Emergencies Flashcards
(78 cards)
1
Q
What to do in Airway?
A
Check patency - airway maneuvers, suction
Sats - 15L O2 NRM;
aim for 88-92% in COPD –> titrate using 24-28% venturi mask if T2RF
Protect C-spine if necessary
2
Q
What to do in Breathing?
A
RR
Examine the chest –> look, palpate, percuss + auscultate for signs or resp distress [symmetrical chest expansion? tracheal deviation?]
Squeeze calves to look for DVT!
3
Q
What to do in Circulation?
A
HR - ?arrhythmias
BP
CRT
Auscultate the heart + ECG
UO + Catheter
2xLarge bore cannulae [send blood for FBC, U+Es, LFT, cross match, clotting, G+S]
Fluids - 500ml bolus of normal saline (+rpt)
4
Q
What to do in Disability?
A
AVPU --> if abnorm --> GCS Pupils (PEARL) Glucose Temp \+/- abdo/neuro examinations
5
Q
What to do in Exposure?
A
Expose patient
Look for bleeding, rash, trauma etc
6
Q
What to do after ABCDE?
A
Continue monitoring Full colateral hx R/v notes/charts R/v lab/radiolog results ?escalate care --> HDU/ICU Document + handover
7
Q
What to do before ABCDE assessment?
A
SBAR handover Check notes, drug chart, vital signs, ecg, bm Quickly eyeball pt ?critically ill Brief hx including relevant PMH If help needed, get help early --> 2222
8
Q
Signs to assess for in a patient with acute breathlessness?
A
wheeze stridor crepitations chest clear other
9
Q
DDx of acute breathlessness + wheeze
A
ashtma
copd
HF
anaphylaxis
10
Q
DDx of acute breathlessness + stridor
A
foreign body tumour epiglottitis anaphylaxis trauma (laryngeal fracture)
11
Q
DDx of acute breathlessness + crepitations
A
HF
pneumonia
bronchiectasis
fibrosis
12
Q
DDx of acute breathlessness + clear chest
A
PE hyperventilation metabolic acidosis eg DKA anaemia drugs (aspirin OD) shock PCP
13
Q
Breathlessness +
Hyper-resonant to percussion?
Stony dull to percussion
A
pneumothorax
pleural effusion
14
Q
Life threatening causes of chest pain? (3 categories)
A
CARDIAC [acute MI, ACS, aortic dissection]
RESP [tension pneumothorax, PE]
GI [oesophageal rupture]
15
Q
what is coma?
A
unrousable unresponsiveness
16
Q
how to quantify coma?
when do you need to intubate?
A
GCS
intubate when <8
17
Q
Causes of coma? (2 categories)
A
METABOLIC [drugs, poisoning, hypoglycaemia, hypoxia, hypercapnia, septicaemia, hypothermia, hepatic/uraemic encephalopathy]
NEUROLOGICAL [trauma, infection, tumour, vascular, epilepsy]
18
Q
Scoring for best motor response?
A
6 - obeys commands 5 - localise to pain 4 - withdraw to pain 3 - flex to pain 2 - extends to pain 1 - no response
19
Q
scoring for best verbal response?
A
5 - oriented 4 - confused 3 - inappropriate speech 2 - sounds 1 - none
20
Q
scoring for eye opening?
A
4 - spontaneous
3 - to speech
2 - to pain
1 - none
21
Q
How to cause pain in assessing GCS?
A
fingernail bed pressure
supraorbital pressure
sternal pressure
22
Q
What is shock?
A
circulatory failure –> inadequate organ perfusion
SBP < 90 / MAP <65
23
Q
Calculate MAP?
A
MAP = CO x SVR
So shock results from a drop in CO or a loss of SVR or both..
24
Q
Causes of shock? (CATEGORISE) 2
A
INADEQUATE CARDIAC OUTPUT
hypovolaemia –> bleeding / fluid loss
pump failure –> cardiogenic shock, 2dary cause
LOSS OF SVR sepsis --> vasodilation anaphylaxis neurogenic endocrine failure other
25
Management for septic shock?
ABCDE (primarily 'C')
2xLarge bore cannulae, check ECG, signs of ischaemia
Septic shock --> BCs, abx in 1h (Tazocin + gentamicin + vancomycin) fluid bolus, ? refer to ICU
26
Management of anaphylactic shock?
| including 3drugs and doses
Type 1 - IgE mediated hypersensitivity
A/B - secure airway; 100% O2; ?intubate if obstruction
Remove the cause, raise feet
C - ADRENALINE IM 0.5mg (rpt every 5mins as needed)
IV access ->
CHLORPHENAMINE 10mg IV
HYDROCORTISONE 200mg IV
IV fluids, 500ml boluses, up to 2L
27
Further management of anaphylactic shock..?
