Emergency (NEW) Flashcards
1
Q
ACS definitions
A
STEMI
- Acute
- > persistent ST segment elevation (1 small square) in 2 contiguous leads (except V2/3)
- > new LBBB with symptoms
- does not require elevated troponins
- Consider posterior STEMI
- > ST depression in V1-3
- Old findings
- > ST segment at isoelectric
- > small R
- > pathologic Q (1/3 corresponding R)
- > inverted T wave
Non-STEMI
- > diffuse ST segment depression
- > depression in focal area likely STEMI with reciprocal changes
- > elevated troponins without ST elevation
UA
- > unstable/new/severe/frequent angina
- > no trops
- > only transient ECG changes
2
Q
ACS evaluation
A
Hx
- pain (OPQRST)
- > Onset is gradual
- > Precipitated by exercise/Palliated by rest/NO
- > Quality is discomfort/crushing/tightness etc
- > Radiates to epigastrium/scapula/jaw/throat/arms
- > Site is diffuse, should not be able to point with one finger
- > Time longer than 20 minutes
- associated symptoms
- > most commonly SOB
- > palpitations
- > nausea/vomiting
- > diaphoresis/clamming
- > syncope/presyncope
- absence of pain
- > older age
- > women
- > diabetics
Consider risk factors
- Non modifiable
- > male
- > old
- > family Hx men <55, women <65
- > established CAD
- Modifiable
- > overweight/obesity
- > metabolic syndrome
- > physical inactivity
- > dyslipidaemia
- > diabetes
- > hypertension
- > smoking
- > cocaine use (acute and chronic)
- > renal dysfunction
Exam
- evidence of hypoperfusion
- > hypotension
- > tachycardia
- > altered mental status
- > pale, cool, clammy skin
- evidence of heart failure
- > JVP elevated
- > crackles
- > S3 gallop
- > MR murmur
Immediate Tests (confirm ischaemia)
- ECG
- > confirms STEMI diagnosis
- > assessment for reperfusion immediately after
- High sensitivity troponin
- > baseline with repeat within 3 hours
- > confirms STEMI/non STEMI if symptomatic with rise/fall with one >99th centile
Consider non ischaemic chest pain (PPP GRAMMA)
- ddx
- > pneumothorax
- > pericarditis
- > PE
- > GORD
- > Ruptured viscus
- > Aortic dissection
- > Myocarditis
- > Musculoskeletal
- > Anxiety
- safe discharge
- > consider HEART score
Secondary tests
- Glucose
- > hyper/hypoglycaemia common
- FBC
- > anaemia (anti-platelet therapy)
- > leukocytosis (acute phase reactant)
- Electrolytes and CMP
- > arrhythmias
- Creatinine/eGFR
- > baseline for angiography contrast
- > baseline for medications
- CXR
- > rule out ddx
Consider
- ABG
- > signs of shock of pulmonary oedema
- Echo
- > MI complications
3
Q
ACS management
A
General management
- ACCU transfer/early cardio consult
- 2x IV canula
- O2
- Cardiac monitoring + serial ECGs
- Routine bloods
- CXR
- Pharmacological management (THROMBINS2)
- > Thionopyridines (clopidegrel)
- > Heparin/enoxaparin
- > RAS (ACEI/ARB)
- > O2
- > Morphine
- > Beta blocker (bisoprolol/metoprolol)
- > Invasive treatment (PCI) preferred
- > Nitoglycerine
- > Salicylate (aspirin)
- > Statin
- Balance ischaemic and bleeding risk
- > GRACE = ACS mortality
- > CRUSADE = bleeding risk in ACS
Common pathway
- Dual anti platelet
- > aspirin 300mg oral/dissolved
- > clopidegrel 300-600mg
- Anticoagulation
- > enoxaparin 1mg/kg SC
- > give initial 30mg IV bolus then SC if for fibrinolysis
- > additional dosing not required for PCI
- > use UFH if severe kidney disease (different pathway)
- Consider
- > abciximab (high risk/at time of PCI)
- > or bilalirudin (if high risk of bleeding)
STEMI
