SFP Acute conditions Flashcards
What is sepsis and septic shock
Life-threatening organ dysfunction (defined >=2 on qSOFA) caused by a dysregulated host response to infection; ≥ 10% mortality
Septic shock: sepsis + despite adequate fluid resuscitation, hypotension requiring inotropes to maintain MAPs >65, or lactate 2
What is the qSOFA for poor outcome
GCS <15
RR>22
SBP <100
How would you approach a patient with sepsis
I’d be worried about sepsis, looking out high risk criteria and completing the SEPSIS 6
A
B: ABG (lactate), portable CXR
C: bloods + cultures Mx: fluids, IV Taz + evidence, ask for catheter
D: GCS (<15 part of qSOFA)
E: non-blanching rash, mottled skin, lines/ drains, swabs
Hx: localising signs for source of infection, immunosuppression
Definitive Ix:
Sepsis Screen: CXR, urinalysis, blood cultures, ?LP, swabs
Definitive Rx:
Microbiology guidelines
Escalation
Isolate patient/ PPE
How is sepsis managed
Sepsis 6 (3 in and 3 out)
3 In:
- Antibiotics: broad spectrum IV (per Trust protocol) e.g. Tazocin 4.5g IV QDS (+) vancomycin if MRSA/ severe HAI
If penicillin allergic: vancomycin + ciprofloxacin - Fluids: 500-1000ml of resuscitation fluids/15 minutes + reassess after each bolus; if refractory:
- Passive leg raise
- USS of IVC
- ITU support: vasopressors
- Oxygen - 15L by non-rebreather mask
3 out:
- Lactate
- Blood cultures - preferably before Abx but do not delay Abx administration
- Urine output - start fluid balance chart, consider catheterisation, hourly urine output measurements
How should sepsis be escalated
Immediate senior review (ST3+)
Rapid response team (RRT)/ critical care outreach team (CCOT)
ITU/ HDU: invasive monitoring, supporting organ dysfunction: renal replacement, inotropes, mechanical ventilation
MAP = Diastolic + 1/3 (Systolic – Diastolic)
>60 required to be needed to maintain adequate tissue perfusion
>65 recommended with severe sepsis and septic shock
What are other differentials for sepsis
Other causes of shock:
* Hypovolaemia
* Cardiogenic
* Obstructive
* Anaphylactic
Pain
What are features suggesting neutropenic sepsis
Chemo in last 30 days
Known neutrophil count
MDS (myelodysplastic syndromes)
How should you approach a patient suspected of having neutropenic sepsis
Full set of observations
FBC (but do not wait for neutrophil count)
As suspecting neutropenic sepsis —> Sepsis 6
A
B: ABG (lactate), portable CXR
C: bloods + cultures (+ fungal)
Mx: fluids, IV Taz + evidence, ask for catheter
D:
E: non-blanching rash, mottled skin, lines/ drains, swabs
Hx: localising signs for source of infection, immunosuppressed
Definitive Ix:
Sepsis Screen: CXR, urinalysis, blood cultures, ?LP, swabs
Definitive Rx:
Microbiology guidelines
Escalation: Onc review
Isolate + PPE
How should neutropenic sepsis be managed
Sepsis 6
Antibiotics (check hospital trust for Abx anti-fungals): tazocin IV 4.5g QDS, if p/a: meropenem IV,
Severe:
- vancomycin + gentamicin + metronidazole
Isolate patient + PPE
How should you escalate in neutropenic sepsis
Immediate senior review
Inform Haematology SpR
Inform Oncology SpR
What are features of different acute asthma severity
Acute severe:
- Can’t complete sentences
- SpO2 <92
- PEFR 33-50
- Pulse >110
- RR>25
Life threatening:
- Silent chest
- Cyanosis
- Poor respiratory effort
- Hypotension
- Exhaustion
- Confusion
- PEFR <33
Near fatal:
- Raised PaCO2
How should you approach a patient suspected of having acute asthma attack
Assess severity using BTS guidelines
A: Can’t complete sentences = acute severe
B: SpO2 <92 or RR>25 = acute severe,
Poor resp effort/ exhaustion —> life threatening
ABG: normal or raised PaCO2 —> escalate (in all Pts) Wheeze —> nebulisers (+) ipratropium
At this point if life threatening/ near fatal —> senior input
C: HR >110 = acute severe, ECG: salbutamol (drop K+ —> arrhythmias)
D: Confusion —> acute severe, drug chart: level of asthma care
E:
Hx: asthma exacerbations – ever been to hospital
Definitive Ix: PEFR Consider CXR
Definitive Rx: Steroids
Escalation: Mg sulphate, ITU support for IV salbutamol or intubation/ ventilation
How would you manage a patient with an acute asthma attack
Life-threatening or near fatal: immediate escalation RRT or 2222 peri-arrest
All attacks:
- Salbutamol nebulisers 5mg (repeat at 15-30 mins intervals)
- Steroids: prednisolone 50mg PO (1st day of 5-day course) or 100mg hydrocortisone IV
Acute severe or life threatening:
- Consider continuous nebulisation at 5-10mg/hour + Ipratropium nebulisers (0.5mg QDS)
- IV magnesium sulphate bolus 2g/ 20 mins
Step down:
- Nebulised salbutamol every 4- 6hr
- Prednisolone 40-50mg PO OD for 5-7 days
Discharge once: been stable, had inhaler technique checked, PEFR >75%, GP apt within 2 days, respiratory clinical apt within 4 weeks
How should an acute asthma attack be escalated
Immediate senior review
Senior anaesthetic assistance (if considering intubation/ ventilation)
ITU/HDU: ventilatory support, intensification of therapy:
- IV salbutamol bolus (15mcg/kg)
- IV aminophylline Intubation/ ventilation
What are some differentials for an acute asthma attack
Anaphylaxis
Inhaled foreign body
Pneumothorax
IE of COPD
Myocardial infarction
Pulmonary oedema
Anxiety
What is acute COPD
Acute onset worsening of a person’s symptoms from their usual stale state beyond normal day to day variations
How should you approach a patient with acute COPD
A:
B: check if known CO2 retainer, 24-28% Venturi, if hypoxic/ unstable —> high-flow
Polyphonic wheeze
ABG: type II respiratory failure
Lactate (sepsis)
Salbutamol 5mg nebulisers (+) ipratropium 0.5mg
C:
D:
E:
Hx: compare to baseline: SOB, sputum volume, sputum colour
Definitive Ix:
Repeat ABG —> guide further O2, NIV (BiPAP) if pH <7.35 despite adequate oxygen
Sputum culture
CXR
Definitive Rx:
Steroids: prednisolone 30mg PO
Antibiotics: amoxicillin 500mg/8h PO
Resp review
How should acute COPD be managed
Consider if the patient has a ceiling of care in place
Controlled O2: maintain between 88-92%
Consider NIV if pH <7.35 & PaCO2 >6
Consider doxapram if NIV not available
Salbutamol nebulisers 5mg/4hours
Ipratropium nebulisers (0.5mg 4-6 hrly)
Steroids: prednisolone 30mg/day for 7 days PO or 100mg hydrocortisone IV
Antibiotics: e.g. amoxicillin 500mg/8h PO or clarithromycin or doxycycline
Step up:
IV aminophylline
NIV (BiPAP)
How should acute COPD be escalated
Immediate senior review
Discuss with respirator SpR or consultant
Consider senior anaesthetic assistance (pH <7.26 consider invasive ventilation)
What are some differentials for acute COPD
Anaphylaxis
Inhaled foreign body
Pneumothorax
Acute asthma
Myocardial infarction
Pulmonary oedema
Anxiety
How should you approach a patient with anapylaxis
A:
2222 peri-arrest call
Adrenaline 0.5mg IM (1:1000),
Chlorphenamine 10mg,
Hydrocortisone 200mg slow IV
B:
High flow O2
C:
IV fluids (distributive shock)
D:
