MET Flashcards
Stroke thrombolysis indications
Disabling stroke (NIHSS>5) due to large vessel occlusion
<4.5hrs
or
4.5-9hrs post onset or mid point of sleep for CT perfusion selected
Prior to endovascular thrombectomy if thrombolysis indicated
Stroke thrombolysis contraindications
Haemorrhage on CT brain
Extensive hypodensity on CT brain
Active non compressible systemic bleeding
Recent GI/GU bleeding, surgery or trauma
IE, aortic dissection, malignant brain tumour
DOAC <48hrs
BP >185/105
BGL <2.7
INR > 1.7
Platelets <100
Stroke alteplase administration
Dose
0.9mg/kg up to 90mg, infuse over 60 mins with 10% bolus over 1 min
Admit to ICU
CT brain if
-severe headache
-acute hypertension
-nausea or vomiting
-worsening neurological exam
Avoid NGs, IDC, art lines
CT or MRI brain
-24hrs post
-prior to stating antiplatelets/anticoagulants
BP and neurological assessments
-every 15 mins during infusion and for 2hr post
-then every 30 mins for 6hrs
-then hourly until 24 hrs
Labetalol dose in stroke
10-20mg IV over 1-2 mins. Can repeat once
Nircardipine dose in stroke
5mg/hr IV, titrate up by 2.5mg/hr every 5-15 mins, max 15mg/hr
ICH management
Intensive BP lowering
-to around 140 (not substantially below)
Reverse anti coagulation
-warfarin: prothrombinex + vit K
-dabigatran: idarucizumab
-rivaroxaban/apixaban: andexanet alfa
-antiplatelets: NO platelet transfusions
Surgery
-posterior fossa with mass effect
-possibly for supratentorial with mass effect
NIHSS components
Level of consciousness
-Alert
-Minor stimulation
-Repetitive stimulation
-Movements to pain
-Postures or unresponsive
Month and age
-Both right
-One right
-Neither right
-Dysarthric, trauma, language barrier, intubated
-Aphasic
Language and aphasia
-Normal
-Some obvious changes without significant limitation
-Fragmentary speech, inferences needed, cannot identify objects
-Mute, coma, no usable speech or comprehension
Dysarthria
-Normal, intubated, unable to test
-Slurring, can be understood
-Unintelligible speech, mute
Blink eyes and squeeze hands
-Both tasks
-One task
-Neither task
Horizontal eye movements
-Normal
-Partial gaze palsy or can be overcome with occulocephalic reflex
-Fixed gaze deviation
Visual fields
-Normal
-Partial hemianopia
-Complete hemianopia
-Bilateral hemianopia or blind
Facial palsy
-Normal symmetry
-Flat nasolabial fold, smile asymmetry
-Lower face unilateral weakness
-Unilateral or bilateral upper and lower weakness
Limb drift
-No drift for 10 seconds, amputation, joint fusion
-Drift, doesn’t hit bed
-Drift, hits bed
-Effort against gravity
-No effort against gravity
-No movement
Finger nose and heel shin
-No ataxia, doesn’t understand, amputation, joint fusion
-Ataxia in one limb
-Ataxia in two limbs
Sensation
-Normal
-Less sharp, more dull
-Compete loss, no response, coma
Inattention
-None
-Sensory, auditory or visual inattention
-Inattention to >1 modality or profound (doesn’t recognise own hand)
Status epilepticus evaluation and management
Treat if
-Over 5 mins continuous
-Repeated seizures without full recovery
-Airway or breathing compromise
Continuous observations
Airway
-Simple manoeuvres/adjuncts
-Consider need for intubation
B
-Hudson mask
-BMV if apnoea, hypoxia or cyanosis
C
-IV access
-Fluids
-Pressors
D
-duration
-awareness
-focal signs
Investigations
-Glucose
-VBG
-Bloods, ASM level, beta hCG
Correct hypoglycaemia
Give thiamine if hypoglycaemic
5 mins
-Midazolam 5-10mg IM/IV or Lorazepam 2-4mg IV
-First dose ASM
10 mins
-Second dose benzo
15 mins
-Contact consultant
-Contact ICU
15-30 mins
-Second ASM
-Prepare for RSI
30mins
-ICU
-Intubation
-Midazolam, propofol, phenobarbital infusion
After seizure
-Monitor back to baseline
-EEG
-Brain imaging
-LP after brain imaging if concerned for infection
