Emergencies Flashcards by John Darlington

What is the definition of a major haemorrhage?

50% blood loss within 3 hours

> 150mls per minute

Full circulatory volume lost in 24 hours

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What should the management be during a major haemorrhage?

Assess if this is a major haemorrhage
- put out major haemorrhage protocol
Restore circulating volume
- IV access
- Fluids - warm if possible
Stop bleeding
Send samples
- emergency cross match
- FBC
- Clotting studies
- ROTEM
- U&;Es
- ABGs
Give blood products

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What is made available following a major haemorrhage protocol?

6 units of RBCs

- O negative will be provided until a 2nd cross matched sample is received

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If there is trauma, obstetric or risk of DIC what should also be requested upon the major haemorrhage protocol?

FFP

Platelets may also need to be requested

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How long does a group specific, cross match take?

- where can O neg blood be found?

Group and save: 25 mins
Cross match: 60 mins

O Neg can be found in:

Blood bank
Satellite fridges

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What haemoglobin should be aimed for in Major haemorrhage?

Hb> 80g/L

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How much time for products do you need to leave during a major haemorrhage?

20mins thawing time for FFP
25 mins for group specific RBCs
60 mins for crossmatch
Transport time

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What drug can be given during a major haemorrhage to help control bleeding?

Tranexamic acid

IV infusion - slowly initially.

then transfusion over 24 hours

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What is the ideal blood product use for DIC?

Cryoprecipitate - contains fibrinogen

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What are the different types of shock?

Cardiogenic shock 
Hypovolemic shock 
Septic shock 
Neurogenic shock 
Anaphylactic
Obstructive

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What are the classifications of shock?

Type I:
<750ml 
15% 
<100bpm 
BP normal 
slight anxious

Type II: 
750-1500ml 
15-30% 
100-120bpm 
BP normal 
Mildly anxious

Type III: 
1500-2000
30-40% 
120-140
BP lowered 
Anxious confused

Type IV: 
>2000
>140 
BP lowered 
RR>35 
Confused lethargic

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How do you manage a haemorrhage causing shock?

Assess if this is a major haemorrhage
- put out major haemorrhage protocol
Restore circulating volume
- IV access
- Fluids - warm if possible
Stop bleeding
- active haemorrhage control
- direct compression
- pelvic binder
Send samples
- emergency cross match**
- FBC
- Clotting studies
- ROTEM (assesses haemostasis in patients)
- U&Es
- ABGs
Give blood products
- give O neg blood initially then move to group specific when able

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How much and how quickly should a fluid bolus be given in an emergency situation?

500ml saline over 15 mins

250ml in heart failure over 15mins

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List some causes of cardiogenic shock:

M.I

Mitral regurgitation

Subarachnoid inducing catecholamine release causing cardiogenic stunning

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Name some causes of obstructive shock

P.E

Cardiac tamponade

Tension Pneumothorax

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List some causes of neurogenic shock, and explain the underlying pathological mechanisms:

High cervical cord trauma

Major brainstem or spinal injury

Guillain Barre syndrome

Loss of vasomotor control induces mass peripheral dilation.
Also damage to sympathetic nerves system can induce severe bradycardia

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What are some clinical features of septic shock?

Warm peripheries
Bounding pulse
Large pulse pressure (120/ 50)

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What are some clinical features of Anaphylactic shock?

Wheeze 
Stridor 
Angioedema - especially facial and laryngeal 
Itch 
Urticaria 
Bounding pulse
warm peripheries 
Large pulse pressure

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What are some mimics of anaphylaxis?

Carcinoid syndrome
Pheochromocytoma
Angioedema
Mastocytosis

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What should be measured to confirm anaphylactic reaction and when?

Tryptase

1 - 6 hours following onset

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What is the management of hemorrhagic shock following from initial ABC (i.e. fluids and oxygen is already on)?

Stop bleeding

pelvic binders
Leg splints

Contact Haematology

Give blood and FFP (1:1 ratio)

O Neg
specific blood

Platelets (keep >100) - platelets

Fibrinogen (>1) - cryoprecipitate

Tranexamic acid

Following ABCDE if someone is in cardiogenic shock, how are you going to treat them?

Diamorphine
- reduce pain and anxiety

Correct arrhythmias and U&E abnormalities

Optimise filling pressures:
Underfilled:
- Plasma expanders

Underfilled:

Inotropic support - dobutamine
Nitrates

Name some complications of shock:

Hypoperfusion to vital organs which may cause irreversible damage.