Drug chart—>check allergies/ add into allergens
E:
Further Ix:
Two blood samples required to measure mast cell tryptase (first ideally w/I 30 mins, 2nd at 2 hours)
Further Rx:
Escalation to ITU
How should a patient with anaphylaxis be managed
Bring the local resuscitation equipment
Remove allergen (e.g. stop drug infusion)
Adrenaline 500ug IM, 1:1000 (0.5ml); can be repeated after 5 mins if no improvement
Consider intubation by a skilled anaesthetist early
High flow O2 via NRBM
Chlorphenamine 10mg slow IV injection
Hydrocortisone 200mg by slow IV injection
IV fluids
Add name of agent that caused reaction into allergies
How should anaphylaxis be escalated
2222 peri-arrest call
What are some differentials for anaphylaxis
Stridor:
- Foreign body
- Peritonsillar abscess
- Croup
- Epiglottitis
- Mass obstruction
Other acute dyspnoea:
- Acute asthma
- IE of COPD
- Pulmonary oedema
What is a massive PE
PE with hypotension
How should a massive PE be approached
A:
B:
Hypoxia—>high flow O2
C:
Hypotensive/ shock —>senior support/peri-arrest call (may need thrombolysis)
May need urgent echo
D:
Drug chart: anti- coagulation (thrombolysis)
E:
Calves SNT
Hx: consider features of Wells score/ RF: malignancy, immobility/ previous surgery, thrombophilia, pregnancy
PERC rule out rule for PE
Definitive Ix:
CTPA or V/Q
Definitive Rx:
LWMH
How should a massive PE be managed
High flow O2
If no shock: consider treatment dose LMWH
If shock: urgent escalation for consideration of thrombolysis
UFH may be given while discussions regarding thrombolysis: 5000 units’ bolus, with continuous infusion (target APTT ratio 2-3)
Thrombolysis: Alteplase -10mg as slow IV over 1-2 mins, infusion over 2 hours (weight dependent)
Then IV UFH if with APTT ratio of 2
In cardiac arrest: 50mg IV altepase immediately (find in resuscitation trolley)
Heparin 5000U bolus followed by heparin infusion (APTT to monitor
How should a massive PE be escalated
2222 peri-arrest call
ITU care
Absolute CI:
- Haemorrhage stroke or stroke of unknown origin at any time
- Ischaemic stroke <6 months
- CNS trauma or neoplasm
- Recent major trauma/ surgery
- GI bleed <3 months
- Known bleeding disorder
- Aortic dissection
What are some differentials for a massive PE
Tension pneumothorax
Cardiac tamponade
Myocardial infarction
Pulmonary oedema
Sepsis
How do you approach a patient with a tension pneumothorax
A:
B:
2222 peri-arrest call
Needle decompression
C:
D:
E:
Definitive Ix: CXR (check decompression)
Definitive Rx: Chest drain
Clinical diagnosis: Reduced expansion, Hyper resonant percussion, Reduced AE, Deviated trachea, Hypotension Distended neck veins
How is a tension pneumothorax managed
Needle decompression: large bore (14-16G) with a syringe into 2nd intercostal space MCL
Chest drain: small bore e.g. Seldinger, 4th or 5th intercostal space, mid to anterior axillary line
How should a tension pneumothorax be escalated
2222 peri-arrest call
What are some differentials for a tension pneumothorax
Massive pulmonary embolism
Cardiac tamponade
How is the severity of acute severe colitis determined
Using Truelove & Witts for UC
Mild:
Stools <4
HR <90
Temp <37.5
Hb >11.5
ESR <20
Moderate:
Stools 4-6
HR ≤90
Temp ≤37.8
Hb ≥10.5
ESR ≤30
Severe:
Stools >6
HR >90
Temp >37.8
Hb <10.5
ESR >30
How should a patient with acute severe colitis be approached
A:
B:
ABG for quick Hb
C:
IV fluids, consider blood products Bloods: FBC, U+E, LFT, CRP, ESR cross-match or GCS
D:
E:
Temp
Abdo: peritonism, PR?
Hx: consider Truelove & Witts criteria if Hx IBD and consider the travel Hx
Definitive Ix:
Stool cultures x3 (include C diff)
Stool chart recording
Consider infective serology (CMV, HIV) AXR (thumb-printing, toxic megacolon)
Urgent inpatient flexible sigmoidoscopy + biopsy megacolon)
Definitive Rx:
Hydrocortisone IV
Thromboprophylaxis
PPE/ infection control
Surgical work up
How would you manage acute severe colitis
IV fluids
Consider parenteral iron or blood transfusion
Hydrocortisone 100mgs IV QDS
Dalteparin
Inform charge nurse: consider isolation, PPE
How would you escalate acute severe colitis
Senior support
On call gastroenterology
On call surgery
What are some differentials for acute severe colitis
Inflammatory colitis
Ulcerative colitis
Crohn’s disease
Ischaemic colitis
Diverticulitis
Infective colitis
C difficile
How is acute pancreatitis severity determined
Glasgow-Imrie criteria for severity of acute pancreatitis:
- PaO2 <8kPa
- Age >55
- Neutrophils >15 Calcium <2
- Renal, urea >16 Enzymes, LDH >600
- AST >2000, Albumin <32
- Sugar, glucose >10
How would you approach a patient with acute pancreatitis
A:
B:
ABG, CXR (ARDS)
C:
Fluids resuscitation
Bloods (consider Glasgow score)
D:
E:
Abdo: peritonism, look for bruising around flanks
Definitive Ix:
Acute abdo work up do basics and then ring SpR
Defintive Rx: Analgesia, IV fluids
Consider: surgical SpR to exclude surgical cause
ITU support if severe ≥ 3 on Glasgow score
What are the components of an acute abdomen work up
Bedside:
- Urinalysis, pregnancy test, ABG
Bloods:
- For diagnosis: FBC, CRP, U+E, LFTs, amylase, calcium, glucose, blood cultures
- For surgery: G+S, cross match, coagulation
Imaging:
- Erect CXR, AXR, USS, CT abdomen
EscalationP
- Surgical SpR
- Surgical work-up
What is the management of acute pancreatitis
Analgesia
IV fluids
TPN/ NG as necessary (enteral feeding is gold standard)
Do not make NBM unless there is a clear reason for this
Surgical intervention:
- ERCP -> remove gallstones
- If severe: laparotomy/ lavage +/- necrosectomy
How should acute pancreatitis be escalated
PANCREAS score/ Modified Glasgow >3 requires ITU/HDU
? Surgical SpR review
What are some differentials for acute pancreatitis
MI
Dissection
AAA
Bowel perforation
Hepatitis
GORD/Ulcer
Pyelonephritis
How should you approach a patient with bowel obstruction
A:
B:
ABG (lactate/ sepsis)
C:
IV fluids
Bloods: U&Es, LFTs, FBC, CRP, cross- match, G+S
D:
E:
Abdo exam: scars, distension, absent/ twinkling bowel sounds, peritonism
Hx: bowel motions/ flatus, vomiting, colicky pain, past surgical Hx
Acute abdo work up
Definitive Ix:
AXR + erect CXR CT + oral contrast medium gastrogaffin
Definitive Rx:
‘Drip + suck’ – IV fluids, wide bore NGT Surgical SpR review
Surgical work up —> laparotomy
How is bowel obstruction managed
Wide bore NGT
IV fluids
Analgesia
Anti-emetic: IV ondansetron IV antibiotics
Prep for emergency laparotomy
How should bowel obstruction be escalated
Senior review
Surgical SpR review
How should you approach a patient with an acute abdomen
A:
B:
ABG: lactate
(erect CXR)
C:
Bloods - FBC, CRP, U+E, LFTs, blood cultures, ßHCG Surgery: G&S, cross match
IV fluids, blood products/ ? MHP
D:
Analgesia
E:
Abdo exam:
Look: distension, bruising around flank (retroperitoneal haemorrhage) peritonism, focal tenderness, bowel sounds
FAST scan (USS: hepatorenal, spleen, bladder etc.)
