Planning management - Acute conditions Flashcards
Management of acute conditions: STEMI
ABC
15L by non-rebreathe mask (unless COPD)
Hx, O/E, ix (ECG, troponin)–> diagnosis STEMI
Aspirin 300mg oral
Morphine 5mg-10mg IV with metaclopramide 10mg IV
GTN spray/ tablet
Primary PCI (preferred) or thrombolysis
Beta-blocker e.g. atenolol 5mg oral - unless LVF or asthma
Transfer CCU
Management of acute conditions: NSTEMI
ABC and O2 15L via non-rebreathe mask unless COPD
Hx, o/e, ix (ECG & trops) –> diagnosis = NSTEMI
Aspirin 300mg oral
Morphine 5-10mg IV with metaclopramide 10mg IV
GTN spray/ tablet
Clopidogrel 300mg oral and LMW heparin e.g. enoxaparin 1mg/kg BD S/C
Beta blocker e.g. atenolol 5mg except LVF/ asthma
Transfer CCU
Management of acute conditions: acute LVF
ABC and O2 15L via non-rebreathe mask unless COPD
Hx, o/e, ix(ECG & trops, bloods)
Diagnosis LVF +/- cause
Sit patient up
Morphine 5mg-10mg IV with metaclopramide 10mg IV
GTN spray/ tablet
Furosemide 40-80mg IV
If inadequate response isosorbide mononitrate infusion +/- CPAP
Transfer CCU
Management of acute conditions: anaphylaxis
ABC and O2 15L via non-rebreathe mask unless COPD
Remove the cause ASAP e.g. blood transfusion
Adrenaline 500micrograms of 1:1000 IM i.e. 0.5ml of 1:1000
Secure IV access
Chlorphenamine 10mg IV
Hydrocortisone 200mg IV
IV 0.9% saline 500ml over 15mins, up to 2L titrate against BP
Asthma tx if wheeze - salbutamol nebs
If still hypotensive consider ITU, adrenaline infusion +/- aminophylline
Amend drug allergies box on drug chart
Management of acute conditions: acute exacerbations of asthma
ABC
Hx, o/e, ix, diagnosis acute asthma
Sit up
100% O2 by non-rebreathe mask
Salbutamol 5mg nebs & Ipratropium 500micrograms nebulised with O2
Hydrocortisone 100mg IV if severe or life threatening or prednisone 40-50mg oral if moderate
CXR to exclude pneumothorax
Theophylline only if life threatening -only if not on aminophylline
Inform seniors and ITU & Magnesium sulphate 1.2-2g over 20 min if not improving
Management of acute conditions: COPD
Same as acute asthma management but add IV antibiotics if infective exacerbation
Give 28% oxygen and do ABG within 30 mins to check for type 2 resp failure
Management of acute conditions: pneumothorax
If secondary I.e. patient has lung disease —> pt needs tx
Chest drain if >2cm or patient SOB or if >50 years old otherwise aspirate
If tension pneumothorax i.e. tracheal deviation +/- shock then emergency aspiration is required but will need chest drain quickly
If primary determine whether the pt needs tx:
If <2cm rim and not SOB then discharge pt with outpatient follow up in 4 weeks
If >2cm rim on CXR or SOB then aspirate and if unsuccessful aspirate again and if still unsuccessful then chest drain
Management of acute conditions: pneumonia
Use CURB65 to assess severity of CAP Confusion - AMTS <8/10 Urea >7.5mmol/L Respiratory rate >30/min Blood pressure (systolic) <90mmHg Age >65 years Score 0 or 1 home treatment Score 2 or more hospital tx with oral or IV abx >3 ITU care
ABC
Hx, o/e, ix, diagnosis pneumonia
High flow oxygen
Antibiotics e.g. amoxicillin or co-amoxiclav
Paracetamol
If low BP or raised HR IV fluids as normal
Management of acute conditions: pulmonary embolism
ABC
Hx, o/e, ix (d-dimer, CTPA), diagnosis –> PE
High flow oxygen
Morphine 5-10mg IV
Metaclopramide 10mg IV
LMWH e.g. tinzaparin 175units/kg SC daily
If low BP, IV gelofusine –> adrenaline –> thrombolysis
Management of acute conditions: Gastro emergencies
Gastrointestinal bleeding