- Choice of reperfusion method
- > PCI if available within 90mins of presentation
- > if not, fibrinolysis within 30mins of presentation
- > if fibrinolysis contraindicated, transfer to PCI
- > unsuccessful thrombolysis
- Fibrinolysis contraindications
- > symptoms >12hrs
- > BP 180/110
- > recent trauma/surgery
- > GI bleeding in past month
- > Stroke/TIA in 3 months
- > Prior ICH
- > known malignancy/vascular lesion/coagulopathy
- Fibrinolysis treatment
- > tenectoplase preferred (bolus regime)
- > alteplase (bolus plus transfusion)
NSTEMI
- Approach
- > CA guided revascularisation (PCI or CABG)
- > no fibrinolysis
- Risk stratified treatment
- > very high risk = CA within 2hrs
- > high risk = CA within 24hrs
- > intermediate risk = CA within 72hrs
- > low risk/no symptoms = guided by provocative testing
4
Q
DKA evaluation
A
Triggers (Don’t PANIC)
- Drugs
- > corticosteroids
- > cocaine
- > simpathomimetics
- > SGLT-2
- > atypical anipsychotics
- Pregnancy
- Acute illness
- New diagnosis (common)
- Infarct
- Compliance
Symptoms
- polyuria/polydypsia
- fatigue/weakness
- nausea/vomiting
- abdo pain
Signs
- hypotension/tachycardia
- hypothermia
- kussmaul breathing
- fruity breath
- altered mental status (GSC)
- dry mucous membranes/slow cap refill
- pulmonary oedema may occur
- evidence of infection
5
Q
DKA labs
A
Investigations
- Glucose
- > greater than 11.1 for criteria
- > can be euglycaemic
- > usually above 45 in HHS
- VBG
- > high anion gap metabolic acidosis
- > K <3.5?
- > plasma osmolality (>320mmol/L in HHS)
- Ketones
- > dipstick tests acetoacetate/capillary tests D-beta-hydroxybutarate level 3x higher
- > capillary ketones >3.0
- FBC
- leukocytosis is common (very high =?infection)
- EUCs
- > urea/creatinine high (dehydration)
- > Pseudohyponatraemia (minus 1.6mmol/L per 5.6mmol/L)
- > K normal despite total body depletion
- > Cl low
- CMP
- > low or normal
Consider testing for ddx’s
6
Q
management DKA
A
Goals
- restore circulating blood volume
- inhibit lipolysis, gluconeogenesis and ketogenesis
- address precipitating factors
- re-establish normal physiology and electrolyte balance
Issues
- acidosis
- dehydration
- hypokalaemia (hyper)
Monitoring
- continuous cardiac monitoring
- regular BP
- hourly
- > BG
- > ketones
- > VBG (particularly pH and K)
Fluids IV
-resuscitate, restore, maintain
Insulin IV
- goal
- > treat acidosis, not hyperglycaemia
- infusion
- > 0.1unit/kg/hr
- > don’t drop BG >5mmol/L/hr (cerebral oedema)
- target
- > glucose 10-15mmol/L
- maintain insulin infusion
- > start 5% glucose infusion
Potassium
- indication
- > serum level <5.5
- > once urinary flow is established
Resolution
- pH >7.3
- bicarb >15
- ketones <0.6
- patient alert
- tolerating oral fluids
Education
- review precipitating events
- discuss symptoms and triggers of DKA
- teach self management
- > during illness/reduced fluid intake
- advise when sick
- > check BG and ketones often
- > maintain hydration
- > present to medical attention early
7
Q
Upper GI bleed evaluation
A
DDx
- peptic ulcer
- malloryweis
- varices
- portal hyptersive gastropathy
- angiodysplasia
- neoplasia
- erosive
- > oesophagitis
- > gastritis
- > duodenitis
Hx
- Typical upper GI bleed
- > haematemesis
- > coffee ground
- > melena
- Typical features
- > epigastric pain = peptic ulcer
- > dysphagia/GORD = oesophageal ulcer
- > emesis/epigastric pain/hiatus hernia = MWT/BS
- > jaundice/distension = gastropathy/varices
