stroke until all sx/signs revolve within 24hrs w/o tx
How long should a pt be assessed by a specialist following a TIA?
Give 300mg aspirin STAT until reviewed within 24hrs
What are the red flags for admission following a TIA?
AF, more than one event within last wk, on anticoags
What should you do if TIA + AF?
Start anticoag w NOAC on the day
What is SIRS?
Systemic inflam response syndrome w >=2: temp >38 or <36, HR >90bpm, RR >20bpm or pCO2 <4.3kPa, WCC >12 or <4 x10^9/L or >10% immature forms
Def of sepsis
Life threatening organ dysfunction caused by a dysregulated host response to infection
Outline how sepsis is operationalised
Quick sequential organ failure assessment (qSOFA) where 2/3 predicts poor outcome: RR >=22bpm, GCS <15, SBP <=100mmHg
Plus just look at the pt: position, exhausted, temp, sweaty, confused, speaking
Def of septic shock
Underlying circulatory, cellular +/or metabolic abnormalities are profound enough to substantially inc mortality
Outline how shock is operationalised
Persisting hypotenion requiring vasopressors to maintain MAP >=65mmHg
Plus lactate >2mmol/L despite adequate fluid resus
Each section of the GCS
E4V5M6
Best eye response: spontaneous, to sound, to pressure, none
Best verbal response: oriented, confused, words, sounds, none
Best motor response: obey commands, localising, withdraws, decorticate, decerebrate, none
What’s a quicker way of recording the level of consciousness? And it’s correlation to GCS?
The AVPU Scale
Alert - 15, Verbal - 12, Pain - 8, Unresponsive - 3
What would be the most likely source of sepsis?
Pneumonia 50%
Urinary Tract 20%
Abdomen 15%
Skin + MSK 10%
Endocarditis 1%
Device Related 1%
Meningitis 1%
Sx that might indicate sepsis
Slurred speech or confusion
Extreme shivering, muscle pain, fever
Passing no urine all day
Severe breathlessness
It feels like they’re going to die
Skin mottled or discoloured
Sev Sepsis vs Septic Shock
Sev: evidence of end organ damage and hypotension responds to fluids
Shock: evidence of end organ damage w an inc lactate and hypotension refractory to fluids and inotropes requiring ITU management
What are the reversible causes of cardiac arrest?
Hypoxia
Hypovolaemia
Hypo/HyperK
Hypothermia
Toxins
Tamponade
Tension Pneumothorax
Thromboembolism
How do the 4H’s and 4T’s translate to the primary survey?
H’s: O2 sats, obvious bleeding and HR/BP, VBG, temp
T’s: known hx, examine, ECG, ultrasound, xray
What do pretty much all pts that come through resus get?
Fluids, O2, full CT
How do you act as a scribe?
Sign in sheet, pt stickers and date pages, pt wristband, age and gender, time of arrival, preload trauma booklet w obs, AMPLE
What does AMPLE stand for?
Allergies Medications PMHx Last Meal Events
Which organs are most prone to ischaemia?
Brain
Heart
Kidneys
What are the two shockable and non-shockable rhythms?
Shockable: VF + pulseless VT -> one shock and 2mins CPR then reassess
Non-Shockable: asystole + pulseless electrical activity -> 2mins CPR then reassess
What does ROSC stand for?
Return of spontaneous circulation
When someone says they’re on HRT what should you inquire?
Reason, cyclical/continuous, SEs
What should you always ask about in a fall hx? (2)
Injury to the head and any neck/back pain
How long they were on the floor for to assess risk of rhabdomyolysis
How to counsel a miscarriage dx?
Very common 1/5 known pregnancies
It usually means the preg isn’t viable and not one you’d want to continue anyway
It doesn’t affect your fertility and chances of getting pregnant again
What can happen if you inject local into an artery?
Arrhythmias + Necrosis
What scoring system do nurses use for every pt?
Manchester Triage System where 1 is immediate resus and 5 is non-urgent
Chest Pain DDx
ACS - arm/neck/jaw, nausea, clammy, SOB, palps
PE + PT - SOB, haemoptysis, tender calves, recent surgery, long travel
Oesoph Rupture - epigastric & vomiting
Aortic Dissection - interscapular & neuro deficits
If they took GTN spray which helped?
Their own spray, when dx with IHD,
When is troponin measured?
Upon arrival and three hrs later
What is a good marker of re infarction?
CK-MB
Asthma Severity BTS
Acute Mod: inc sx + PEF 50-75%
Acute Severe: inability to complete sentences + PEF 33-50%, RR >=25, HR >=110
Life-Threat: clinical signs + PEF <33%, SpO2 <92%, T1RF
Near-Fatal: T2RF +/- requiring mechanical ventilation
Drugs causing pupil dilation
Cocaine, TCA, Atropine
Drugs causing pupil constriction
Opiates, Nicotine, Pilocarpine
What must you stop when reassessing the rhythm?
Chest compressions
What joules is the shock charged to?
150J
What is the definitive airway?
Tracheal intubation by the anaesthetists
How many mL/hr is an infusion rate of one drop per second?
180mL/hr
How do you categorise tachycardia’s?
Narrow Reg: sinus, SVT, Atrial Flutter, AVRT, AVNRT
Narrow Irr: AF
Broad Reg: VT + SVT w BBB
Broad Irr: Torsades + AF w BBB
How do you categorise bradycardia’s?
Sinus + Heart Block
The different types of heart block
AV, RBBB, LBBB, bifascicular, trifascicular
Def of trifascicular block
Presence of conducting disease in all three fascicles: right bundle branch, left anterior fascicle, left posterior fascicle
Def of bifascicular block
Combination of RBBB w either LAFB or LPFB
Which is more common LAFB or LPFB?
LAFB
Which part of the rhythm do you synchronise cardioversion with?