Status epilepticus second line options
Levetiracetam
-60mg/kg up to 4.5g
Valproate
-40mg/kg up to 3g
Phenytoin
-20mg/kg
On phenytoin or valproate
-Recent therapeutic level, give levetiracetam
-Recent subtherapeutic level, give proportionate loading
If on levetiracetam, give levetiracetam, valproate or phenytoin
All equally effective (about 50% at 1hr) and same rates of adverse effects
Status epilepticus midazolam administration
Midazolam 5mg IV or IM
-5mg/5mL ampule
-IV infusion over 2mins
-IM push
-Up to 10mg recommended
-Repeat after 5 mins
Status epilepticus levetiracetam administration
Levetiracetam
-60mg/kg up to 4.5g loading
-Dilute in 100mL normal saline
-Infusion over 5-15 mins
Preferred option
-already on levetiracetam
-liver failure
-limited drug interactions
Renal dose adjustment needed
Adverse effects
-Hypertension
-Nausea
-Neuropsych changes
-Drowsiness and fatigue
Tachycardia pathway
Unstable
-Synchronised cardioversion
-AF or broad complex = 120-150J
-Narrow complex = 70-120J
-Conscious sedation or general anaesthesia
Stable, narrow and regular
-Sinus tachycardia, AVNRT, AVRT, flutter, monofocal atrial tachy
-Vagal manoeuvres
-Adenosine 6mg IV with rapid flush. Repeat twice more with 12mg
Stable, narrow and irregular
-AF, flutter with variable block, multi focal atrial tachy
-Metoprolol 1mg IV aliquots up to 5mg or 12.5-25mg oral
Stable, broad and regular
-VT, supraventricular rhythm with aberrancy
-Amiodarone 300mg IV over 1hr then 900mg IV over 24hrs
-If known supraventricular arrhythmia, consider treating as narrow regular tachycardia
Stable, irregular and broad
-AF with aberrancy, AF with pre-excitation, polymorphic VT
-Seek expert help
Bradycardia pathway
Unstable
-Shock, syncope, MI, HF
-Atropine 600mcg IV, repeat up to 3mg
Risk of asystole
-Recent asystole, Mobitz II, complete AVB, ventricular pause >3s
-Seek expert help
-Transcutaneous pacing
-Isoprenaline 5mcg/min IV
-Adrenaline 2-10mcg/min IV
-Arrange transvenous pacing
Acute asthma management
Life threatening features
-Exhaustion or drowsiness
-Soft or absent breath sounds
-Cyanosis or sats <90%
-Worsening resp acidosis
Initial treatment
-Oxygen aiming sats >92%
-Salbutamol nebuliser, 5mg q15min or 5-10mg/hr continuous
-Hydrocortisone 100mg IV q6hrly
-Move to safe area
Reassess severity
Marked improvement
-Salbutamol MDI 12 puffs x 100mcg q20mins for 1 hr
Or
-Salbutamol nebuliser 5mg q20mins for 1hr
Some improvement
-Continue salbutamol
-Add ipratropium nebuliser 500mcg q20mins for 1hr
No improvement or worsening
-Add 10mmol Mg IV
-Consider NIV or intubation
-Transfer to ICU
Monitor for salbutamol toxicity
-Electrolytes
-Acid base balance
-Lactate
Adrenaline in cardiac arrest
Indication
-Shockable and non shockable rhythms
Timing
-Shockable: after 2nd shock then every 2nd shock
-Non shockable: immediately then every 2nd loop
Dose
-1mg IV/IO
Amiodarone in cardiac arrest
Indication
-Shockable rhythm: yes
-Non shockable rhythm: no
Timing
-After 3rd and 5th shocks
Dose
-First dose 300mg IV/IO in 20mL 5% dextrose/normal saline bolus
-Second dose 150mg
Lignocaine in cardiac arrest
Indication
-When amiodarone unavailable
-Refractory VT/VF
-Shockable rhythm only
Timing
-After 3rd and 5th shocks
Dose
-First dose 1mg/kg IV/IO
-Second dose 0.5mg/kg
-Do not exceed 3mg/kg in 1st hr
Calcium in cardiac arrest
Indication
-Hyperkalaemia, hypocalcaemia , hypermagnesaemia or CCB overdose
Dose
-10mL of 10% calcium chloride IV/IO
Sodium bicarbonate in cardiac arrest
Indication
-Not routinely recommended
-Shockable and non shockable rhythms
-Hyperkalaemia
-Tricyclic overdose
Dose
-50mmol (50mL of 8.4%) IV/IO
Fibrinolytics in cardiac arrest
Indication
-Suspected or proven PE
Dose
-Alteplase 50mg IV bolus. May repeat after 15 mins
Continue CPR for at least 60-90mins
