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Flashcards in Acute Care Scenarios Deck (64):
1

Management of acute exacerbation of COPD?

Nebulised Salbutamol 5mg + Ipratropium bromide 500mcg
IV Hydrocortisone 100mg or PO Prednisolone 50mg
IV Amoxicillin 500mg TDS for 5days
if no response IV aminophylline

2

If a patient with acute COPD develops respiratory acidosis with type 2 respiratory failure what should be commenced?

NIV

3

If a patient with acute COPD pH drops below 7.26 what measure should be taken?

ET intubation

4

What are the different features of asthma attacks according to severity?

M: PEF 50-75%
S: PEF 33-50% RR >25, pulse >110, inability to complete sentances
Life Threatening PEF <33%, silent chest, O2 sats <92% T1RF, arrythmia, cyanosis, altered conscious level
Near fatal: T2RF

5

Management of acute asthma?

RECOGNITION
Oxygen (high flow 15L/min, non re-breather mask)
Salbutamol (5mg) and Ipratropium bromide (0.5mg) nebulised (turn oxygen to 6L/min) (single dose IV salbutamol if no response to inhaled)
IV hydrocortisone (100mg in adults or 4mg/kg in kids)/PO prednisolone (50mg in adults or 2mg/kg in kids, continue for 5 days)
Magnesium sulphate (IV 2g over 20mins)
Anaesthatist (if failing to respond or T2RF)

6

Management of tension pneumothorax?

Large bore cannula in 2nd ICS MCL
Chest drain 5th ICS MAL

7

PE investigations?

History (SOB, pleuritic chest pain, haemoptysis)
Examination (pleural rub, decreased breath sounds, look for DVT)
CXR (portable)
ECG (sinus tachy, right heart strain)
Wells score: >4 CTPA (V/Q in pregnancy) <4 D.dimer (if positive CTPA)
Once confirmed or if delay in CTPA start LMWH (dalteparin sub cut injection dose according to weight)

8

When do you suspect a massive PE and what should be done?

Hypotensive
Bradycardic
Pulseless
Thrombolysis: Alteplase 10mg IV over 1-2mins followed by 90mg infusion over 2hours

9

What are the features of asthma attack in children age 2-5years?

Moderate: SpO2 >92%
Severe: SpO2 <92%, HR >140, RR >40, accessory muscles, cant talk or feed
Life threatening: SpO2 <92%, silent chest, altered consciousness, cyanosis

10

Management of epistaxis?

Assess for shock and resuscitate
Position (sit up and tilt head forward)
Pressure (over cartilage for 15mins)
Remove clots with suction
Oxymetazoline & Lidocaine (vasoconstrictor and topical anaesthetic) spray or saturated into packing for 5mins
Cautery with silver nitrate if visualise bleeding
Packing and ENT help

11

Management of acute COPD?

Oxygen (be wary of sat targets 88-92)
Salbutamol 5mg + Ipratropium Bromide 500mcg nebulised
PO prednisolone 50mg for 5 days
If no response or severely unwell IV aminophylline infusion 5mg/kg in 100mls saline over 20 mins
If T2RF/Ph <7.26 NIV, ET
Amoxicillin 500mg TDS 5 days

12

Management of STEMI?

Morphine (10mg IV titrated to effect with metoclopramide 10mg IV over 3mins)
Oxygen
Nitrates (GTN 3 puffs every 5 mins, Glyceryl Trinitrate 1 tab sublingual every 5 mins)
Aspirin (300mg orally)
Clopidogrel (300mg orally)
<120 mins since symtpom onset call cath lab for PCI (catheter inserted into radial or femoral artery and blockage opened with balloon)
>120 mins then arrange thrombolysis (alteplase)

13

Management of acute heart failure?

Loop (IV furosemide)
Morphine (10mg IV titrated to effect plus metoclopramide 10mg IV over 3 mins)
Nitrates (glyceryl trinitrate IV 100mcg/min titrate to effect)
Oxygen
Posture

14

Management of malignant hypertension?

IV labetalol and nitoprusside

15

Signs of malignant hypertension?

BP >200/130 causing acute impairment of organs
headache, N&V, visual disturbance, papillodema, encepalopathy/seizures

16

Management of regular broad complex tachycardia likely VF?