- > dysphagia/cachexia = malignancy
- > melena w/o vomitting = distal to pylorus
- Severity screen
- > orthostatic presyncope
- > confusion
- > angina/palpitations
- Past hx
- > previous UGI bleed
- > varices
- > liver disease
- > peptic ulcer
- > malignancy
- > coagulopathy
- > renal disease/aortic stenosis/HHT (angiodysplasia)
- > AAA (aortoenteric fistula)
- Meds
- > NSAIDs
- > anticoagulants/antiplatelet
- > doxycycline
- > iron/bismuth
- Social
- > alcohol
- > smoking
- > IV drug use
Exam
- hypovolaemia
- > tachycardia
- > hypotension (orthostatic/supine)
- > pale/cool, clammy peripheries
- > delayed cap refil
- stigmata of chronic liver disease
- evidence of acute abdomen
- > perforation
- PR exam
- > melena/haematochezia
Investigations
- Blood group/cross match
- FBC
- > Hb normal early/lowered by fluid resusc
- > microcytic/iron deficiency = chronicity
- EUCs
- > urea:creatinine >30
- Coags
- LFTs
- Upper endoscopy once stable
- Consider CT abdo
Candidate for outpatient management?
- glasgow blatchford score
- > mortality risk increases with every point
8
Q
Upper GI bleed management
A
Unstable
- Secure airway
- > nasal cannula
- > low threshold for intubation
- Gain IV access
- Fluid resuscitation
- > start immediately
- Transfusion
- > may be required despite high Hb
- > avoid overtransfusion in variceal bleeding
- > FFP/platelets after 4 PRBCs
- Monitor
- > telemetry/ECG’s
- > pulse ox
- > serial BPs
General management of stable patient
- Keep NBM
- Fluid rescus
- PRBs
- > restrictive (<7) approach preferred
- > lower mortality compared to liberal (<9)
- > no difference in MI (including past MI)/CVA/AKI
- FFP
- > give before endoscopy if INR >2
- Platelets
- > consider before endoscopy if thrombocytopaenic
- Medications
- > IV esomeprazole 80mg
- > consider IV octreotide or vasopressin
- > IV erythromycin 30mins prior to endoscopy
- > IV ceftriaxone 1g if cirrhotic
- > consider with-holding anticoagulants/antiplatelets
- Upper endoscopy
- > interventions depend on pathology
Variceal bleeding
- Natural hx
- > mortality rate approx 15%
- > 50% spontaneous resolution
- > 1/3 rebleed in short term
- > 2/3 rebleed in long term
- Initial therapy
- > IV octreotide 50mcg bolus then 50mcg/hr transfusion
- > consider vasopressin
- > balloon tamponade after intubation
- Urgent endoscopy
- > after resuss/within 12hrs
- > band ligation/sclerotherapy
- > successful in approx 90%
- Consider alcoholism complications
- > monitor serum electrolytes
- > check thiamine
- Consider cirrhosis complications
- > hepatic encephalopathy
- > secondary infection
- > electrolyte abnormalities
- > renal failure
Mallory Weiss
- Natural hx
- > mortality rate approx 5%
- > rebleeding in <10%
- Initial therapy
- > IV ondansetron 10mg once daily
- > consider IV ocreotide 25-50cg bolus and transfusion
- Urgent endoscopy
- > after resuss/within 12hrs
- > haemoclip
- > adrenaline + haemoclip/sclerotherapy/band ligation
- > successful >90%
9
Q
thunderclap headache ddx
A
Always Remembering Several Critical Differentials is A Painful Thorn In My Side
- Aneurysm rupture
- > thunderclap headache after trigger/maybe sentinel bleed
- > vomiting/nuchal rigidity/LOC/seizures
- Reversible cerebral vasoconstriction syndrome
- > recurrent TCH over days to weeks
- > similar triggers to aneurysmal rupture
- > may develop neurological deficits due to stroke
- Spontaneous intracranial hypotension