Hx:
Symptoms, PMH, last oral intake
Unstable:
FAST scan: intra- abdominal bleeding Surgical SpR review/ Make Pt NBM
Definitive Ix:
Bedside: urinalysis + pregnancy test
Bloods:
Diagnosis: FBC, CRP, U+E, LFTs, blood cultures, ßHCG Surgery: G&S, cross match
Imaging: erect CXR, AXR, CT, USS/ TVUS
Definitive Rx - depends on cause of acute abdomen
What scoring systems can be used for upper GI bleeds
Blatchford bleeding score
Components:
- Blood urea nitrogen
- Hb
- SBP
- HR
- Melena
- Syncope
- Hepatic disease
- Cardiac failure
Score >0 suggests high risk GIB that is likelyto require intervention
Rockall score - pre-endoscopy - determines mortality w/o endoscopy:
Age
Comorbidities
Shock
Rockall score - post-endoscopy to determine mortality and re-bleeding risk:
Source of bleeding
Stigmata of recent bleeding
What are the stages of shock
1: up to 750ml, BP normal, HR <100
2: 750-1500ml, BP normal, HR>100
3: 1500-2000ml, SBP <100, HR >120
4: >2000ml, SBP <100, HR >140
How do you approach a patient with suspected upper GI bleed
A: airway, blood
B: high flow O2, ABG (PaO2, Hb, lactate)
C: IV access (FBC, clotting, U+E, LFTs, cross-match, G+S); resuscitate: 500ml crystalloid, blood*** (àmajor haemorrhage)
D: AVPU (encephalopathy), glucose, drug chart (anti- coagulation?)
E: hidden injuries/ bruising, PR, CLD signs (jaundice, ascites)
Definitive: from history+ background or blood picture – determine likelihood of variceal
Variceal:
Pre-endoscopy:
Terlipressin 2mg 6hrly as IV bolus, continue for 5 days; GTN patch if Hx of IHD
(Octreotide is an alternative)
Prophylactic antibiotics (e.g. Tazocin)
Urgent endoscopy: band ligation or sclerotherapy or glue infection (band ligation is preferred as sclerotherapy makes subsequent banding difficult)
Post endoscopy:
PPI
Prevention: ß blockers
Rescue therapy: Balloon tamponade (if immediate endoscopy unavailable)
TIPS (need urgent US of portal vein prior)
Peptic ulcer:
Urgent endoscopy
PPIs may be used post- endoscopy
Rescue therapy: Laparotomy
How should upper GI bleed be escalated
Major haemorrhage protocol
Contact for urgent endoscopy
Contact on-call surgical team
ITU/HDU
What are some differentials for upper GI bleed
Oesophageal varices
Peptic ulcer disease
Mallory-Weiss tear
Boerhaave syndrome
Why has liver disease decompensated?
- Infection (chest/urine, SBP)
- GI bleed
How should you approach a patient with major haemorrhage
C spine immobilisation
Catastrophic bleed – apply pressures/ splint fractures
A:
B:
ABG: quick Hb (may be normal)
RO ATOM FC (airway obstruction, tension pneumothorax, open pneumothorax, massive haemothorax, flail chest, cardiac tamponade)
C:
Fluid resuscitation
Major haemorrhage protocol
Bloods: cross match, FBC, coagulation, biochemistry
? tranexamic acid (CRASH-2 study said to do it)
D:
E:
External bleeding Internal bleeding (? FAST scan)
Definitive Ix:
Trauma CT
Full skeletal survey
How should a patient with major haemorrhage be managed
ABCDE + major haemorrhage protocol
Stop active bleeding: apply pressure, splint fractures
Resuscitate with warm IV fluids until blood arrives
? Tranexamic acid
Blood: (aim for Hb >80)
1) Primary Pack
5 unit’s RBC (O if immediate need and/or group unknown) FFP 4 units
Alternative RBC and FFP, ratio 2:1 (or 1:1 in trauma)
2) Secondary Pack
RBC 5 units FFP 4 units
Platelets (if <50) Cyroprecipitate (if fibrinogen <1.5
Correct hypothermia
Correct hypocalcaemia (aim ionised >1.13)
How should you escalate major haemorrhage
2222 peri-arrest call
Contact transfusion: major haemorrhage protocol
Contact surgeons on call
Contact haematologist
What are some differentials for major haemorrhage
GI bleed: variceal vs peptic ulcer
Rupture AAA
Ectopic pregnancy
? DIC
Haemolytic anaemia
How can acute MI’s be diagnosed on ECG
STEMI:
ST elevation >1mm in contiguous limb leads
>2mm in contiguous chest leads
>1mm ST depression + dominant R wave in V1-3
New LBBB
Need 2 of: ECG changes, chest pain or troponin
How should a patient with suspected acute MI be approached
12 lead ECG
Troponin T (time: presentation, 3, 6), U+E, lipids, LFT, glucose, CRP, FBC, coagulation screen
Echocardiogram: all patients after STEMI to assess LV function
A:
B: O2 if <94%
C: BP in both arms, Bloods
ECG —> STEMI/MI (alert senior + PCI, analgesia, aspirin)
D:
E: ? calves
Hx: RFs MI, PE, PMH
Blood:
Troponin T (time: presentation, 3, 6), U+E, lipids, LFT, glucose, CRP, FBC, coagulation screen
Further Ix: NSTEMI: risk tools e.g. GRACE
Echo
Organise PCI
Definitive Rx: 2nd anti- platelet
How should an acute MI be managed
All:
O2 if <94%
Analgesia:
GTN: 2 puffs sublingual, infusion if persistent pain, SBP maintained >100
Morphine 5-10mg slow IV + anti-emetic e.g. metoclopramide 10mg IV Aspirin 300mg PO (check if given pre-hospital)
If STEMI:
STEMI:
2nd anti-platelet i.e. Prasugrel 60mg PO or clopidogrel 600mg or Ticagrelor 180mg
PCI (target <120 mins) - if undergoing this then give IV unfractionated heparin
If NSTEMI
2nd anti-platelet i.e. Clopidogrel 600mg or Ticagrelor 180mg
Antithrombin:
Fondaparinux 2.5mg OD SC if angiography >24 hours
If <24 hours, UFH
Assess risk: ECG, trops, scoring systems e.g. GRACE Consider glycoprotein IIb/IIIa inhibitors
Angiography (+/-) PCI (<96 hours)
Long term:
Education conservative methods
Anti-platelet: aspirin 75mg OD lifelong + clopidogrel 75mg Od (for 1 year)
ß blocker e.g. bisoprolol ACE inhibitor e.g. ramipril Statin e.g. atorvastatin 80mg PO
Consider aldosterone antagonists
GRACE: estimates admission 6-month mortality for patients with ACS
How should an acute MI be escalated
2222 peri-arrest call
Alert PPCI team
Cardiology SpR on call
Evidence shows effective PCI critical
What are the differentials for an acute MI
Aortic dissection
Pulmonary embolism
Pneumothorax
Acute asthma
Pericarditis
How should you approach a patient with pulmonary oedema
ABG
Bloods: FBC, U+E, LFT, CRP, Troponin
12 lead ECG Portable CXR
Urgent echocardiogram
A
B: sit patient up, coarse crackles, ABG, CXR
C: explain caution fluid resus
D: drug chart (fluids)
E: leg oedema
Definitive Ix: Inpatient echo
Definitive Rx:
IV furosemide
Consider nitrates if normotensive
? Diamphorine (evidence base)
Inotropes
CPAP
How should pulmonary oedema be managed
Sit patient up
High flow oxygen 15L NRBM
Diuretics: Furosemide 50mg IV
Nitrates:
If BP >100 SBP give 0.5mg GTN S/L, consider GTN infusion (aim for BP >100)
If BP low:
Escalation: (cardiogenic shock)