Amioderone 300mg IV over 20-60 mins then 900mg over 24hrs

17

Management of irregular broad complex tachycardia?

Seek help

18

Management of a regular broad complex tachycardia in a patient with known SVT and BB?

Follow narrow complex tachycardia
- Vegal manoeuvres

19

Management and investigation in aortic dissection? (sharp pain radiating to back, pulse deficiencies)

ECG rule out MI (may have some STD)
Cardiac enzymes (negative)
CT angio ASAP (shows intimal flap)
Transthoracic echo if unstable
If unstable noradrenaline 0.5mcg IV and dobutamine. Surgery.
If stable labetalol (reduce force into thin walled falselumen) and nitroprusside (vasodilator). Surgery (open or endovascular stent)

20

Signs of adverse features on brady or tachy arrythmia?

Shock (altered cognition, hypotension <90, decreased peripheral perfusion, high RR, high PR)
Syncope
Myocardial ischaemia
HF (pulmonary odema, raised JVP)

21

What to do if signs of adverse features on tachycardia?

Synchronised DC shock up to 3 attempts (use sedation if conscious)
Help
Amioderone 300mg IV over 10 mins

22

Principles for management of stable tachycardia?

Is QRS narrow <0.12 or wide >0.12 (3 small squares)
Is it regular or irregular

23

Management of stable regular narrow complex tachycardia?

Vegal manouvres (carotid sinus massage, valsava)
Adenosine 6mg IV bolus
Adenosine 12mg IV bolus x2
Seek help (atrial flutter likely)

24

Likely causes of regular narrow complex tachycardia?

SUPRAVENTRICULAR TACHYCARDIA
Sinus tachycardia, AVNRT, AVRT (WPW)

25

What is meant by a paroxysmal SVT?

SVT that doesnt cause any significant symptoms

26

Management of stable irregular narrow complex tachycardia?

(probably AF)
Control rate with BB + diltiazem

27

Management of stable regular wide complex tachycardia?

(probably VT)
Amioderone 300mg IV over 20mins
Amioderone 900mg IV over 24hrs

28

Management of stable irregular broad complex tachycardia?

Seek help

29

Management of adverse features in bradycardia?

Atropine 500mcg IV repeat to max 3g
Consider transvenous pacing

30

Management of bradycardia with no adverse features?

Is there a risk of systole? (recent asystole, mobitz 2, complete HB, ventricular pause >3sec)
YES Atropine 500mcg IV
NO observe

31

Management of anaphylaxis?

Stop possible causes
0.5mg IM adrenaline (can repeat at 5min intervals)
500ml 0.9% NaCl IV stat
Chlorphenamine 10mg IV
Hydrocortisone 200mg IV
Call for senior help
(if a drug with known allergy has been given report as major incident)

32

Signs of end organ failure in sepsis?

BP<90
UO <30ml/hr
Lactate >4mmol
New altered mental state
New need for O2
Serum creatinine >150mmol
Unexplained coagulopathy/thrombocytopenia

33

Management of end organ failure in sepsis?

Senior help immediately

34

SIRS criteria?

RR >20
HR >90
Temp <36 >38
WCC <4 >12
Altered mental state
Known or suspect neutropenia

35

What is sepsis?

>2 SIRS and infection likely

36

Management of sepsis?

Give: Oxygen, fluids (500ml 0.9% NaCl IV stat), abx (according to suspected infection)
Take: Cultures, lactate, UO

37

STEMI locations?

II, III, aVF: inferior (RCA)
I, aVL, V5, V6: anteriolateral (circumflex)
V1-V4: anterioseptal (LAD)
V1-V6: anterior (LCA)
STD V1-V3: posterior

38

Management of NSTEMI?

Morphine (10mg IV titrated to effect with 10mg IV metoclopramide over 3mins)
Oxygen
Nitrates (GTN 3puffs every five mins, glyceryl trinitrate 1 tab sublingual every 5 mins)
Aspirin 300mg
Clopidogrel 300mg
Coronary angiograph asap

39

Key differences between all the ACS?

UA: ST depression, T wave inversion, no troponin rise
NSTEMI: ST depression, T wave inversion, troponin rise
STEMI: ST elevation, troponin rise

40

STEMI criteria?

>1mm STE in 2 adjacent limb leads
>2mm STE in 2 precordial leads
New onset LBBB

41

Generic management of ACS?