- > postural headache after trauma/CSF drain
- > nuchal rigidity/nausea/vomiting sometimes
- Cluster headache
- > eye/temple pain lasting up to 3 hours
- > red eyes/ipsilateral lacrimation/rhinorrhea/horners
- Dissection (cervical artery)
- > stroke/TIA/neck or head pain
- > partial horners (no anhidrosis)/tinitus/bruit
- > trauma/connective tissue disorder
- Acute angle glaucoma
- > blurred vision/halos/red eye/dilated pupil
- Posterior reversible encephalopathy syndrome
- > HTN/seizure/visual symptoms/insidious headaches
- > white matter oedema
- > sometimes UMN signs and focal deficits
- Thrombus (venous)
- > VTE risk factors/neuro deficits across arterial territories
- Ischaemic stroke
-Meningitis
- Spontaneous intracerebral haemorrhage
- > HTN/anticoagulated/older
- > gradual focal neuro signs (putamen/post int capsule)
- > headache/vomiting/meningism/stupour
10
Q
Headache evaluation
A
Red flags on history
- sudden and severe onset
- precipitated by exertion or trauma
- altered mental status
- seizure
- visual disturbance
- pain down into neck or around eye
- systemic symptoms
- > fever
- > vomiting
- > dizziness
- concurrent head infection
- no past hx
- family hx of SAH
- medications
- > anticoagulants/NSAIDs
- > COCP
- > simpathomimetics
Red flags on exam
- Cushings triad
- Fever
- > inflammation or bleeding
- HTN
- Toxic appearance
- Altered mental status
- Focal neuro signs
- Meningismus
- Eye
- > papilloedema
- > red eye
- > visual deficits
- > CN IV/VI palsy
Investigations
- CT or MRI
- > non con
- > neck/cerebral angiography
- LP (if imaging negative)
- > high opening pressure = pathology
- > RBC dilution across 4 tubes/xanthochromia
- > biochemical analysis
- FBC
- > anaemia?
- > thrombocytopaenia?
- Coags
- EUCs
- > hyponatraemia (SIADH)
11
Q
Aneurysmal SAH management
A
Consider complications (Bloody Hot CHIPS)
- > Bleeding (mortality increased to approx 70%)
- > Hydrocephalus
- > Cardiac (arrythmia/trops/takasubo)
- > Hyponatraemia
- > Ischaemia (delayed due to vasospasm)
- > Pressure (increased ICP)
- > Seizures
Transfer
- > to ICU
- > tertiary institute
- Grading
- > Hunt and Hess
Core supportive measures
- Blood pressure
- > withold management unless severe/stuporous
- Vasospasm
- > Nimodipine 60mg oral immediately
- Analgesia
- > paracetamol
- > opioids
- Monitor
- > neurological status every 1-2hrs
- > transcranial doppler daily
Additional measures
- Anti-thrombotic reversal
- > antiplatelet = desmopressin
- > warfarin = IV vit K + FFP
- > UHF = protamine
- > DOACs= some have direct inhibitors
- Euvolaemia
- > prevent hypovolaemia and stroke
- > avoid raising BP
- > correct hyponatraemia
- Definitive treatment
- > surgical clip/coiling
12
Q
Meningitis evaluation and management
A
ddx (MASES PTSD)
- Meningitis
- > bacterial
- > aseptic
- Abscess
- Subdural empyema
- Encephalitis
- SAH
- Petechial ddx’s
- Trauma
- Septicaemia
- > meningococcus
- > varicella
- > pneumococcal
- Drugs
- > sulfur containing
- > antibiotics
- > anticonvulsants
Initial evaluation
- concurrent primary survey + history to confirm
- key issues
- > shock
- > hypoxia
- > hypoglycaemia
- > hyponatraemia
- > seizures
Investigations
- Consider CT before LP if signs of raised ICP
- Lumbar puncture
- Blood cultures
- > useful if LP is delaying treatment
- Glucose
- FBC
- EUCs
- CMP
- CRP
- Coags
Initial management
- dexamethasone 10mg (0.15mg/kg) IV before antibiotics
- > ideally before antibiotics