```
Admit + monitor ECG
Measure mast cell tryptase 1-6h
Continue chlorphenamine
Education about epipen
Skin prick tests to find allergens
```
28
How does sepsis cause shock?
Systemic Inflammatory response syndrome (SIRS)
| cytokine cascade, free-radical production and release of vasoactive mediators.
29
Management of ACS? (STEMI)
```
Aspirin 300mg PO
Morphine 5-10mg IV (+anti-emetic)
GTN
Oxygen (if <95%)
Restore coronary perfusion --> PCI within 120mins; if PCI not available fibrinolysis
Anticoagulation
```
30
Management of ACS? (NSTEMI)
```
Aspirin 300mg PO
Morphine 5-10mg IV (+anti-emetic)
GTN
Oxygen (if <90% or breathless)
Beta-blocker
Fondaparinux
IV nitrate if pain continues
```
31
Mx of severe pulmonary oedema?
If does not improve
```
Sit upright
O2
Investigate
Diamorphine 1.25-5mg IV
Furosemide 40-80mg IV
GTN
```
If no improvement --> further dose of furosemide +/- CPAP, nitrates (if systolic >100)
32
Causes of severe pulmonary oedema?
LVF
ARDS
Fluid overload
Neurogenic
33
Mx of cardiogenic shock?
O2
Diamorphine 1.25-5mg (for pain + anxiety)
Correct arrhythmias, electrolyte disturbance
Find any reversible causes (e.g. MI, PE)
?filling pressure --> under filled give plasma expander
--> over filled give inotropes
34
Causes of cardiogenic shock?
```
MI
Arrhythmia
PE
tension pneumothorax
cardiac tamponade
myocarditis
endocarditis
aortic dissection
```
35
Define broad complex tachycardia? (2 things)
Rate > 100bpm
| QRS > 120ms (>3 small squares)
36
DDx of broad complex tachycardia?
VT
| TdP
37
Mx of broad complex tachy?
O2
Correct electrolytes
If regular --> amiodarone
If irregular --> TdP give Mg
+/- DC shock
38
Define narrow complex tachycardia?
Rate > 100bpm
| QRS < 120ms (<3 small squares)
39
DDx of narrow complex tachycardia?
```
Sinus tachy
Atrial tachyarrhythmias (AF, AFlut, junctional)
```
40
Mx of narrow complex tachy?
```
O2
continuous ECG trace
Vagal manoeuvres
Adenosine
+/- cardioversion [DC / amiodarone]
```
41
Acute severe asthma - how to assess severity?
```
LIFE THREATENING = 33,92,CHEST
PEFR < 33%
O2 < 92%
Cyanosis
Hypotension
Exhaustion
Silent chest
Tachycardia
```
42
Mx of severe asthma attack?
```
OSHITMS + escalate to ICU
O2
Salbutamol neb 5mg
Hydrocortisone IV 100mg
Ipratropium 0.5mg add to neb
Theophylline
MgSO4 2g IV
```
43
AECOPD?
common medical emergency
| viral or bacterial infection
44
Mx of AECOPD?
```
Neb bronchodilators --> salbutamol + ipratropium
Controlled O2 therapy (monitor rpt ABGs)
Steroids --> IV hydrocortison 200mg
Abx --> amoxicilline/doxy/clarithro
+/- aminophylline
+/- NIPPV / intubation
```
45
When to suspect PE?
sudden collapse 1-2weeks post surgery
46
RFs for PE
```
malignancy
surgery
immobility
COCP
prev VTE
```
47
Mx of large PE
O2 if hypoxic
Morphine 5-10mg IV (+anti-emetic)
If peri-arrest consider thrombolysis (50mg alteplase)
Otherwise, IV heparin/LMWH
If systolic <90 --> ICU input; colloid infusion, +/- dobutamine, adrenaline
If systolic >90 --> warfarin loading.
48
Causes of acute upper GI bleed
```
PUD
Gastroduodenal erosions
Oesophagitis
Mallory-Weiss
Varices
Malignancy
```
49
Mx of upper GI bleed
Protect airway, NBM, 2xLarge-bore cannulae
Bloods [FBC, U+E, LFT, clotting screen, crossmatch]
IV crystalloid
Blood transfusion
Correct any clotting abnormalities
Urgent endoscopy for diagnosis +/- control bleeding
50
pre-hospital mx of meningitis
IM benzylpenicillin
51
Hospital mx of meningitis (no signs of septicaemia)
ABC: IV fluids
Cefotaxime 2g (+ ampicillin if >55yo)
Dexamethasone 4-10mg/6h IV
52
Hospital mx of meningococcal septicaemia
ABC: IV fluids
Cefotaxime 2g (+ampicillin if >55yo)
ICU --> intubation, ionotropes, aim for MAP>70
Careful monitoring
53
Mx of viral encephalitis
Aciclovir 10mg/kg/8h IV for 14d
+ supportive treatment
+phenytoin if seizures
54
Sx of encephalitis
```
Prodrome of raised, temp, rash, lymphadenopathy, cold sores etc +:
odd behaviour
reduced consciousness
focal neuro
seizure
```
55
Define status epilepticus
seizures > 30min
| rpt seizures without intervening consciousness
56
Mx of status epilepticus
A- maintain airway, lay in recovery position, insert airway +/- intubate
B - O2 100% + suction as required
1 - lorazepam 01.mg/kg
2 - rpt lorazepam if no response in 10mins
3 - phenytoin
4 - GA
57
what other drugs (non-anti-epileptics) could be useful in treating the cause of status epilepticus?