The R wave
Tx for SVT
Vagal Manoeuvres: carotid massage + valsalva
IV Adenosine
DC Cardioversion
NB: skip to DC cardioversion if haem unstable or others contraindicated
Tx for VT
Pulseless - defibrillation
Unstable - DC cardioversion
Stable - IV amiodarone
What should you have on standby when giving IV adenosine?
Resus equipment in case of VF or bronchospasm
What do you need to consider when performing a carotid massage?
Always auscultate for bruits first and don’t perform it on both sides simultaneously
Tx of Torsade de Pointes
IV Mg Sulfate
Why do pts fall?
CVS: arrhythmia, syncope, postural hypotension
Neuropsychiatric: vision, vestibular, cerebellar lesion, peripheral neuropathy, cognitive
MSK: instability, deconditioning, gait
Toxins: meds, polypharm, substance abuse
Environmental Hazards
How do you assess someone after a fall?
Hx + Collateral: location and activity, associated sx, drug hx, mobility aids, ADLs
O/E: CVS (HR BP HS ECG), Neuro - LL, MSK - Hip, Timed Up and Go Test (>12s), TURN180 (>4 steps)
Selection of adults for CT head scan
GCS <13 @ initial assessment
GCS <15 @ 2hrs after injury
Or: suspected skull fracture, any sign of basal skull fracture, post traumatic seizure, focal neuro deficit, >1 ep of vomiting since injury
Selection of children for CT head scan
GCS <14 @ initial assessment
GCS <15 @ 2hrs after injury
Or: suspected skull injury, tense fontanelle, any sign of basal skull fracture, focal neuro deficit, NAI
Signs of a basilar skull fracture
Raccoon eyes w tarsal plate sparing, haemotympanum, CSF otorrhea (Halo sign), postauricular ecchymosis (Battle sign)
What else should you enquire about if the pt complains of PV bleeding?
FLAWS + Anaemic Sx
Ddx for exertional chest pain that gets better w rest
CAD + AS/AR
What do you need to say when you put out a major haemorrhage call?
Paed v Adult
Med v Surg
Hosp, Ward, Bed
Who will be alerted following a major haem call?
Porter, haem, blood bank, resus team, hosp coordinator, theatre
What can the critical care outreach team do?
Nurses who can support the airway and prescribe
When you call 2222 what call can you put out?
Cardiac Arrest (3mins), Peri Arrest (5mins), Major Haem, Trauma, Obs/Neo/Paeds
What are the clinical signs of life-threatening asthma?
Altered conscious level, exhaustion, arrhythmia, hypotension, cyanosis, silent chest, poor resp effort
Outline the CURB-65 scoring
Confusion Urea >7.0mmol/L Resp Rate >30 sBP>90 | dBP <60 >65yrs
+1 point for each feature: 0-1 if stable discharge w PO amoxicillin 500mg/8h, 2 admit to wards, 3-5 admit to critical care unit
Outline the modified wells scoring: high prob of PE
> 4 —> CTPA
<=4 —> D-dimer
If the pt is tachy what ix do you need to do?
ECG
Outline the PERC rule: low prob of PE
If any of the below are +ve cannot rule out PE: age >50, HR >100, sats <95, unilateral leg swelling, haemoptysis, recent surgery/trauma, prior PE/DVT, hormone use
LOC DDx (5)
Reflex: vasovagal, carotid sinus hypersensitivity, situational (cough + micturition)
Cardiac: arrhythmia, WPW, outflow obstrc, stokes-adams, orthostatic
Neuro: seizure, narcolepsy, SAH/ICH
Metabolic: hypoglycaemia, hypoNa, polypharm, benzos, alcohol/drugs
Hypovolaemic: aortic dissection, AAA, ruptured ectopic
What is the definition of syncope?
A sudden transient LOC due to a reduction in blood supply to brain w spontaneous recovery: reflex, stokes-adams, orthostatic
Syncope vs Seizure
Syncope: trigger, prodrome, a/w posture/twitch, short duration, rapidly reoriented
Seizure: no trigger, deja/jamais vu, a/w jerking/tongue biting/incontinence, prolonged duration, prolonged post-ictal disorientation
What are the 3 P’s of syncope?
Provoked, Prodrome, Postural
Workup for TLoC
Hx: collateral, SOB, dizxy, fhx sudden death, RFs, risk stratify
O/E: A-E, GCS, cardio, neuro, head injury, fractures, AMTS
Ix: obs, lying+standing BP, ECG, bm, preg test, bloods, CT head
What is the San Francisco syncope rule?
Predicts risk for srs outcome at 7d if the pt has any of:
Congestive HF Haematocrit <30% EKG Abnormal Short of Breath SBP <90mmHg
Do not use if definite seizure, head trauma, alcohol/drug related, persistent altered mental status or new neuro deficits
What is the OESIL score?
Predicts risk for 12m all cause mortality:
CVD
Age >65
Syncope w/o Prodrome
EKG Abnormal
What is a sig change in lying and standing BP?
> 20 Systolic
>10 Diastolic
What are the RFs in the hx for falls?
Prev hx, injuries, immobility, afraid, meds
List the three broad categories of syncope
Reflex
Cardiac
Orthostatic
How do you perform lying+standing BP properly?
Take the BP after the pt has been lying for 5mins then again after they’ve been standing for 1min and 3mins
What are the ECG findings of Brugada syndrome?
Pseudo RBBB and persistent ST elevations in V1-2
What safety issues should be considered for epileptics?
Looking after children, driving, bathing alone, working w heights/heavy machinery
A-E Approach: A
Patent? Responsive? Added sounds?