Morphine (10mg IV titrated to effect with 10mg IV metoclopramide over 3mins)
Oxygen
Nitrates (GTN 3 puffs every 5 mins, glyceryl trinitrate 1 tab sublingually every 5 mins)
Aspirin 300mg
ECG and troponin ASAP

42

Management of open pneumothorax?

3 sided cover
Chest drain 5th ICS MAL

43

Stroke management?

Maintain hydration, O2 sats
CT SCAN ASAP
Ischaemic: Aspirin 300mg. If <4.5 hours from symptoms thrombolysis (alteplase)
Haemorrhagic: Neurosurgery. Stop antiplatelets and anticoagulants.

44

How is aspirin given?

Orally

45

Reversible causes of cardiac arrest?

Hypothermia, hypoxia, hypovolemia, hypoglycaemia
Tension pneumothorax, toxins, tamponade, thrombosis

46

GCS?

E4 (open, voice, pain, no)
V5 (orientated, confused, inappropriate words, sounds, no)
M6 (obeys, moves to, moves away, flex, extend, no)
Trap squeeze for pain
Name, DoB, Location
Can you make a fist with your right arm

47

What GCS score needs airway protection?

<8 (severe)

48

When to activate major haemorrhage protocol?

50% blood loss in 3hrs
Hb <100 with ongoing bleeding or <80 without

49

What happens in major haemorrhage protocol?

Major haemorrhage identified, call 2222 and state major haemorhage on ward X
Call blood bank on 33394 and give info
Blood bank will provide: 4 units of O-, 4 units of FFP delivered
Ask for 1 platelets
Deliver at 2:1 ration or 1:1 in trauma
In the mean time take FBC, Coagulation, U&Es, Crossmatch

50

What are GCS scorings?

>13 minor
9-12 moderate
<9 severe

51

Management of head injury?

Assess GCS
CT scan

52

Daily fluid requirements?

25-30ml/kg/day
Na 2mmol/kg/day
K 1mmol/kg/day
Cl 1mmol/kg/day
Glucose 50-100g/day

53

Maintenance fluid regime?

1 salty (500mls 0.9% NaCl 4-5hourly) 2 sweet (500ml 0.5% dextrose 4-5hourly)

54

Management of DKA?

0.9% NaCl 500ml over 15 mins repeat (children 10mls/kg as risk of cerebral odema)
Insulin 0.1units/kg/hr
40mg KCl infusion (as H+ increases in acidotic state the K+/H+ exchanger increases which pumps more K+ out so initially hyperkalaemia but as insulin is given K+ moves back into cells so risk of hypokalaemia)

55

What is kaussmaul respiration?

Deep hyperventillation in an attempt to blow of CO2 and reduce acidity

56

Why does DKA not normally occur in T2 diabetics?

When the body lacks insulin lipolysis occurs and free fatty acids are released into the blood and used as energy whilst forming ketone bodies. In T2 diabetic insulin levels are still relatively high (the body has just built up resistance) so lipolysis doesnt occur and ketogenesis is inhibited

57

Diagnosis and management of hypoglycemia?

Glucose <4
Stop all insulin infusions
Conscious and able to swallow: 15-20mg quick actin carb (lucosade) repeat up to 3x every 15 mins
Disorientated and cant swallow: glucogel repeat up to 3x every 15 mins
Unconscious: Glucagon 1mg IM, 20% glucose 80ml IV
(glucagon metabolises glycogen stores to release glucose)

58

Management of hyperkalaemia?

(K>5.5)
IV Ca Gluconate 10mls 10% over 10mins repeating every 5 mins watching ECG (protects the heart)
IV insulin, nebulised salbutamol
Diuretics, dialysis

59

If RR falls below 10 what should be considered?

Bag mask assistance

60

Common causes of metabolic acidosis?

DKA, renal disease, aspirin OD
(SOB)

61

Causes of stridor?

Croup, epiglottitis, foreign body

62

Management of status epilepticus?

4mg IV lorazepam

63

Management of acute ischaemic bowel disease?

Resus
CT with contrast/CT angio
Empiric abx, exploratory laparotomy

64

Diagnosis of HHS and treatment?

Elderly T2 diabetic with altered mental state, polyuria and polydipsia. Glucose >33
Fluid resuscitation, measure potassium