Thiamine (if alcoholism)
Glucose
Dexamethasone (for vasculitis/cerebral oedema)
58
Head injury:
How to diagnose rising ICP?
Cause of rising ICP?
What to do?
Unequal pupils
EDH
Urgent involve neurosurgery
59
Signs of basal skull fracture?
CSF rhinorrhoea/otorrhoea
Battle's sign
Panda eyes
Blood behind the ear drum
60
Indications for CT head?
```
GCS < 13 at any time
GCS=13/14 at 2h post-injury
Focal neuro deficit
Suspected skull fracture
Post-traumatic seizure
Vomiting > once
LoC + [age>65, coagulopathy, dangerous mechanism, anterograde amnesia]
```
61
Indications for ventilation post head injury
GCS =< 8
PaO2 <9kPa on air / <13kPa in o2
Resp irregularity
62
Mx of head injury
```
ABC
O2
Treat blood loss
Assess GCS
Involve neurosurgery
```
63
Mx of raised ICP
```
ABC
Correct hypotension
Brief examination (any clues to cause)
Mannitol
Dexamethasone (for reducing oedema around tumours)
Fluid restriction
Close monitoring
If focal cause --> urgent neurosurgery (craniotomy/Burr)
```
64
signs of raised ICP
Cushing's triad!
- Hypertension
- Low heart rate
- Low resp rate
65
Pres of DKA
```
gradual drowsiness --> coma
vomiting
dehydration
abdo pain
polyuria/dipsia
ketotic breath
Kussmaul breathing
```
66
Triggers for DKA
```
4 Is
Infection (UTI, pancreatitis)
Infarction (MI)
Iatrogenic (surgery, chemo, antipsychotics)
Insulin (missed dose)
```
67
Diagnosis of DKA
Acidaemia (pH < 7.3)
Hyperglycaemia
Ketonaemia
68
Mx of DKA
A - patent airway
B - O2 if desat
C - 2xLarge-bore cannulae; if SBP<90 give 500mL saline --> if no response - 2nd + ICU advise. If responds (SBP>90 after 1st bolus --> start fluids)
Fluids -> insulin 50U to 50ml 0.9% saline - infusion at 0.1U/kg/h.
--> until ketones<0.3mmol/L, pH>7.3 and bicarb>18mmol/L
+/- K+ replacement
When glucose < 14mmol/L start 10% glucose @ 125mL/h alongside insulin
69
Pres of paracetamol OD
late signs
initially asympto
vomiting +/- RUQ pain
later --> jaundice + encephalopathy
70
what dose of paracetamol can be fatal?
150mg/kg
| 12g in adults
71
mx of paracetamol OD:
<4h?
<10h?
>10h?
Activated charcoal in first 4h
N-acetylcysteine (use treatment line)
N-acetylcysteine
72
How to give N-AC?
IVI 150mg/kg in 5% dextrose
73
F/U of paracetamol OD?
INR, U+E, LFT on day after
| If continued deterioration --> liver transplant
74
AKI mx
Urgent ABG to check K+ / ECG for signs
1) treat hyperkalaemia - Calcium gluconate; actrapid + glucose
2) Fluid input/output monitoring
3) Fluid challenge if dehydrated until SBP>100
4) If vol overload consider dialysis
75
Causes of AKI
Pre-renal [hypotension, sepsis, cardiac dysfunct]
Renal [drugs, GN, vasculitis]
Post-renal [obstruction]
76
Principles of AKI treatment
```
Treat hyperkalaemia
Treat hypotension/sepsis [pre-renal]
Catheterise [post-renal]
Treat pulm oedema w/ diuretics
Contact renal team if no UO
Urgent USS to r/o supra-bladder obstruction
?ICU requirement
```
77
When would someone need urgent dialysis in AKI?
Unresponsive hyperkalaemia
Unresponsive pulm oedema
Uraemic complications (pericarditis, encephalopathy)
Severe metabolic acidosis
78
How to gauge severity of pancreatitis?
```
Glasgow criteria
PaO2<8kPa
Age>55
Neutrophilia (WBC>15x10)
Calcium<2
Renal (Urea>16)
Albumin<32
Sugar (Glucose>10)
```
3 or more positive in first 48h suggests severe pancreatitis -> transfer to HDU/ITU