If not responsive: look, listen, feel approach
If not breathing: check pulse, call help, start CPR
Think about airway manoeuvres/adjuncts, suction, protect c-spine
If struggling to maintain bleep the anaesthetist and only move on once happy
A-E Approach: B
Obs: RR and O2 sats
O/E: inspect chest, tracheal deviation, expansion, percuss, ausc
Ix: ABG, CXR, Covid Swab | Mx: O2
A-E Approach: C
Obs: HR and BP
O/E: inspect peripheries, CRT, JVP, HS I+II, large bore cannula in each ACF, take bloods, G+S/XM, cultures, give fluid challenge, UO
Ix: ECG, Troponin, BNP | Mx: Abx
A-E Approach: D
Work around the C: pupils, AVPU/GCS, temp, glucose, drug chart
A-E Approach: E
Examine entirety for rashes, trauma, bleeding
Plus perform crude abdo, consider urine dip and PR, NV limb exams
What is a definitive airway?
It’s cuffed + below level of the vocal cords
What do you want to check if the pt has suspected infective endocarditis?
Obs: fever
Heart: murmur
Abdo: splenomegaly + microscopic haematuria
How do you measure up a guedel?
Soft-to-soft: tragus of ear to lateral edge of nostril
Hard-to-hard: angle of mandible to the midpoint of incisors
Outline the GCS
E4: spontaneous, verbal, pain, none
V5: oriented, confused, inappropriate, incomprehensible, none
M6: obeys, localises, withdraws, flexion/decorticate, extension/decerebate, none
How does AVPU match GCS?
A - 15
V - 13
P - 8
U - 6
How could you test if hypotension was secondary to fluid depletion?
Elevate the legs whilst lying down then take the BP again
RFs for Ectopic
Age
Smoking
Assisted Fertility
Prev Ectopic, Abdo/Pelvic Surg, STI
On which side is an ovarian cyst rupture or torsion more likely?
Right as the rectosigmoid protects the L ovary
What are the comps of chlamydia infection?
Inc ectopic risk, dec fertility, PID, Fitz Hugh Curtis syndrome
Ddx for Miscarriage w Open/Closed Os
Open: Inevitable + Incomplete
Closed: Threatened, Complete, Missed
Mx of Miscarriage
Expectant, Misoprostol, MVA
What are your ddx for ptosis?
3rd Nerve, Horners, MG: check pupil size and if uni/bilateral
What are causes of UMN signs? (3)
Stroke
Multiple Sclerosis
Cord Compression
What would you like to ask pt w spinal back pain +/- neurology?
Bladder + Bowel Sx
What are the causes of small muscle wasting in the hands?
Spinal cord: compression, syphilis, MND
Brachial plexus: trauma, cervical rib, pancoast tumour
Peripheral nerve: median palsy, ulnar palsy, RA
What triad identifies virtually all NFT1?
Neurofibroma
Lisch Nodules
Cafe Au Lait Spots >15mm >6
What is the chromosomal involvement in NF type 1 and type 2?
1 - Chr17
2 - Chr22
What is loin to groin pain in the elderly until proven otherwise?
AAA
What are the LT causes of epigastric pain?
Inferior MI, AAA, perf ulcer
How do you distinguish clinically b/w the different causes of shock?
Peripheries Temp + JVP
How do you risk stratify PE pts?
PESI
Ddx of Atraumatic Back Pain
Disc Prolapse Muscle Spasm Cauda Equina Pott Disease Metastasis
Plus: MI, AAA, perforated GU/DU, pancreatitis, renal colic
What are the red flags of back pain?
Age <20 or >55 Thoracic Saddle Anaesthesia Bladder/Bowel Dysfunction Progressive Neuro Deficit Disturbed Gait Hx of Carcinoma FLAWS
O/E of Back Pain
Neuro (LL) + MSK (Hip)
Plus: SLR, Post Void Bladder Scan, DRE
Selection of infant for CT head scan
GCS <15 @ initial assessment
Or: presence of bruise, swelling or laceration >5cm on the head
Why is an ABG useful in the acute scenario?
Met Acidosis
Resp Failure
Lactate
NB: always write how much O2 pt is on and compare the gas to any prev
What are the indications for a CXR in asthma?
Suspected pneumothorax/consolidation
LT
Failure to respond to initial therapy
Require ventilation
How is hypothermia staged?
Mild 32-35
Mod 28-32
Sev <28
Tx of Hypothermia
‘Noone is dead until warm and dead’
Withhold adrenaline until >30° and give every 6-10mins
Once above >35° every 3-5mins
Treat arrhythmias
Rewarm: passive, active, internal, external
What toxins cause cardiac arrest?
Opioids
Benzos
TCAs
What are the common iatrogenic causes of cardiac tamponade?
Cardiac Surgery
Pacemaker Insertion
Penetrating Trauma
Opioid Toxidrome
Red RR, GCS, Pinpoint Pupils
Mx: naloxone 0.4mg if rapidly falling GCS, abnormal breathing pattern, T2RF - beware of opioid withdrawal and provoking seizures
If sx relapse within 1hr run a naloxone infusion 10mg in 50ml dextrose, partial response consider doxapram, no effect intubate
Anticholinergic Toxidrome
Dry, Dilated, Delirious
Obs: tachycardic, hypotensive, pyrexic
Mx: bicarbonate 8.4% if QRS >120ms, refractory hypotension, cardiac arrest - aim for arterial pH 7.5 to promote binding of drug to plasma proteins and stabilise the myocardium
If prolonged QT give magnesium + prolonged CPR can yield favourable neuro outcomes
Serotonin Syndrome
Overactive ie agitated, sweating, hyperreflexic
Obs: tachycardic, hypertensive, hyperpyrexic
Biochem: dec Na, inc CK, DIC, met acidosis
Mx: external cooling, benzos for agitation and muscle rigidity, low threshold to intubate ventilate paralyse to control temp, dantrolene, avoid fluids and paracetamol
Benzodiazepine Toxidrome
Drowsy, Ataxic
Obs: bradycardic, hypotensive, hypoventilation
Mx: intubate and ventilate until the drug wears off + use flumazenil w caution only if pt develops T2RF and observe for seizures
What is the specific antidote for methanol/ethylene glycol?