Inotropes: Dobutamine or intra-aortic balloon pumping CPAP: with a PEEP of 5- 10mmHg
Address cause: treat arrhythmias
How should pulmonary oedema be escalated
Immediate senior support
Call cardiology SpR on call
Contact ICU/HDU
What are differentials and triggers for pulmonary oedema
Pneumonia
PE
Triggers:
MI
Arrhythmia
What is the definition of hypertensive urgency/emergency/malignant HTN
Hypertensive urgency:
SBP >180, DBP >110 and no target end organ damage
Hypertensive emergency:
SBP >180, DBP >110 and target end organ damage
Malignant HTN: papilloedema present
How should you approach a patient presenting with hypertensive emergency
A:
B:
C:
BP (in both arms)
ECG
Bloods: U+ES, troponin
D:
Altered mental status
Drug chart
E:
Hx: symptoms (headache, visual problems, CP), drugs, flushing, (pregnancy)
Definitive Ix:
Target end organ: ECG, urinalysis, fundoscopy
Bloods:
Plasma renin, aldosterone
TFTs
Plasma metanephrines/ 24 hr urinary collection
How should a patient with a hypertensive urgency/emergency be managed
Hypertensive urgency:
1. Oral labetalol or CaV blocker e.g. amlodipine 5mg, nifedipine (Never use an ACEi due to rapid BP lowering)
Hypertensive emergency - escalate
1) IV labetalol (CI asthma, heart failure) or hydralazine or sodium nitroprusside
If myocardial ischaemia then GTN
Rapidly lowering BP is dangerous - aim to lower MAP by 25% over first 24 hours
How should hypertensive emergency be escalated
Seek senior support/cardiology SpR
HDU/ITU
What are some differentials of hypertensive emergency
Uncontrolled essential hypertension
Pain: anxiety Endo: Conns, phaeo, hyperthyroid
Drugs: ciclosporin, post-surgical vasopressors
Renal: Acute glomerulonephritis
How should you approach a patient with cardiac tamponade
A:
B: high flow, ABG (lactate; organ perfusion)
C: Beck’s triad (hypotension, raised JVP, muffled HS)
IV access
ECG (low voltages) —> If concerned: PERI- ARREST CALL: need senior for urgent pericardiocentesis, in mean time get urgent Echo
D:
E:
Hx: symptoms, last oral intake
Bloods: surgical work- up, FBC, crossmatch + G&S, baseline U+Es, LFTs
Fix: Echocardiogram (FICE)
How is cardiac tamponade managed
Urgent pericardiocentesis by senior
Who should cardiac tamponade be escalated to
Cardiothoracic surgeons
ITU
What are some differentials for cardiac tamponade
Obstructive - PE
Hypovalaemia - Graft failure
Cardiogenic - MI, acute HF
What are some differentials for cardiac tamponade
Obstructive - PE
Hypovalaemia - Graft failure
Cardiogenic - MI, acute HF
What are adverse features of bradyarrhythmias
Shock
Syncope
MI
Heart failure
What are features of high risk of asystole in bradyarrythmias
Recent asystole
Mobitz II AV block
Complete HB with broad QRS
Ventricular pause >3s
How should you approach a patient with a bradyarrhythmia
A:
B: ABG (electrolytes, lactate)
C:
ECG, if adverse features —> escalate —> atropine 500mcg IV
D:
Drug chart
E:
Hx: onset symptoms, drug chart
How should a bradyarrhythmia be managed
If adverse features/ high risk of asystole: 2222 call
Atropine 500mcg IV
If no satisfactory response:
Atropine 500mcg IV up to max of 3mg
Isoprenaline 5mcg/min IV
Adrenaline 2-10mcg/min IV
Seek senior expert help: Consideration of transcutaneous pacing (will need sedation)
How should bradyarrhythmias be escalated
Seek senior input
Alert on-call cardiology SpR
Alert anaesthetic team
What are the causes of bradyarrhythmias
Post-MI
Infective endocarditis
Myocarditis
Endocrine/metabolic
Hypothermia etc
What are the causes of bradyarrhythmias
Post-MI
Infective endocarditis
Myocarditis
Endocrine/metabolic
Hypothermia etc
What are adverse features in tachyarrhythmias
Shock
Syncope
MI
Heart failure
How should you approach a patient with a tachyarrhythmia
A:
B: ABG (electrolytes, lactate)
C: ECG monitoring —> adverse features —> 2222 —>DC shock
If wide-complex + regular —> 2222
D:
E:
Hx:
Bloods: FBC, U&Es (includes Mg and K+), bone profile, TFTs, CRP, blood cultures?)
Definitive Ix: Echo
How should a patient with a tachyarrhythmia be managed
If adverse features: 2222 call
Synchronised DC shock up to 3 attempts (need sedation) Subsequent:
- Amiodarone 300mg IV/ 10-30 min
- Repeat shock
- Amiodarone 900mg/ 24 hours
If stable:
Wide QRS + regular + no BBB: (likely VT —> RRT/ 2222) Amiodarone 300mg IV/ 20-60 mins
Irregular: MgSO4
Wide QRS + irregular: Escalate to RRT/ cardio SpR - treat as AF
Narrow QRS + regular:
Escalate to senior reg/ cardio SpR
Vagal manoeuvres
Adenosine 6mg IV bolus
Adenosine 12mg IV bolus
Further 18 mg IV bolus
Narrow QRS + irregular (AF):
Escalate to senior reg/ cardio SpR
How should you escalate a tachyarrhythmia
Seek senior input
Alert cardiology SpR on-call
Alert anaesthetic team
What are precipitants for AF
Infection
Dehydration
Hypovolaemia
Electrolyte disturbances
Thyroid
Hypoxia e.g. PE
How do you approach a patient with AF
Look for signs of adverse features: shock, syncope, MI, heart failure
A:
B:
Chest: HF v Pneumonia
ABG: lactate, electrolytes
C:
12 lead ECG/ monitoring
If Adverse featuresà 2222/ Rx
Bloods: FBC, CRP, U+Es, TFTs
D:
E:
Hx: onset, known AF,
RFs: syncope, PMH
Definitive Ix: ? CXR
? Echo
Definitive Rx:
Treat any obvious causes – see if settles
<48h: rate or rhythm >48h: rate
How do you manage a patient with AF
If adverse features:
2222 call
Synchronised DC shock at 200J up to 3 attempts (sedation prior)
Subsequent:
- Amiodarone 300mg/ 20 mins
- Reattempt shock
No adverse features:
Is there an obvious precipitant to be corrected
<48 hours: rate or rhythm
>48 hours: rate
Rate:
Oral bisoprolol 2.5mg OD Diltiazem 60mg TDS
Rhythm:
If the atrial fibrillation (AF) is definitely of less than 48 hours onset patients should be heparinised. Patients who have risk factors for ischaemic stroke should be put on lifelong oral anticoagulation. Otherwise, patients may be cardioverted using either:
electrical - ‘DC cardioversion’
pharmacology - amiodarone if structural heart disease, flecainide or amiodarone in those without structural heart disease
Following electrical cardioversion if AF is confirmed as being less than 48 hours duration then further anticoagulation is unnecessary
If the patient has been in AF for more than 48 hours then anticoagulation should be given for at least 3 weeks prior to cardioversion. An alternative strategy is to perform a transoesophageal echo (TOE) to exclude a left atrial appendage (LAA) thrombus. If excluded patients may be heparinised and cardioverted immediately.