Brain - coma
Kidneys
Ischemic Hepatitis
Myocardial ischemia

What clinical signs may you see with cardiogenic shock?

Low BP/ High diastolic 
Weak pulse 
Raised JVP 
Low GCS 
Oliguria
Cool peripheries

What is the management of anaphylaxis ?

Secure Airway - intubation may be needed Remove cause ``` IM adrenaline - 0.5mg - 1:1000ml - repeat every 5 mins if needed + IV chlorpheniramine + IV steroids ``` IV saline ``` still hypotensive: - ICU - IV Adrenaline + - IV aminophylline ```

What are the generalised stages of shock?

Initial Compensating Progressive/ Decompensating Refractory/ irreversible

List some signs of hypovolemic shock?

altered mental status Cool clammy skin Mottled skin weak, thready pulse tachycardia thirsty/ dry/ low JVP Pupil dilation

In E of the ABCDE, what are you looking for in shock?

Signs of blood loss: - injury sites - penetrations - bruising across the flanks / abdomen - High riding prostate Signs of infection: - Rash

When should someone be admitted following a head injury?

``` <15 GCS Focal neurological symptoms Vomiting Amnesia Alcohol ingestion Coagulopathy Suspected cranial fracture ```

What are the signs of a basal skull fracture?

``` Panda eyes Hemotympanum Otorrhoea - CSF from ears Rhinorrhoea - CSF from nose Battle's sign - bruising on mastoid ```

What is a LBBB in keeping with in the setting of an M.I?

Large anterior M.I

What are the rhythms that cause arrest?

PULSELESS VT VF Pulseless electrical activity Asystole

How are you going to monitor a patient with shock?

``` Mental status Vitals - HR, BP, RR, Stats Cap Refill Urine output ECG Skin colour and temperature CVP - if in place ```

What immediate investigations do you want when someone is in shock?

``` Bloods: - FBC - U&Es - ABG - Coagulation studies - LFTs - Glucose +/- CRP +/- Blood cultures ``` Orifices: - Urine output +/- urinalysis X-rays: - Ultrasound of heart (if cardiosuspected) +/- CXR ECG Special tests: - tryptase - D-dimer

How are you going to monitor someone following shock?

``` Mental status Urine output Vitals - HR, STATS, BP Skin Colour Cap Refill CVP ECG ```

What makes up the trauma triad?

Hypothermia Coagulopathy Acidosis

If you are at bedside with a patient who has collapsed, what bedside investigation should you always do?

BM's

In addition to atropine, what additionally inputs can be done into severe bradycardia?

external pacing Adrenaline Temporary pacing wire

What important medication must be given when there is stridor and oxygen sats falling?

Nebulised Epinephrine + Contact anesthetists

List actions you would take during a AAA?

Major haemorrhage protocol Give O negative blood Senior help/ Vascular surgery

What bedside tests can be done to confirm an AAA?

Ultrasound FAST scan **CT confirms whether it has rupture

Give some differentials for stridor:

Inspiratory: - Epiglottitis - Glandular fever - Laryngitis - Croup Expiratory: - Tracheal compression

If a person goes into cardiac arrest following a P.E and is treated with thrombolysis - how long should CRP be continued for?

90 minutes. thrombolytic drug needs time to work

If someone presents with a collapse - what is a very important aspect of the systemic enquiry history you want to ask about?

Melena or G.I bleed. they be volume depleted leading to low BP

What signs may you see during a P.E?

Tachypnea Pleuritic chest pain Hemoptysis Syncope Right ventricular heave Loud 2nd heart sound Splitting of heart sound Increased JVP

Management of a P.E?

``` Oxygen Fluids LMWH or Thrombolysis ```

Immediate management of NSTEMI:

``` Beta blockers Aspirin Ticagrelor Morphine Anticoagulation - LMWH Nitrates +/- Oxygen (<94%) ``` GRACE Score >10% = PCI or CABG Follow up they will need: - Echocardiogram - Stress ECG - Angiogram

During an upper G.I bleed, when should O- blood be given?

If they patient is severely unstable or Hb <7

When in an upper G.I bleed is terlipressin and antibiotics given?

If high suspicion of varices i.e. liver failure. given before scope

What are the initial symptoms of anaphylaxis?

Tingling Warmth Itchiness Mild oedema followed by: - urticaria - generalised flush - wheeze - bronchospasm - hypotension

What biochemical directly correlates with the severity of an anaphylactic reaction?

Serum Platelet Activating Factor