Emergencies Flashcards
(43 cards)
How do you manage DKA?
- Fluid replacement therapy 5-8L
- 0/9% 1 L over 1 hour
- 0.9% with K 1L over 2 hours x2
- ” over 4 hours x2
- ” over 6 hours x1
- Insulin
- Rapid acting 1st: 0.1unit/kg/hour
- 5% dextrose once glucose <15
- Then long-acting insulin
- Electrolyte replacement (insulin drives K into cells)
What is the diagnostic criteria for DKA?
- glucose > 11 mmol/l or known diabetes mellitus
- pH < 7.3
- bicarbonate < 15 mmol/l
- ketones > 3 mmol/l or urine ketones ++ on dipstick
What will hyperosmolar hyperglycaemic state look like on investigations?
- Hypovolaemia
- Marked Hyperglycaemia (>30 mmol/L) without significant ketonaemia or acidosis
- Significantly raised serum osmolarity (v thick and dehydrated) (> 320 mosmol/kg
- NO acidosis or ketones
What is the management for hypoglycaemia in hospital?
Alert: quick acting carbohydrate eg. glucose tablets and long acting
Unconscious: IM glucagon 1mg
75 ml IV 20% glucose through large vein
then recheck glucose
Don’t omit insulin - can reduce dose instead
What are the features of a thyroid storm?
Stormy autonomic function: tachycardia, hypertension, heart failure, fever >38.5
Stormy gastro: nausea and vomiting, jaundice and abnormal LFTs
Stormy head: confusion and agitation
What is the management of thyroid storm?
- Treat cause
- IV propanolol
- anti-thyroid drugs e.g. propylthiouracil
- Lugol’s iodine
- dexamethasone 4mg QDS - blocks t4-t3
What is myxoedema coma?
Opposite of thyroid storm: very low thyroid hormone, presents with confusion and hypothermia
What is the management of myxoedema coma?
- IV thyroid replacement
- IV fluid
- IV corticosteroids (until the possibility of coexisting adrenal insufficiency has been excluded)
- electrolyte imbalance correction
- sometimes rewarming
What is the management of an Addisonian crisis?
- hydrocortisone 100 mg im or iv
- 1 litre normal saline infused over 30-60 mins (or with dextrose if hypoglycaemic)
- continue hydrocortisone 6 hourly until the patient is stable
- oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days
What is the drug management of a STEMI?
Aspirin 300mg loading dose
Ticagrelor
Heparin if for PCI
+ MONA
What investigations are needed in ACS? (ignore the FBC, examination etc)
ECG (+/- repeat)
Serial troponins
CXR
Coronary angiography
What risk assessment tool is important in an NSTEMI?
GRACE - determines what investigations and management needed
If high risk then coronary angiography +/- PCI following on should be offered
What is the management for VT?
Unstable: electrical cardioversion
Stable: amiodarone / lidocaine / procainimide
What is the management of SVT?
- vagal manoeuvres e.g. carotid sinus massage, Valsalva
- IV adenosine 6mg, then 12 then 18 UNLESS asthmatic = verapamil
- DC cardioversion
What are the signs of acute respiratory distress syndrome?
what are the 2 key investigations?
Clinical features are typically of an acute onset and severe:
- dyspnoea
- elevated respiratory rate
- bilateral lung crackles
- low oxygen saturations
Investigations: ABG and chest xray
What is the management of ARDS?
Send to ITU!
- oxygenation/ventilation to treat the hypoxaemia
- general organ support e.g. vasopressors as needed
- treatment of the underlying cause e.g. antibiotics for sepsis
- certain strategies such as prone positioning and muscle relaxation have been shown to improve outcome in ARDS
How do you assess for a PE?
- If low probability of PE, use PERC (PE rule out criteria). If all absent then unlikely PE
- Wells score
- If likely, then arrange CTPA
- If unlikely, arrange then d-dimer first
Other: ECG and CXR
What is the management of confirmed PE? (stable)
apixaban or rivaroxaban for 3 months
if provoked you can stop after 3 (6 if cancer)
if non-provoked continue for 6 months - use HASBLED
What is the management for PE that is haemodynamically unstable?
Thrombolysis
What is the management for acute liver failure?
Treat cause
Liver transplant
What do you give in hepatic encephalopathy
Lactulose
What is the treatment for acute pulmonary oedema?
- A-E
- POD MAN:
Position (sit up)
Oxygen
Diuretic (furosemide)
Morphine
Anti-emetic (metaclopramide 10mg IV)
Nitrates (if severe - IV infusion or spray)
How do you treat atrial fibrillation / flutter?
- rate/rhythm control
- Rate: Old and IHD → bisoprolol and diltazem
- Rhythm: clear acute onset <48 hours ago / 4 weeks antiocoag. Cardioversion:
- electrical
- chemical
- amiodarone
- flecinide if structural heart disease
- treat cause
- therapeutic anticoagulation (CHADS2VASC-dependent)
How do you treat bradycardias?
- Treat cause e.g. hypothyroid
- Atropine IV 500mcg every 3-5 minutes maximum 3mg