NICE recommend electrical cardioversion in this case
Following electrical cardioversion patients should be anticoagulated for at least 4 weeks. After this time decisions about anticoagulation should be taken on an individual basis depending on the risk of recurrence
All:
Treatment dose LMWH: dalteparin 200U/kg OD; until full assessment by CHAD2DS2VASC
What is status epilepticus
Seizure >5 minutes
How should you approach a patient with status epilepticus
Start time/ consider safety: avoid moving/ put pillows around
A:
Suction: blood, vomit Airway (nasopharyngeal: trismus, avoid putting things in mouth)
B:
High flow O2
Ventilation (can be low due to benzos)
C:
Establish IV access —> lorazepam 0.1mg/kg
D:
Check reversible: Pabrinex, glucose
E:
Injuries
Rashes
Bloods: FBC, U+Es, CRP, VBG (lactate),glucose, toxicology, drug levels
Toxicology
Post seizure: CXR for possible aspiration
How do you manage a patient with status epilepticus
Note the time
Early status: Benzodiazepines:
IV lorazepam 0.1mg/kg (usually 4mg) slow bolus, if no response after 10-20min, give 2nd dose +
—> ESCALATE
IM/buccal midazolam
Rectal diazepam
Consider reversible causes:
thiamine 250mg IV or glucose 50% 50ml
Established status:
IV anticonvulsant: Phenytoin infusion 15- 18mg/kg at rate 50mg/min (requires BP + ECG monitoring)
Others:
- Valproate
- Levetiracetam
- Phenobarbital
Refractory status: general anaesthesia (rapid sequence induction)
- Propofol
- Midazolam
- Thiopental
How should you escalate status epilepticus
Contact on call anaesthetist
Contact ICU
What are some causes of status epilepticus
Provoked:
1) Infection:
meningitis,
sepsis
2) Metabolic:
hypoglycaemia
3) Toxins:
alcohol
withdrawal,
overdose
Non-seizure:
Non-epileptic attack disorder (NEAD)
How do you approach a patient with an overdose
Airway
Breathing: RR,
SpO2, ABG
Circulation: BP, 12 lead ECG, bloods: paracetamol levels, salicylate levels, LFTs, U+Es, clotting studies, glucose
Disability: glucose, GCS, pupils*, limbs: tone, body temperature
Exposure: feel skin*, needle track marks
Fluids: urinary toxicology screen
History: find out when medications available: paramedics, GP, friends/ family
How do you manage an overdose
ABCDE:
Consult ToxBase or UK National Poisons Information Service
Consider enhanced GI elimination of drug:
- Activated charcoal if present <1hr
If require haemodialysis —> escalate
Paracetamol:
Depending on time post ingestion – give NAC infusion
Kings College Criteria for Transplant:
- Acidosis pH <7.35
- INR >6.5 or PT >100
- Creatinine >300
- Grade III or IV
encephalopathy
Opioid: treat in B
B: 400mcg Naloxone IV/IM
Stop opioid administration
Continue and come back + reassess at 1 minute
Consider: bag-valve mask Then continue ABCDE
Definitive:
1st: naloxone 400mcg
2nd: 800mcg for up to 2 doses at 1 min intervals
3rd: 2mg for 1 dose
Infusion: set at 60%of initial resuscitative IV injection per hour
How should you escalate an overdose
2222 call/ RRT
ITU/HDU
If lack capacity can treat under MCA 2005
If capacity but refuse
—> Psychiatry
If psychiatric illness may be detained under MHA and treatment given (as a consequence of mental disorder)- It must be done by psychiatrist in charge of care
Consider specialities i.e. hepatology SpR
How do you approach a patient with a stroke
ECG: AF
Bloods: FBC, LFT, U+E, CRP, glucose, coagulation screen
Urgent non-contrast CT
Consider: carotid USS (if carotid territory ischaemic stroke)
A ? bulbar function
B: ? aspiration
C: carotid bruit, 12 lead ECG - AF
D: Neuro exam (spasticity, weakness, hyperreflexia, speech, visual fields), anti- coagulation drug chart
E: ? head trauma
History: onset of symptoms, CI for thrombolysis
Bloods: FBC, LFT, U+E, CRP, glucose, coagulation screen
Definitive Ix: Urgent non-contrast head
SALT assessment
Definitive Rx: Thrombolysis
How do you manage a patient with a stroke
ABCDE
Ischaemic stroke:
Once CT excluded haemorrhage —>
Consider thrombolysis (<4.5 hours) with alteplase [If patient thrombolyse avoid anti-platelets for first 24 hours, then repeat CT to exclude haemorrhage]
Aspirin 300mg (orally [only if safe swallow], rectally or via NGT) to all patients once a haemorrhagic stroke has been excluded
Continue for 2 weeks
LT anti-thrombotic: Clopidogrel lifelong: 300mg loading dose, 75mg OD
If, AF: warfarin or DOAC
Haemorrhagic stroke: Reverse any anti-coagulation e.g. warfarin using Vit K and PTC, dabigatran call haematologist for Idarucizumab
Control BP: if SBP >150 give labetalol IV
TIA:
Aspirin 300mg, followed by 2 weeks of aspirin and then clopidogrel LT
Specialist assessment and Ix within 24 hours (if high risk), 1 week (if low risk)
How should you escalate a stroke
Inform radiology
Contact stroke team
SALT assessment
Alert neurosurgery if GCS low / evidence of raised ICP
Depending on centre consider Thrombectomy
What are some differentials for a stroke
Hypoglycaemia
Todd’s paraesis Hemiplegic migraine Functional
How should you approach a patient with a SAH
ABCDE
CT scan/ CT angiogram (call radiology)
LP only if CT negative and Hx suggestive
How should you manage a patient with an SAH
ABCDE
Definitive: GCS <9
Intubate + ventilate
BP: aim for SBP 120-160, —> if low support using IV fluids, caution if high, consider labetalol
Nimodipine 60mg 4 hrly via NGT
Neurological observations: pupil checks every 20 minutes
GCS >=9:
BP, nimodipine as above Analgesia
Anti-emetics
Neurological observations
How should you escalate a patient with an SAH
Alert radiology
Contact anaesthetics
Contact neurosurgery
Contact ITU
How would you approach a patient with a reduced GCS/raised ICP
ATLS principles:
C spine immobilisation
A:
Vocalising/ help V of GCS
RRT / anaesthetic support → intubation?
B:
If low —> bag valve mask
Aspiration? Portable CXR
ABG for electrolytes
C: fluid resus Sepsis? (qSOFA, link reduced GCS)
D: GCS, pupils (unequal 3rd nerve, pinpoint opiate), neuro exam, glucose, drug chart (? Opioid —> 400mcg naloxone)
E: temp (hypothermia) full skeletal survey, head trauma
Definitive Ix:
Urinalysis + toxicology
Bloods: FBC, CRP, cultures, U+Es, LFTs, glucose, toxicology
CT head and/or cervical spine/ full trauma CT
LP
Definitive Rx
Reversal agents: naloxone, alcohol withdrawal?