Fomepizole
Salicylate OD
Tinnitus, N+V, Hyperventilation, Dehydration, Sweating
Mild: <150mg/kg or <300mg/L
Mod: 150-300mg/kg or 300-700mg/L
Sev: 300-500mg/kg or >700mg/L
What is the oxygen content of the blood?
Hb x SaO2 x 1.3 x 10
What is the delivery of oxygen to tissues?
Hb x SaO2 x 1.3 x 10 x Cardiac Output
How can you improve DOT?
Inc 1. Hb 2. FiO2 3. CO
Oxygen Dissociation Curve
Left Shift: dec temp, 2-3 DPG, [H+]
Right Shift: inc temp, 2-3 DPG, [H+]
How can you tell the different causes of shock apart?
The JVP will be elevated if the cause is cardiogenic and the peripheries will be warm if the cause is septic or neurogenic
Criteria making anaphylaxis likely
Sudden onset and rapid progression of sx
Life threatening ABC problems
Skin and/or mucosal changes (flushing, urticarial, angioedema)
Exposure to a known allergen for the pt supports the dx
Most reactions occur over several minutes and quicker if an IV trigger
The patient will look and feel unwell
There may also be GI sx such as D+V
Mx for anaphylaxis
Stop offender, high flow O2, early anaesthetist intervention to I+V if required, 500microg IM adrenaline, 200mg IV hydrocortisone, 10mg IV chlorphenamine, 1L Hartmann’s solution
What is Livedo Reticularis?
A normal phenomenon resembling mottling of the skin caused by red blood flow
When is Livedo Reticularis concerning?
DIC plus severe sepsis
The sepsis six
IN
O2, abx, fluid challenge
If remain hypotensive despite fluids then crit care review for consideration of vasopressors
OUT
Lactate, cultures, urine output
Plus FBC, U&Es, LFTs, CRP, ABG
Mx for asystole
I+V, 100% O2, 0.9% saline/Hartmanns bolus, CPR w adrenaline every 3-5mins during rhythm checks
How does sepsis cause a cardiac arrest?
Acute MI, hypoxia, hypovolaemia
What is the rule of nines for working out percentage total body SA involved in a burn?
Wallace’s Rule of Nines:
Ant Trunk - 18%
Post Trunk - 18%
Whole Leg - 18%
Whole Arm - 9%
Whole Head - 9%
Palm/Genitals - 1%
How do you calculate the fluid requirement for the first 24h following a burn?
All adults w burns >15% TBSA should receive fluids using the Parkland Formula: 4ml x Wt in kg x %Burn
Over what time period are fluids given following a burn?
First half of fluids given over first 8hrs and second half given over nxt 16hrs
When do you catheterise burn pts?
> 20% TBSA or if they’re intubated
Consider if 15-19% TBSA or if w perineal burns
When titrating fluids what urine output do you wish to maintain?
> =0.5ml/kg/hr
What are the indications for referral to a regional burns unit?
Burns >10% TBSA in an adult, >5% TBSA in a child, >5% TBSA if full thickness
Burns of face, hands, feet, perineum, genitalia or major joints
Circumferential, chemical or electrical burns
Burns in the presence of major trauma or significant co-morbidity
Burns in the very young, pregnant or elderly patient
Suspicion of NAI
Why are burns painful?
Air moving across exposed nerve endings hence apply cling film
What can you give if simple analgesia is not controlling the pain from a burn?
One off dose of intra-nasal diamorphine
Superficial v Partial v Full
Superficial burns are usually dry, sometimes with minor blistering and erythema. Painful. Often due to sunburn or minor scalds. Involve the epidermis.
Partial thickness burns are moist and red, usually with broken blisters and normal capillary refill. Involve the dermis. They are usually painful unless they are deep dermal. Deep dermal burns may also have sluggish capillary refill.
Full thickness burns are dry, charred and often white. They are painless and have absent capillary return. They have destroyed the epidermis and dermis and have begun to destroy the underlying subcutaneous tissue.
Why should you deroof the blisters following a burn?
To accurately assess the depth
Mx for epistaxis
Pressure to ant aspect for 15-20mins
Cautery w silver nitrate to the side bleeding
Rapid rhino into both nostrils for up to 24hrs
Foley catheter nose-oropharynx and repack nose
What is the toxic dose of paracetamol?
75mg/kg
What are the Toxbase guidelines following a paracetamol OD?
> 75mg/kg: bloods at 4h post ingestion, plot results on normogram, either NAC or referring to psych
> 150mg/kg: if unable to act on bloods within 8h post ingestion give NAC immediately
What is immediately administered once cardiac arrest has been confirmed and pt does not have a shockable rhythm?
Adrenaline
TCA OD
Mild-Mod: dilated pupils, tachycardia, drowsiness, dry mouth, urinary retention, confusion and agitation
Severe: hypotension, cardiac rhythm disturbance, hallucinations and seizures
Diazepam OD
Drowsiness, respiratory depression, ataxia and hypothermia
Sertraline OD
Vomiting, tremor, drowsiness, dizziness, tachycardia and seizures
What are the indications for treating amitriptyline od?
Metabolic acidosis or wide QRS complexes
What do you do after diagnosing an acute subdural haematoma, raised INR and stopping the warfarin?
Discuss w neurosurgery and give Octaplex w 5mg IV vitamin K
What are the shockable and non-shockable rhythms?
Shockable: VF + pulseless VT -> one shock and 2mins CPR then reassess
Non-Shockable: asystole + pulseless electrical activity -> 2mins CPR then reassess
What is the dosing of NAC?
150mg/kg over an hr
50mg/kg over nxt 4hrs
100mg/kg over nxt 16hrs
Which bloods do you recheck after the 21h NAC infusion?
INR and ALT
When should you admit a pt w burns to secondary care?