- cefotaxime/ceftriaxone 2g (child 50mg/kg) IV
- > as soon as possible
- > should not be delayed by investigations
- Maintenance fluids for euvolaemia
- ICP
- > sit bed at 45 degrees
- > if raised = consider monitoring/osmotherapy/sedation
13
Q
Anaphylaxis evaluation and management
A
ASAP Fluids, Ventilation, Adrenaline
- anaphylaxis
- shock
- asthma attack
- panic attack
- foreign body aspiration
- vasovagal reaction
- acute exacerbation COPD
Immediate response
- remove allergen
- lay flat
- call for help
- prepare IM adrenaline
- collapsed
- > assess pulse and breathing
- > ALS pathway
A -examine lips, tongue, pharynx -assess for obstruction ->stridor/angioedema = upper ->wheeze = lower -ladder of interventions ->low threshold for intubation ->oxygenation is priority -ask patient to speak ->change to voice with angioedema B -high flow O2 via hudson/non rebreather C -IM adrenaline >10mcg/kg (up to 0.5mg) ->min dose = 0.1mg (<1yr old) ->outer thigh ->repeat every 5 mins -not responding after approx 2 doses ->prepare adrenaline infusion ->contact ICU ->fluid boluses ->consider IV glucagon in beta blocker patient -any signs of shock ->1-2L boluses adult ->20mL/kg bolus child -D ->serially assess -E ->any more allergens?
Resistant to treatment
- transfer to ICU
- adrenaline infusion
- fluid boluses
- upper airway obstruction
- > nebulised adrenaline
- lower airway obstruction
- > nebulised salbutamol
14
Q
anaphylaxis post acute care
A
Treatment
- consider H2 antihistamines (ranitidine/cimitadine)
- > itch
- consider corticosteroids (methyprednisone)
- > biphasic
- > limited evidence
Observation
- at least 4 hours
- longer if
- > severe
- > hx of biphasic
- > risk factors for fatal anaphylaxis
- > remote or isolated
- biphasic reaction
- > overal risk approx 5% (higher in kids)
- > up to 3 days later
- consider tryptase for follow up
Discharge (SAFE)
- Safety net
- > recurrence in 20%
- > patient education
- > provide anaphylaxis action plan (ASCIA)
- Allergen avoidance
- Follow up with immunologist
- > diagnosis revised in up to a third
- > confirm allergen
- > immunotherapy for stinging insects
- > address co-morbidities
- Epinephrine
- > prescribe 2x auto injectors
- > urge patient to fill immediately
- > education on proper use
15
Q
Undifferentiated shock
A
When to suspect (Red flags)
- hypotension
- > SBP <90/MAP <65/orthostatic
- > not always present (compensated shock)
- tachycardia
- oliguria
- abnormal mental status
- cool, clammy, cyanosed skin
- cap refill >3 seconds
- metabolic acidosis
- lactic acidosis
- tachypnea
Initial response
- secure airway
- support breathing
- gain IV/IO access (x2)
- > fluid bolus (adults=500mL, paeds=10mL/kg)
- > draw blood for lab
- risk stratify
- > brief hx and exam
Risk stratified response
- life threatening condition suspected
- > begin empiric life saving therapies
- > do not delay for results lab studies
- patient stable but undifferentiated
- > focused hx and exam
- > ECG
- > CXR
- > ultrasound (RUSH) or echo
- > lab studies
Lab studies for undifferentiated
- ABG
- FBC
- EUC
- LFTs
- Coags and D dimer
- Troponin and BNP
- Lactate
Empiric treatment
- IV fluid boluses
- > adults = 20mL/kg up to 1L then ICU
- > paediatrics = 10mL/kg up to 40mL/kg then ICU
- > smaller if cardiogenic suspected
- Inotropes/pressors
- > only use when fluid resus has failed (can worsen hypovolaemic shock)
- > norad or metaraminol (pressor choice doesn’t matter)