Escalate: Neurosurgery ITU
What are signs of raised ICP
Vomiting/ headache
Progressive reduction in
GCS
Fundal haemorrhages
Papilloedema? In acute setting
Fixed +dilated pupil/ 3rd/6th nerve palsy (evidence of Cushing’s triad: bradycardia, HTN, fixed & dilated pupil)
How would you manage a patient with raised ICP/reduced GCS
GCS: Moderate (9-13)
GCS: Severe (3-8):
Immediate intubation & ventilation
Treat hypotension aggressively
Neuroprotection:
Ensure head in mid-line position, head tilted to 30 degrees
Maintain well oxygenated Maintain PaCO2 at 4.5 Maintain CPP >60 (CPP = MAP – ICP)
Raised ICP
Remove patient from ventilator & initiate manual hyperventilation
Increase noradrenaline to increase CPP
Give mannitol 0.25g/kg over 20 mins
How should you escalate raised ICP/low GCS
Contact anaesthetist
Contact neurosurgery/ neurology on call
Alert ITU
What are some differentials for raised ICP/low GCS
Trauma
Intracranial bleed Hypoglycaemia Electrolyte: Na+, hypercalcaemia Hypothermia Overdose (opioid + benzodiazepines) Intracranial infection Sepsis
What are contraindications for an LP
- Suspected raised ICP
- Local superficial
infection at the LP site - Coagulopathy
How should you approach a patient with CNS infection
A:
B:
ABG (lactate)
C:
ECG
Bloods, cultures Empirical Abx
D: GCS, pupils, focal neurology
E: rash, temp
Hx: signs of meningism, immunosuppressed?
How do you manage a patient with a CNS infection
Suspected meningitis: -
- Isolate patient
- Empiric treatment initially (then focus): Ceftriaxone 2g IV 12- hourly
If p/a: chloramphenicol
- Add vancomycin if suspecting penicillin resistant pneumococcal meningitis
- Dexamethasone base 7.6mg IV 6 hourly for 4 days on admission
Special groups:
If immunocompromised or >60 or pregnant: add ampicillin/amoxicillin to provide Listeria cover (if p/a: co-trimoxazole)
Viral encephalitis:
Aciclovir 10mg/kg IV 8 hourly for 14-21 days
How should you escalate in a CNS infection
Alert senior input
Alert neurology, infectious diseases SpR
Alert PHE (Chemoprophylaxis: ciprofloxacin 500mg PO)
What are some differentials for CNS infection
Meningitis
Encephalitis
Brain abscess
?SAH – generally not febrile
How should you approach a patient with head trauma
Throughout my assessment I would look for signs of raised ICP + criteria for a CT head
Follow ATLS principles
C-spine immobilisation
A: ? vomit
B: Aspiration? ABG (lactate)
C: baseline surgical bloods: FBC, U&Es, LFTs, X-match
D: Assess full GCS, pupils (3rd nerve palsy)
Drug chart (anticoagulation)
E: CT head signs, full skeletal survey, temperature
H: what happened, amnesia
Fix:
Fundoscopy (papilloedema)
Organise CT head (if guidelines) +/- neck?
If no CT head: Use Canadian C-spine rules / Nexus (less sensitive/ specific) to determine if require X- ray Spine
Consider full trauma CT if other injuries
Other points:
In children ? NAI If intoxicated → consider baseline alcohol + risk of withdrawal
How would you manage a patient with head trauma
Def mx:
Supportive
Raised ICP mx
Or neurosurgery for decompression
CT head guidelines: within 1 h
1. GCS<13 on initial
assessment in ED
2. GCS<15 when assessed
2h after injury in ED
3. Suspected open or
depressed skull fracture
4. Any sign of basal skull
fracture (hameotympanum – ‘panda’ eye, CSF leakage from ear or nose + Battle’s sign)
5. Post-traumatic seizure
6. Focal neurological deficit
7. More than 1 episode of
vomiting
Should be imaged within 8h of injury / immediately if present 8h or more after injury
If amnesia/ LOC since injury +
1. Age >65
2. Dangerous mech of injury
3. More than 30mins
retrograde amnesia of events immediately before
the head injury
4. Coagulopathy:
a. History of bleeding
b. Clotting disorder
c. Current treatment of
warfarin
Who should head trauma be escalated to
Neurosurgical review
ITU
How should you approach a patient with cauda equina
A:
B:
C:
D: Neuro –weakness, paraesthesia, anal tone PR), saddle anaesthesia
Pain relief:
E: Spinal exam for ? fracture
Emergency MRI of whole spine (call radiology)
How should you treat a patient with cauda equina
If Hx of cancer: Dexamethasone 16mg PO or IV stat, followed by 8mg BD
Definitive management: Urgent radiotherapy Neurosurgical intervention
How should you escalate a patient with suspected cauda equina
Alert radiology
Contact oncology SpR
Contact neurosurgery SpR
What are some differentials for cauda equina
GBS
Transverse myelitis
How should you approach a patient with spinal cord compression
? Ceilings of care in place ? appropriateness of aggressive ABCDE resus.
A:
B:
C: ? only wide bore access if shocked
D: Neuro – Sensory level, UMN/LMN signs
Pain relief:
E: Spinal exam for ? fracture
Fix:
Emergency MRI of whole spine
How should you manage a patient with spinal cord compression
Pain relief
If Hx of cancer:
Dexamethasone 16mg PO/IV stat, followed by 8mg BD
Definitive management: Urgent radiotherapy Neurosurgical intervention
How should you escalate a patient with spinal cord compression
Alert radiology
Contact oncology SpR
Contact neurosurgery SpR
What are some differentials for spinal cord compression
GBS
Transverse myelitis
How should you approach a patient with delirium
ABCDE
Bloods: FBC, U&E, creatinine, LFT, calcium, glucose, CRP, B12, folate, TSH
Infection screen:
Urine for MC&S CXR
Consider CT head if Hx of falls or no other reversible cause ID
Assessment tests:
4-AT
ID cause:
Constipation
Urinary retention Dehydration
Electrolyte imbalance Infection
Pain Medication SE
What is delirium
Change or fluctuation in behaviour:
Cognition (poor attention, confusion)
Perception (hallucinations, paranoia)
Activity (hyper or hypoactivity)
How should a patient with delirium be managed
Non-pharmacological:
De-escalation techniques (communication + environnent)
Ensure appropriate lighting (night light)
Provide continuity of care where possible
Ensure hearing aids/ spectacles worn
Maintain good fluid intake Treat constipation
Involve relatives and carers
Pharmacological: Sedation is a last resort
Use oral where possible: Otherwise IM:
Haloperidol 0.5-1mg PO/IM Risperidone 0.5mg PO Olanzapine 2.5mgPO
Don’t use anti-psychotics in LBD
2nd line: benzodiazepines e.g. lorazepam 0.5mg PO/IM
If pharmacological management:
HR, RR, temperature, BP, ECG
How should you escalate a patient with delirium
If requiring repeated doses over 48 hours consider referral to liaison psychiatry or SAFE (Specialist Advice for Frail Elderly)
What are some triggers and differentials for delirium
Triggers:
Constipation
Urinary retention Dehydration
Electrolyte imbalance Infection
Pain
Medication SEs
Differentials:
Ongoing dementia Depression
Alcohol intoxication
Head injury
How should you approach a patient with an Addisonian crisis
A:
B: ABG
C: Resus fluids
D: ? steroids not given, IV dextrose if hypoglycaemia
E:
H: symptoms suggestive of trigger
Bloods: FBC, U+E, LFT, venous glucose, CRP, TFTs