> 3% TBSA
What appearance of a burn suggests which depth?
Superficial epidermal: red + painful
Superficial dermal: pale pink, painful, blistered
Deep dermal: typically white but may have patches of non-blanching erythema + red sensation
Full thickness: white/brown/black, no pain, no blisters
What NEWS score is considered significant?
5 or more in total or 3 or more in one domain
How do you assess the airway?
Protect cervical spine if an injury is possible
Look inside the mouth and remove objects/dentures
Assess for signs of obstruction
○ Use wide-bore suction under direct vision if secretions are present
If vocalising, can assume airway is patent
Listen for stridor, snoring or gurgling
Establish a patent airway using:
○ Manoeuvres (e.g. chin lift, jaw thrust)
○ Adjuncts (e.g. oropharyngeal airway (Guedel))
If airway still impaired –> CALL ARREST TEAM (2222)
How do you assess breathing?
Look for chest expansion (equal? Fogging of mask?)
Listen for air entry (equal?)
Feel for expansion and percussion (equal?)
Start 15 L oxygen via a non-rebreather
Use a bag valve mask if there is poor or absent respiratory effort
Monitor SaO2 and RR
Check for tracheal deviation and cyanosis
If NO respiratory effort –> CALL ARREST TEAM (2222)
○ Intubate and ventilate
If breathing is compromised, give 15 L oxygen through a non-rebreather mask
How do you assess circulation?
Look for pallor, cyanosis and distended neck veins (JVP)
Feel for central pulse (carotid/femoral) - rate and rhythm
Monitor defibrillator ECG and BP
Gain venous access and send bloods if time allows
12-lead ECG
Treat shock
If NO cardiac output –> CALL ARREST TEAM (2222)
How do you assess disability?
Consciousness (GCS/AVPU)
Pupils
Blood glucose
What are some common causes of peri-arrest?
Arrhythmia MI Hypovolaemia Sepsis Hypoglycaemia Hypoxia Pulmonary oedema PE Metabolic (hypo or hyperkalaemia) Tension pneumothorax
What are the components of qSOFA?
RR > 22
GCS < 15
SBP < 100
What is the difference between severe sepsis and septic shock?
Severe sepsis: sepsis with evidence of organ hypoperfusion (e.g. hypoxaemia, oligaemia, confusion)
Septic shock: severe sepsis with hypotension despite adequate fluid resuscitation
What are the sepsis 6?
Give oxygen (15 L through NRB) Give IV fluids (bolus = 20 mL/kg) Take blood cultures Take lactate Monitor urine output (aim >=0.5ml/kg/hr) Give broad-spectrum antibiotics
ALL WITHIN 1 HOUR
When should sepsis patients be escalated further?
SBP fails to reach > 90 mm Hg
Lactate remains > 4 mmol/L
How should haemorrhagic shock be managed?
2 L of crystalloid
If this fails to resuscitate –> X-match
Give FFP and packed red cells (1:1) aiming for platelets > 100 and fibrinogen > 1
Which medications are used in the management of anaphylaxis?
Adrenaline 0.5 mg IM (0.5 mL of 1:1000) Repeat every 5 mins as necessary Chlorphenamine 10 mg IV Hydrocortisone 200 mg IV IV fluid bolus if shocked
What should be done after the a patient with anaphylaxis has been stabilised?
Admit to ward
Monitor ECG
Continue chlorphenamine 4 mg per 6 hours PO if itching
Suggest MedicAlert bracelet
Prescribe autoejector
Consider skin-prick testing or specific IgE
Outline the management of aortic dissection.
Fast bleep cardiothoracic surgery
Transfer to ITU
Use hypotensives (e.g. labetalol) to maintain SBP 100-110
Document and debrief
Outline the management of a ruptured AAA.
Fast bleep vascular surgery and anaesthetics Take the patient straight to theatre Gain IV access Administer O- if necessary Keep SBP < 100 mm Hg
Outline the initial management of a STEMI.
Morphine 5-10 mg IV (repeat after 5 mins if necessary)
Metoclopramide 10 mg IV
Oxygen 15 L via non-rebreather
Nitrates
Aspiring 300 mg PO (with clopidogrel or ticagrelor)
What doses of second antiplatelet agents are used with aspirin in the prevention of atherothrombotic events in ACS?
Clopidogrel 300 mg followed by 75 mg
Ticagrelor 180 mg STAT followed by 90 mg BD
Which medications should patients who have had an MI take home?
Dual antiplatelet therapy (continue for 12 months) GTN spray Beta-blocker ACE inhibitor Statin
Outline the management of acute heart failure.
Diamorphine 1.25-5 mg IV (caution in liver failure or COPD)
Furosemide 40-80 mg IV
GTN spray 2 puffs sublingual (consider isosorbide mononitrate infusion 2-10 mg/hour)
What should be considered if a patient in acute heart failure deteriorates?
Further dose of 40-80 mg furosemide
Consider CPAP
Increase nitrate infusion
Refer to ITU
How should a patient with acute heart failure be managed once they have been stabilised?
Monitor daily weight and observations
Repeat CXR
Switch to oral furosemide or bumetanide
ACE inhibitor if LVEF < 40%
Consider beta-blocker and spironolactone
Consider biventricular pacing or transplantation
Consider digoxin and warfarin
Outline the management of broad complex tachycardia in a haemodynamically UNSTABLE patient.
- DC cardioversion
- Hypokalaemia and hypomagnesaemia
- Amiodarone 300 mg IV over 10-20 mins through a central line
- Procainamide and sotalol in refractory cases
Outline the management of broad complex tachycardia in haemodynamically STABLE patients.
Correct electrolyte abnormalities
Amiodarone 300 mg IV over 10-20 mins
If it fails –> DC cardioversion
NOTE: after correction of VT, patients should be given maintenance antiarrhythmic therapy (e.g. sotalol)
Outline the management of torsades des pointes.