ABC 15L O2 via non-rebreathe mask Hx, o/e, ix --> diagnosis acute GI bleed 8 Cs Cannulate - 2 large bore Catheter (and strict fluid monitoring) Crystalloid/ colloid Cross match 6 units of blood Correct clotting abnormalities** Camera - endoscopy Stop Culprit drugs - NSAIDs, aspirin, warfarin, heparin Call the surgeons
**if PT/aPTT more than 1.5 normal range –> give fresh frozen plasma (unless due to warfarin –> give prothrombin complex e.g. beriplex
If platelets <50x10^9/L and actively bleeding give platelet transfusion
Management of acute conditions: Neuro emergencies
Meningitis
GP would have already given 1.2g benzylpenicillin if meningitis suspected
ABC Hx, o/e, ix, diagnosis meningitis High flow oxygen Iv fluid Dexamethasone IV unless severely immunocompromised LP +/- CT head 2g cefotaxime IV - give pre-LP if having a CT head or prolonged LP Consider ITU
Management of acute conditions: Neuro emergencies
Seizures and status epilepticus
Management of any seizure
ABCDE
Ensure airway patent
Put in recovery position to prevent vomits/ aspiration
Check for provoking factors - plasma glucose, electrolytes
Seizures lasting >5min
Buccal midazolam 10mg, diazepam IV 10mg or lorazepam 2-4mg IV
If still fitting after 2 min repeat diazepam
Inform anaesthetist
Phenytoin infusion
Intubate and then propofol
Status epilepticus = seizing for longer than 30 min
Management of acute conditions: Neuro emergencies
Stroke
ABCDE
H/x, o/e, ix (blood glucose and CT head to exclude haemorrhage) –> diagnosis ischaemic stroke
If aged <80 years and onset <4.5 hours ago consider thrombolysis
Aspirin 300mg oral
Transfer to stroke unit
Management of acute conditions: Metabolic emergencies
Hyperglycaemia
ABCDE
Hx, o/e, inv, diagnosis: DKA
IV fluid: 1L stat then 1L over one hour, then 2 hours, then 4 hours then 8hours
Sliding scale insulin & continue long acting insulin
Hunt for trigger - infection, MI, missed insulin
Monitor BM, K+ and pH
How do you diagnose DKA?
Diabetic i.e. hyperglycaemia with BM >30mmol/L
Keto i.e. check blood or urine ketone levels
Acidosis i.e. low pH on ABG
& watch out for increased potassium
How to diagnose hyperglycaemic HONK coma
Hyperglycaemia >35mmol/L
Hyperosmolar - osmolality >340mmol/L (calculated by (2Na + 2K)+ urea + glucose
Non ketotic i.e. no ketones in blood or urine
HONK management is the same as DKA management, except half the rate of fluids is required
Hypoglycaemia (BM glucose <3mmol) management
If pt able to eat and drink give sugar rich snack - oragne juice and biscuits
If unable to eat i.e. drowsy & vomiting give IV glucose via cannula e.g. 100ml 20% glucose (traditionally 50ml 50% glucose IV but can cause extravasation)
If unable to eat and no cannula give 1mg IM glucagon
Management of AKI
ABC Hx, o/e, inv, diagnosis - AKI Cannula and catheter, strict fluid monitoring IV fluid 500ml stat. then 1L 4 hourly Hunt for causes and complications Monitor U&E and fluid balance
Management of acute poisoning
ABC
Hx, o/e, inv, diagnosis = acute poisoning
Cannula and catheter, strict fluid balance
Supportive measures
Correct electrolyte disturbance
Reduce absorption - if within 1 hour by carrying out:
1. gastric lavage i.e. stomach pumping unless caustic/acid content
2. whole bowel irrigation (if lithium/iron)
3. charcoal (dx-dependent)
Increase elimination
1. NAC - if paracetamol level at 4 hours or more is over the line on treatment nomogram
2. Naloxone if opiates have been taken and there is slow breathing or low GCS
3. Flumazenil if benzos have been taken
Psychiatric management