Fix: ID & treat precipitating factors (eg septic screen)
How should a patient with an Addisonian crisis be managed
Acute
IV or IM hydrocortisone 100mg stat
Hydrocortisone 50mg IV QDS maintenance
IV fluids
IV dextrose if hypoglycaemia
ID & treat precipitating factors
How should you escalate an Addisonian crisis
ITU support
Consider endocrinology input
What are triggers for an addisonian crisis
Triggers:
Infection
Trauma
Surgery
Stopping long-term steroids
How does Addison’s disease/crisis present
Lethargy, weakness, anorexia, nausea & vomiting, weight loss, ‘salt-craving’
hyperpigmentation (especially palmar creases), vitiligo, loss of pubic hair in women, hypotension, hypoglycaemia
hyponatraemia and hyperkalaemia may be seen
Crisis: collapse, shock, pyrexia, abdominal pain, vomiting, diarrhoea, pain in lower back/legs, weakness
How should you approach a patient with hypoglycaemia
<4mmol/L
A:
B:
C:
D: def mx
drug chart (? Insulin/ oral hypoglycaemics)
E:
H: ?diabetic vs non- diabetic + ? cause
Fix:
If non-diabetic ? cause
How is hypoglycaemia defined
<4mmol/L
How should you manage a patient with hypoglycaemia
Get hypo box on bottom shelf of resus trolley
Glucagon is in ward fridge
Patient unconscious: 2222 peri-arrest call:
100mls of 20% glucose IV Unable obtain IV access: 1mg glucagon IM or SC
Recheck BMs after 15 mins
Patient conscious/ cooperating: Carbohydrate snack: e.g. glucojuice recheck after 15 mins
If >4 follow up with a long-acting carbohydrate e.g. slice of bread, 2 digestives
If <4: repeat, senior support
How should you escalate in hypoglycaemia
Seek senior support early if not responding
Refer to diabetes team and ask for help if cause of hypoglycaemia is not ID immediately
What are causes for hypoglycaemia
Diabetic: chief cause insulin/ oral hypoglycaemic overdose
Non-diabetic:
Exogenous insulin Pituitary insufficiency
Liver failure
Addison’s
Islet cell tumours
How should you approach a patient with DKA
A:
B: ABG – ketones, acidosis, glucose
C: bloods, ECG, resus fluids
D: insulin chart – ensure continue long- acting insulin
E:
Bloods: glucose, ketones, U&E, CRP, FBC
Fix: urinalysis – ketones, repeat VBGs to monitor glucose, K, ketones
What are the features of DKA
Hyperglycameia - >11mmol/L
Ketonaemia - >3mmol/L
Acidosis - pH <7.3 and or bicarbonate <15 mmol/L
How would you manage a patient with DKA
FLUIDS:
Resuscitation fluids, or
1L 0.9% saline/ 1hr then 2hrs, 2hrs, 4hrs
INSULIN:
Fixed rate IV infusion (0.1units/kg/hr)
Continue long acting insulin
POTASSIUM:
K+ >5.5: none
K+ 4-5.5: 20mmol/L of 0.9% NaCl
K+ <4: 40mmol/L of 0.9% NaCl
GLUCOSE
If glucose falls <14 and ketone remain >0.6
IV infusion of 10% dextrose at 125mls/hr
Thromboprophylaxis
(prophylaxis dose)
How would you escalate in DKA
Seek senior support ITU/ HDU support
Inform diabetes/ endocrinology team
What are some differentials for DKA
Diabetes related: Hypoglycaemia HHS
Lactic acidosis
Other:
Drug toxicity
Head injury
Liver failure
What are the features of hyperglycaemic hyperosmolar state (HHS)
Hypovolaemia +
Hyperglycaemia (>30mmol/L) without significant ketonaemia (<3 mmol/L) or acidosis (pH >7.3)
Osmolality >320 mosmol/kg 2(Na+K) + urea + glucose
How should you approach a patient with hyperglycaemic hyperosmolar state
A:
B: ABG – ketones, acidosis, glucose
C: bloods, ECG, resus fluids
D: insulin chart – E:
Bloods: glucose, ketones, U&E, CRP, FBC
Fix:
VBG:
Cap blood glucose & ketones
How should you manage a patient with hyperosomolar hyperglycaemic state
FLUIDS
IV 0.9% saline over 48h, Na fall should not exceed 0.5mmol/h
INSULIN
Only used if significant ketonaemia (>1mmol/L) or plasma glucose not falling with IV fluids
Consider thromboprophylaxis (treatment dose)
Who should you escalate hyperglycaemic hyperosmolar state to
Seek senior support ITU/ HDU support
Inform diabetes/ endocrinology team
What are some differentials for hyperosmolar hyperglycaemic state
Diabetes related: Hypoglycaemia HHS
Lactic acidosis
Other:
Drug toxicity
Head injury
Liver failure
What are the features of hyperkalaemia
> 6.5mmol/L or ECG changes (Tall tented T waves, PR prolongation, P wave flattening, bradyarrhythmias, sine waves, VF, PEA/asystole)
How should you approach a patient with hyperkalaemia
A
B: ABG K+
C: ECG: tall tented T waves, small/ absent P waves, wide QRS —> Treatment
U+Es (K+, creatinine)
D: drug chart
E:
How should you manage a patient with hyperkalaemia
10ml of 10% calcium gluconate IV (in the resus trolley) bolus/5 mins (improvement should be seen within 1-3 mins, repeat every 10 mins, if on digoxin bolus over 20 mins)
Actrapid 10U in 50ml of glucose 50% IV/ 15-30 mins (+) Nebulised salbutamol
Oral calcium resonium 15g TDS & regular lactulose 10ml with each dose
Stop any causative drugs e.g. ACEi, K+ sparing diuretics
Tumour lysis syndrome (TLS):
IV fluids
Rasburicase
Who should you escalate hyperkalaemia to
Consider urgent referral to Nephrology (acute dialysis may be indicated)
What are some differentials for hyperkalaemia
False result (lysing on draw)
Tumour lysis
AKI
Endo: Addison’s
Rhabdomyolysis
Iatrogenic: supplementation, drugs
How should you approach a patient with burns
A:
Protect C spine if needed
If facial or inhalation burns —> airway support
B:
C:
Large bore IV access x2
Resuscitation using parkland formula [4ml x TBSA x body weight kg/ 24 hours]
D:
Pain assessment Morphine IV 0.1mg/kg E:
Remove rings, bracelets, jewellery
Assess TBSA
Assess burn depth
Keep patient warm Consider escharomoty (emergency surgical procedure involving incising through areas of burnt skin to release the eschar (the tough leathery skin after a full thickness burn) and its constrictive effects, restore distal circulation, and allow adequate ventilation)
How should you manage a patient with burns
Analgesia: titrate morphine
Partial thickness burns >15% require IV fluid resus
Parkland’s formula: 4ml/kg/% burn Hartmann’s (give 1st 50% over 8 hours)
§
Dressing:
- Perform debridement
- Use sedation
- Use silver base creams
for burns
How should you approach a patient with acute alcohol withdrawal
A
B:
C:
D: pabrinex before glucose
E:
H: last drink, calculate CIWA
Bloods: FBCs, LFTS, U&Es, creatinine, calcium, phosphate, Mg, serum glucose, clotting, PT + albumin.
History: Calculate Clinical Institute Withdrawal Assessment (CIWA)
How should you manage acute alcohol withdrawal
Use CIWA score to determine chlordiazepoxide dose + monitor symptoms with it
Treatment of Wernicke’s encephalopathy:
1. TWO pairsPabrinex (i.e. 4 ampoules) THREE times daily, usually for FIVE days
How should you escalate in acute alcohol withdrawal
Escalate in line with severity
Psych liaison assessment
Addictions liaison nurse
How should you assess a patient with hypothermia
A:
B: warm humidified O2, CXR: (pneumonia a cause of hypothermia in older pts)
C:
- Cardiac monitoring (J waves, prolonged QRS, ST changes, A fib).