Stop predisposing drugs (e.g. TCAs)
Correct hypokalaemia
Give magnesium sulphate 2 g over 10 mins
Outline the management of narrow complex tachycardia.
Vagal manoeuvres
Adenosine 6 mg IV bolus (followed by 0.9% saline flush)
If unsuccessful –> after 2 mins give 12 mg bolus
If unsuccessful –> after 2 mins give 12 mg bolus
Alternative: verapamil 2.5-5 mg over 2 mins
How should AF in an unstable patient be treated?
Emergency cardioversion
If unavailable –> IV amiodarone
Control ventricular rate: verapamil 40-120 mg/8 hrs PO or bisoprolol 2.5-5 mg/day PO
Start anticoagulation with LMWH
NOTE: cardioversion is only recommended if it can be done within 48 hours of the onset of symptoms
Which medications should patients with AF be given to take away?
Use CHADS-Vasc to calculate need for anticoagulation (1 or more requires warfarin) Rate control (beta-blocker or CCB) Rhythm control (flecainide if no structural heart disease, otherwise amiodarone)
Outline the investigations that you would request for a suspected acute asthma attack.
Bedside: PEFR, ECG, ABG, SaO2
Bloods: FBC, U&E
Imaging: CXR?
Outline the management of severe acute asthma.
Nebulised salbutamol 5 mg with oxygen
IV hydrocortisone 100 mg (or PO prednisolone 40-50 mg)
If it worsens
- add ipratropium bromide nebuliser 0.5 mg
- stat dose of magnesium sulphate 1.2-2 g IV over 20 mins
If a patient with a severe asthma is showing signs of improvement, how should they be cared for?
Nebulised salbutamol every 4 hours
Prednisolone 40-50 mg OD for 5-7 days
Monitor PEFR and oxygen saturations
How should a patient with life-threatening acute asthma be escalated if initial treatment fails to cause an improvement?
Refer to ICU
May need ventilatory support (e.g. intubation)
May need intensified treatment (e.g. IV aminophylline, IV salbutamol)
Outline the management of an infective exacerbation of COPD.
BRONCHODILATOR: nebulised salbutamol 5 mg/4 hr + nebulised ipratropium 0.5 mg/6 hr
OXYGEN: at 24-28% via venturi mask aiming for 88-92%
STEROIDS: IV hydrocortisone 200 mg (or oral prednisolone)
ANTIBIOTICS: trust guidelines (e.g. amoxicillin or doxycycline)
How should the treatment of a patient with an infective exacerbation of COPD be escalated if they fail to respond to initial treatment?
Consider IV aminophylline
Consider NIV
Consider intubation and ventilation
Consider respiratory stimulant (e.g. doxapram)
Which investigations may be useful in patients with acute pancreatitis?
Bedside: glucose
Bloods: amylase, lipase, FBC, U&E (calcium), LFTs, ABG, glucose
Imaging: USS, erect CXR, AXR (rule out other causes of acute abdomen), ERCP
Outline the management of acute pancreatitis.
Assess severity using Modified Glasgow Criteria
NBM
IV fluids to achieve normal vital signs (3rd spacing)
Insert catheter to monitor urine output
Analgesia (IM pethidine 75-100 mg/4 hr or morphine)
If worsening –> ITU (may need ERCP)
Outline the management of a primary pneumothorax.
No SOB + < 2 cm rim of air on CXR –> consider discharge and repeat CXR in a few weeks
SOB + > 2 cm rim of air on CXR –> aspiration
- if unsuccessful –> repeat aspiration
- if unsuccessful –> insert chest drain
Outline the management of a secondary pneumothorax.
No SOB, age < 50 yrs + < 2 cm rim of air –> aspiration
- if successful –> admit for 24 hours
- if unsuccessful –> insert chest drain
SOB, age > 50 yrs and > 2 cm rim of air –> insert chest drain
Outline the management of tension pneumothorax.
Insert a large-bore needle that is partially filled with saline into the 2nd intercostal space in the MCL on the side of the suspected pneumothorax - remove plunger to allow air to bubble through the syringe
OR: into the safe triangle
Outline the management of PE in a stable patient.
Oxygen
Morphine 5-10 mg IV with 10 mg metaclopramide
SC tinzaparin 175 U/kg/24 hrs (or UFH 10,000 IV bolus)
How does the systolic BP affect the management of PE?
SBP > 90 mm Hg –> warfarin loading regimen (e.g. 5-10 mg warfarin PO)
SBP < 90 mm Hg –> IV colloid infusion + contact ICU –> dobutamine 2.5-10 µg/kg/min IV –> IV noradrenaline infusion –> consider thrombolysis
Describe the ongoing management of PE after the immediate situation has been dealt with.
Reduce risk of recurrence (e.g. compression stockings)
LMWH should be continued with warfarin until INR > 2 for 24 hours or 5 days after starting warfarin (whichever is longest)
If obvious cause of VTE –> 3 months warfarin
If no obvious cause of VTE –> continue for 3-6 months
How is a massive PE in a haemodynamically compromised patient treated?
10 mg alteplase followed by 90 mg infusion over 2 hours
What crucial blood tests should be requested in patients with an acute upper GI haemorrhage?
FBC Group and save X-match 6 units of blood Clotting screen LFT
Outline the immediate management of shocked patients with an acute upper GI bleed.
Protect airway and keep NBM
Insert two large-bore cannulae
Rapid IV crystalloid infusion up to 1 L
If grade III-IV shock, give O- blood until X-match is complete
Correct clotting anomalies (e.g. PCC, vitamin K)
Consider ICU referral for central venous line
Catheterise to monitor urine output (aim > 30 mL/hour)
Monitor vital signs
Notify surgeons
Endoscopy within 4 hours for variceal bleed and within 12-24 hours if unstable on admission
Outline the medical management of acute upper GI bleeds.
