PACES acute Flashcards
Anaphylaxis management
- Secure the airway- give 100% O2. Intubate if respiratory obstruction
- Remove the cause, raise the feet of the bed
- Adrenaline IM 0.5mg, every 5mins as guided by BP/pulse/resp function
- Secure IV access
- Chlorphenamine 10mg IV and hydrocortisone 200mg IV
- IVI 0.9% saline over 15mins (up to 2L may be needed); titrate against BP
- If wheeze, tx for asthma; may require ventilator support
- If still hypotensive, admit to ITU and give IVI adrenaline +/- aminophylline and nebulized salbutamol; get expert help
- Admit to ward. Monitor ECG
- Continue chlorphenamine 4mg/6h PO if itching
- Medic Alert bracelet
Refer to allergy clinic - Teach about Epipen
- Skin prick tests to identify cause
Tryptase 12hours post to confirm
ACS with STEMI
- ABCDE
- Attach ECG monitor and 12 lead ECG (hyper acute T. waves, St elevation, t wave inversion, q waves LBBB)
- O2 2-4L aim for SaO2>95% (mask or nasal prongs)
- IV access- bloods for FBC, U&E, glucose, lipids, cardiac enzymes- measure at presentation and 12 hours
- Brief assessment:
i. Hx of CV disease; risk factors for IHD, contraindications to thrombolysis? Examine: pulse, JVP, cardiac murmurs, signs of heart disease, scars from previous surgery - Aspirin 300mg PO, +/- clopidogrel
- Morphine 5-10mg IV + antiemetic e.g. metoclopramide 10mg IV
- GTN sublingually or 2 puffs or 1 tablet PRN
- Primary PCI (best if ongoing ischaemia and presentation within 12h) or thrombolysis
BB, ACEi, statin, dual AP
Admission with continuous ECG
ACS with NSTEMI
- ABCDE
- Attach ECG monitor and 12 lead ECG
- O2 2-4L aim for SaO2>95% (mask or nasal prongs)
- IV access- bloods for FBC, U&E, glucose, lipids, cardiac enzymes
Morphine + meto + aspirin and GTN
GRACE score
age
heart rate, blood pressure
cardiac and renal function (serum creatinine)
cardiac arrest on presentation
ECG findings
troponin levels
Low risk- aspirin and ticagrelor
High risk- PCI and ticagrelor
Pulmonary oedema Mx
- ABCDE
- 100% oxygen
- IV access and monitor ECG; treat any arrythmias
- Invx: CXR, ECG, U&E, ‘cardiac’ enzymes, ABG, consider ECHO
- (during treatment monitor progress with BP/pulse/cyanosis/resp rate/JVP/urine output/ABG)
- Diamorphine 2.5-5mg IV slowly- caution in liver failure and COPD
- Furosemide 40-80mg IV slowly- larger doses in renal failure
- GTN 2 puffs SL or 2 x 0.3mg tablets SL (NOT if BP<90)
- If patient is worsening: further dose of furosemide 40-80mg. Consider ventilation (invasive or non-invasive
- If systolic BP<100mmHg, tx as cardiogenic shock i.e. insert Swan Ganz catheter and inotropic support
- Daily weights; BP and pulse/6h. Repeat CXR
Long term- ACEi, BB, spirono, SGLT2i,
Entresto
Biventricular pacing
Specialist nurse
Cardiogenic shock
- ABCDE
- Oxygen titrated to adequate arterial saturations
- Diamorphine 2.5-5mg IV for pain and anxiety
- Invx- ECG, U&E, cardiac enzymes, ABG, CXR, ECHO. IF indicated do CT thorax or V/Q scan
- Monitor- CVP, BP, ABG, ECG, urine output. 12 lead ECG hourly until diagnosis. Consider Swanz-Ganz catheter for pulmonary wedge pressure and cardiac output, and an arterial line to monitor pressue. Catheterise for urine output.
- Correct arrhythmias, U&E abnormalities or acid-base disturbance
If available measure pul capillary wedge pressure - swanz
IF low- fluid bolus
If high-inotropic support- dopamine
Shock management
A-E
Call for help
Raise feet- unless cardio
IV access- 2 large bore
ECG
Cold, JVP
Septic- warm, no JVP, fever- sepsis 6- broad antibiotics, fluids ect
Hypovolaemic- no JVP, cold- fluids, transfusion
Broad complex tachycardia
A-E
Check pulse
2222
O2, ECG, IV access
Cardiac monotor and defib pad
No signs- correct cause, amiodarone, torsades- MgSo4
Adverse signs- experts, sedation, DC shock, amiodarone
Acute severe asthma
A-E
100% O2
Salb 5mg, Ipra 0.5mg- bedulised
HC IV or pred PO
ABG, CXR, FBC, U+E
O2 sats, HR, RR, PEF
Life threatening- IV magnesium
Continue nebulisers every 15 mins
and magnesium
Aminophylline IV
Seniors
Before discharged- stable on meds for 24 hours, technique, PEF >75, management plan, GP in 1 wk, resp clinic in 4
Acute COPD Mx
A-E approach
High flow- titrate down
Or 24-28%
Nedulised salbutamol and ipratropium
Steroids
ABx if think infection
Physio- remove sputum
IV aminophylline
BPAP- if <7.35 pH
<7.25- ITU and intubation
Discharge- GP steroids reduction, smoking, vaccines,
Rehab, LTOT
Pneumothorax mx
A-E
tracheal deviation or signs of tension
CXR
Tension- large 14G with syringe
After air- CXR and chest drain
1- >2cm- aspirate
Admit for 24 hours if successful
2- <2cm aspirate, >2cm chest drain
If bilateral, lung fails to expand after drain, multiple past on same side- surgery
PE management
100 O2
IV access- FBC, UE, clotting, ECG, CXR, ABG, D dimer, CTPA
Analgesia
Unstable- thrombolyse
CI_ unfractionated heparin
Senior help
Wells score- >4- CTPA- DOAC
<4- doppler
Acute upper GI bleed
A-E
Shocked- 2 large bore cannulas- draw blood- FBC, UE, LFT, fluids, X match 6 units
Protect airway, NBM
Fluids and blood
Clotting- check INR
Rockall score- age, comorbidity, liver disease, haemodynamic disturbance, continued bleeding, elevated blood urea
Vital signs monitor- 15 mins
Endoscopy urgent- same day
If variceal- terlipressin and ABx before= banding
Massive- Sengstaken Blakemore tube
Non- high dose PPI
Status epilepticus mx
Maintain airway- recovery position
Oxygen
IV access- take bloods- BM test, Ca, toxicology
Thiamine- alcohol