- Bloods (U&Es, amylase, TFTs, FBC, blood cultures, clotting)
- Warm fluids
D:
E: remove wet clothes + provide blankets
Definitive: if non-invasive rewarming is ineffective → senior staff may consider warmed fluid lavage (intraperitoneal/ intravesical), dialysis or ECMO
How should you manage a patient with hypothermia
ABCDE
Prepare the crash trolley (Hypothermia is a cause of arrest)
if non-invasive rewarming is ineffective → senior staff may consider warmed fluid lavage (intraperitoneal/ intravesical), dialysis or ECMO
What are some differentials for hypothermia
Sepsis
Hypothyroidism Environmental
Risk —> Cardiac arrhythmia
What are the features of compartment syndrome
Raised pressure within a closed myofascial compartment —> hypoperfusion, hypoxia + local tissue ischaemia
How should you approach a patient with compartment syndrome
Remove all circumferential dressings
Elevate the limb
Patients should be re-evaluated w/i 30 minutes
If symptoms persist —> urgent surgical decompression
Hx: fracture/ surgery
If diagnostic uncertainty: pressure monitoring >40mmHg
How should you manage a patient with compartment syndrome
Compartment syndrome is a surgical emergency and surgery should occur within an hour of the decision to operate
How should you escalate a patient with compartment syndrome
Orthopaedic SpR on- call
What are some differentials for compartment syndrome
DVT
Critical limb ischaemia (pulseless)
Fracture
How should you approach a patient with acute urinary retention
Hx:
Symptoms: inability to void, desire to void, lower abdo pain; timing/speed of onset
Recent surgery/ anaesthesia
PMH related to urinary tract (BPH)
Medications: anti- cholinergics, TCAs, opiate analgesics
Examination:
Distension
Percuss the bladder Palpate
How should you manage a patient with acute urinary retention
Def Ix:
Bladder scan
Def management:
Urgent catheterisation
- Try urethral route (14 or 16Ch) otherwise escalate for suprapubic (need urology SpR)
Further Ix:
DRE after catheterisation (size/ texture of prostate, anal tone)
Focused neurological examination
Urinalysis
Bloods: U+Es
Imaging: TRUS, cystoscopy
Further Rx:
TWOC: trial without catheter
BPH: alpha blockers, 5a reductase inhibitors
How should you escalate acute urinary retention
Urology SpR
What are contraindications to catheterisation
Blood at urethral meatus
High-riding prostate on rectal exam
Penile, scrotal, perineal haematoma
Radiographic evidence of urethral/bladder trauma
What are differentials for acute urinary retention
Obstruction:
BPH
Malignancy
Neuropathic:
SCC compression
Multiple sclerosis
What are the stages of an AKI
Stage 1: <0.5ml/kg per h/6h
Stage 2: <0.5ml/kg per hx 12h
Stage 3: <0.3 ml/kg per h x24hr, anuria / 12hrs
(normal UO = 0.5-1.5 ml/kg/hour)
Creatinine:
Stage 1: X 1.5
Stage 2: X 2
Stage 3: X3
How should you approach a patient with an AKI
ABCDE
- Correct any
1. Shock
2. Hyperkalaemia
3. Pulmonary
oedema
History:
Symptoms e.g. blood, rate of onset, anuric vs oliguric —> Fluid chart
If catheter—>ask nurse to flush
Exam:
Pre-renal: dehydration Renal: rash/ vasculitis Post-renal: percuss bladder
Investigations:
Urinalysis
Bladder scan
VBG: K+, anion, gap acidosis
Bloods: FBC, U+Es
Myeloma screen
Imaging: renal tract
How should you manage an AKI
Pre-renal:
Fluid management
Renal:
Drugs (e.g. stop offending drug, Abx, steroids)
Post renal:
Catheterise
Indications for dialysis:
- Refractory
hyperkalaemia
- Volume overload
- Uraemic complications:
encephalopathy, pericarditis
What are dialysis indications in an AKI
- Refractory
hyperkalaemia - Volume overload
- Uraemic complications:
encephalopathy, pericarditis
Who should you escalate an AKI to
Renal SpR
What are risk factors for an ectopic pregnancy
- PID
- Tubal surgery
- Previous ectopic
pregnancy - IUD
How should you approach a patient with an ectopic pregnancy
A
B
C
Shock (hypovolaemic) Fluid resuscitation, blood products (MHP)
D
E
Focussed abdo exam
Hx: LMP, shoulder tip pain, syncope/ dizziness, RFs
Exam: consider bimanual, speculum
Def Ix:
Urinalysis +
pregnancy test
Bloods: FBC, U+Es, serum hCG, G+S, x- match, clotting studies TVUS
How should you manage a patient with an ectopic pregnancy
Contact gynaecological SpR
Def Rx
Emergency laparoscopy (salpingectomy) or laparotomy
Other:
Conservative (very rarely used due to rupture risk)
Medical (methotrexate - if small but also unlikely if presenting acutely as they will have abdo pain) Surgical (laparoscopic salpingectomy)
Who should you escalate an ectopic pregnancy to
Gynacology SpR
What are the differentials for an ectopic pregnancy
Gynae:
Ovarian torsion Pedunculated fibroid
PID
Miscarriage
Abdo:
Appendicitis
Renal colic
What are the conditions you look for in a trauma survey and what scoring system can be used for determining if major trauma
ATOM FC:
- Airway obstruction
- Tension pneumothorax
- Open pneumothorax
- Massive haemothorax
- Flail chest
- Cardiac Tamponade
Injury severity score (ISS): 1-75, >15 defined as major trauma
How do you approach a trauma patient
C spine
Catastrophic bleed
A:
Jaw thrust Airway adjuncts/ defintive airway
B:
High flow O2
ATOM FC —> decompression
C:
Simple dressings with direct pressure
Pelvic binder
Topical haemostat —> Massive haemorrhage protocol IV access & bloods
IV fluid resuscitation, blood products
IV tranexamic acid
D:
GCS
Pupils Assess pain/ analgesia (IV morphine)
E:
Minimise heat loss Fractures
?FAST scan (although don’t delay CT)
How should you manage a trauma patient
Put out a hospital trauma call - team made of:
- Trauma lead consultant (ED)
- Primary survey: A (anaesthetist), BCD: general surgical SpR, T&O SpR
- ED doctor
- Airway nurse
- Circulation nurse
- Drug nurse
- Scribe
Def Ix:
Trauma CT (C spine, chest, pelvis)
Skeletal survey
Def Rx:
Open fractures
- Cover wound with saline soaked dressing
- Give IV Abx
- surgery
How should you approach a transfusion reaction patient
Possible signs of acute transfusion reaction —> STOP THE TRANSFUSION
A:
Anaphylaxis: rash, angioedema, stridor —> PERI-ARREST, get crash trolley, initiate Rx
B:
High flow O2 (ABG)
C:
Fluid resuscitation
Bloods: serum tryptase
D:
Drug chart, check patient ID/ blood compatibility, other causes
E:
How do you manage a patient with a transfusion reaction
Def Ix:
Second serum tryptase
Inform the hospital transfusion department and return the unit with delivery set to lab.
Def Rx:
? Repeat
Mild allergic: give chlorphenamine 10mg and restart transfusion at a slower rate, observe frequently
Febrile non-haemolytic transfusion reaction: if temp rise <1.5, observations stable, give paracetamol, restart at slower rate, observe frequently
ABO incompatibility: STOP infusion, fluid resuscitation
TACO: stop infusion, give O2, furosemide
TRALI: stop infusion, O2, treat as ARDS
What are some differentials for transfusion reaction
Mild:
Mild allergic reaction Febrile non- haemolytic transfusion reaction
Major:
Anaphylaxis
ABO incompatibility
Transfusion associated circulatory overload (TACO)
Transfusion associated acute lung injury (TRALI)
How should you escalate a patient with suspected cauda equina
Alert radiology
Contact oncology SpR
Contact neurosurgery SpR