Major ulcer bleeding –> omeprazole 80 mg IV stat over 40-60 mins followed by 8 mg/hour for 72 hours
Variceal bleeding –> resuscitate then urgent endoscopy for banding or sclerotherapy + terlipressin 2 mg SC QDS
NOTE: if large bleed, Sengstaken-Blakemore tube may be used to tamponade the bleed and lactulose may be given to reduce absorption of nitrogenous products
Outline the management of bacterial meningitis.
Sepsis 6
Cefotaxime 2 g IV (add ampicillin 2 g/6 hrs IV if immunocompromised or > 55 years)
Call critical care team
If meningitis only: consider adding dexamethasone 4-10 mg/6 hrs IV
Outline the ongoing management of a patient with bacterial meningitis who has been stabilised.
Discuss antibiotic treatment with microbiology
Isolate in side-room for 24 hours
Treat contacts with ciprofloxacin 500 mg PO
Which drug treatment is used for suspected encephalitis?
IV aciclovir (10 mg/kg/8 hrs IV)
How much insulin should be given to patients with DKA?
50 u actrapid in 50 mL of 0.9% saline
Infused continuously at 0.1 u/kg/hour
Aim for a fall in ketones of 0.5 mmol/L/hour
OR rise in venous bicarbonate of 3 mmol/L/hour with a fall in glucose of 3 mmol/L/hour
NOTE: check VBG at 1 hour, 2 hours and 2 hourly thereafter
When should glucose be added to the infusion in DKA?
10% glucose at 125 mL/hour alongside saline when glucose < 14 mmol//L
Outline the management of acute abdomen.
Gain IV access
Catheterise and place on fluid balance chart if hypotensive
Analgesia: 100 mg diclofenac PR for renal pathology, or 5-10 mg morphine IV for intra-abdominal pathology
Send blood sample for FBC, U&E, amylase, LFT, CRP and G&S
IV antibiotics if indicated
NBM
Outline the management of stroke.
15 L/min oxygen if low saturations or SOB
NBM
100 mL/hour 0.9% saline
Treat arrhythmias
Get exact timescale of symptom onset
Request urgent CT scan
Once haemorrhagic stroke ruled out: aspirin 300 mg STAT and thrombolyse with tPA of < 80 yrs and < 4.5 hours or > 80 yrs and < 3 hours
Outline the treatment of hyperkalaemia.
10 mL 10% calcium gluconate IV over 2 mins (repeat every 15 mins up to 5 doses)
10 IU Actrapid with 50 mL 50% dextrose IV over 10 mins
Consider 5 mg salbutamol nebuliser
Monitor ECG and have access to crash trolley
Check ABG for acidosis
How are pre-renal and post-renal causes of AKI treated?
Pre-renal: fluid resuscitation with 0.9% saline (250-500 mL bolus) followed by infusion of 20 mL + last hour’s urine output
Post-renal: catheterise
NOTE: pulmonary oedema should be treated with furosemide IV
List the indications for dialysis in AKI.
Hyperkalaemia unreponsive to medical treatment in an oliguric patient
Pulmonary oedema unresponsive to medical treatment
Uraemia (e.g. encephalopathy)
Severe metabolic acidosis (pH < 7.2)
Outline the management of hypokalaemia.
Monitor U&E and ECG
40 mmol/L KCl in 1 L of 0.9% saline (unless oliguric –> insert catheter to ensure accurate assessment of urine output)
Admit to ICU for insertion of a central line if > 10 mmol/hr needed
If MILD: oral K+ supplementation (SandoK)
Which investigations would be useful in a patient with hyponatraemia?
Hypovolaemic –> low urine sodium
Euvolaemic –> TFT, SST, plasma and urine osmolality
Hypervolaemic –> low urine sodium
Outline the management of hyponatraemia.
Do NOT correct faster than 8-10 mmol/L/24 hrs
Hypovolaemic –> 0.9% saline
Euvolaemic –> fluid restriction
Outline the management of hypocalcaemia.
Mild and asymptomatic: monitor, consider vitamin D supplements and calcichew
Severe tetany: 10 mL 10% calcium gluconate IV over 10 mins
Outline the management of hypercalcaemia.
Correct dehydration with 0.9% saline (3-6 L in 24 hours with the first 1 L going in over 1 hour)
Furosemide may be needed in elderly patients who are prone to pulmonary oedema
Insert catheter to monitor urine output
IV bisphosphonate for bone pain (takes 1 week to work)
Which investigations are important to order in patients with status epilepticus?
U&E FBC LFT Glucose Calcium Toxicology AED levels CT/MRI head
Outline the management of status epilepticus.
Secure the airway (may need adjuncts)
STEP 1: Slow IV bolus of IV lorazepam 2-4 mg
Second dose if no response within 10 mins
Thiamine if alcoholism is suspected
Glucose 50 mL 50% IV if hypoglycaemia is suspected
STEP 2: IV phenytoin infusion 15-20 mg/kg at < 50 mg/min
STEP 3: rapid sequence induction with thiopental and EEG monitoring
Outline the management of pneumonia.
Treat hypoxia and hypotension if necessary
Antibiotics following local guidelines (e.g. CAP = coamoxiclav and clarithromycin; HAP = tazocin)
Analgesia if pleuritic chest pain
CPAP if no improvement
Which investigations should be requested in suspected pneumonia?
Bedside: oxygen saturation, ABG, sputum sample, urine sample (Legionella)
Bloods: FBC, U&E, CRP, atypical serology
Imaging: CXR
Which investigations would you request in a patient with delirium?
Bedside: glucose, ABG, ECG, urine dipstick
Bloods: FBC, U&E, LFTs, blood glucose, blood cultures
Imaging: CXR, CT/MRI
Outline the management of bradycardia.
Sit the patient up (unless dizzy)
15 L/min oxygen if hypoxic
Give 0.5 mg atropine IV every 2-3 mins (up to max 6 doses)
If unsuccessful –> isoprenaline 5 µg/min
If unsuccessful –> adrenaline 2-10 µg/min
If unsuccessful –> transcutaneous pacing
Outline the management of hyperosmolar hyperglycaemic state (HHS/HONK).
Rehydrate slowly with 0.9% saline over 48 hours (deficit is typically 110-220 mL/kg)
Equated to 8-15 L for 70 kg adult
First 1 L may be given quickly over 30 mins
Replace K+ when urine starts to flow
Use insulin sliding scale if glucose is NOT falling by 5 mmol/L/hr with rehydration
Keep glucose at 10-15 mmol/L for first 24 hours (avoid cerebral oedema)
If a nurse contacts you regarding a patient who has become unconscious, what should you tell them to do?
Check for respiratory effort/pulse and begin CPR if absent
How should an Addisonian crisis be treated?
100 mg hydrocortisone STAT
Followed by 100 mg/8 hrs hydrocortisone
NOTE: they may need fludrocortisone, glucose and fluids
What are the components of a SOFA score?
Respiratory rate Bloodpressure GCS Liver (bilirubin) Coagulation (platelets) Renal (creatinine and urine output)
Sepsis = infection + increase of 2 or more on SOFA
Outline the management of NSTEMI.
Give oxygen if breathless or SaO2 < 90%
Morphine 5-10 mg IV + antiemetic
Nitrates (GTN spray or sublingual)
Aspirin 300 mg PO + second antiplatelet agent (clopidogrel, ticagrelor, prasugrel)
Oral beta-blocker (e.g. metaprolol) if hypertensive/tachycardic/low LV function
Fondaparinux 2.5 mg OD SC or LMWH 1 mg/kg/12 hours SC
IV nitrate if pain continues
HIGH RISK PATIENT
- Features: rise in troponin, dynamic ST or T wave changes, risk factors
- Begin infusion of tirofiban and refer for inpatient angiography (within 72 hours)
- Angiography may need to be within 24 hours if GRACE score > 140
Which additional measures may be used during the A to E approach of a trauma patient?
Check for blood on the floor
Arrange FAST scan/pelvic X-ray
For unstable pelvic fractures use a pelvic band to reduce blood loss
Outline the algorithm for the major haemorrhage protocol.
Take baseline blood samples (FBC, G&S, X-match, Clotting, fibrinogen)
If trauma < 3 hrs: give tranexamic acid (1 g over 10 mins, then 1 g/8 hrs infusion)
Limit use of O-negative blood and use group-specific blood as soon as possible
What is the definition of major haemorrhage?
Loss of more than one blood volume in 24 hrs
Loss of 50% blood volume in 3 hours
Bleeding in excess of 150 mL/minute
Which extra parts of an A to E would you do in a patient with suspected spinal cord compression?
D - palpate for spinal tenderness and perform a lower limb neurological examination to assess tone, power, reflexes and sensation
E - percuss the bladder (urinary retention), perform a rectal examination (tone and saddle anaesthesia) - important to consider cauda equina as a differential
Outline the management of cord compression.
Ix: urgent MRI whole spine within 24 hours
Rx: dexamethasone 16 mg PO
Discuss with neurosurgery
Definitive: RADIOTHERAPY or decompressive surgery
What must be done before a CTPA is performed in a patient with suspected PE?
Check renal function and ask about allergy to contrast
What must always be done before thrombolysing a patient?
Discuss with a senior
What is Cushing’s reflex?
Irregular breathing (Cheyne-Stokes)
Hypertension
Bradycardia
Who could angry patients be directed towards?
PALS
NOTE: always gain consent from the patient before discussing their care with a family member
What is the first step in managing a patient with VT?
Put out a peri-arrest call
What are the 4 Hs and 4 Ts of cardiac arrest?
Hypoxia Hypovolaemia Hypokalaemia/hyperkalaemia Hypothermia Toxic Thromboembolic Tamponade Tension pneumothorax
Which medications should be continued after correction of VT?
Establish and treat the cause
Maintenance: amiodarone infusion for 12-24 hours followed by oral sotalol or amiodarone
How can recurrence of VT be prevented?
Ablation of arrhythmogenic area OR ICD
Outline the management of hypothermia.
Prepare crash trolley Confirm temperature with low-reading thermometer (PR) and check every 30 mins Set up ECG (bradycardia and J waves) Remove wet clothing Give warmed humidified oxygen Slowly rewarm at 0.5 degrees per hour CARDIAC MONITORING IS ESSENTIAL
What is the difference between the Glasgow Blatchford and Rockall scores?
Blatchford - used at first presentation
Rockall - used after intervention to determine risk of re-bleed/death
Which investigations are important to request in someone who has taken a paracetamol overdose?
Paracetamol levels (4 hrs post-dose) LFTs Clotting studies U&E FBC Bone profile ABG (acidosis and lactate)
Outline the management of bowel obstruction.
IV 0.9% saline 5-10 mg morphine IV NBM NG tube aspiration Correct electrolyte imbalance Consider giving antibiotics if septic/perforated (co-amoxiclav and gentamicin)
Outline the management of acute limb ischaemia.
URGENT open surgery and angioplasty
ALERT the vascular surgeons
If embolic: surgical embolectomy or thrombolysis (tPA)
Anticoagulate with LMWH after either procedure and look for source of emboli (e.g. AF, aneurysms)
WARNING: post-op reperfusion injury can lead to compartment syndrome
Compartment syndrome is treated with fasciotomy
It is very painful so patients should be given morphine
Who is part of the cardiac arrest team?
Medical team on call (Med reg, SHO, FY1) Anaesthetist Nurse Porters CCOT
What are some contraindications for NIV?
Pneumothorax
Drowsiness
For the treatment of hyperkalaemia, what do you mix the insulin in?
10 U Actrapid in 100 mL of 20% dextrose given over 30 mins
