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Emergency Flashcards

1
Q

Anaphylaxis doses?

A

Adrenaline 0.5 mg 1:1000

Hydrocortisone 200mg IV
Chlorphenamine 10mg IV
Salbutamol 5mg neb

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2
Q

SIRS criteria?

A

HR >90
RR >20 or PaCO2 <4.3
Temp <36 or >38.3
WCC <4 or >12

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3
Q

Sepsis classification?

A

Sepsis = SIRS + known/suspected infection

Severe sepsis = sepsis + signs of hypoperfusion/organ failure

Septic shock = persistent hypotension despite adequate fluid resuscitation

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4
Q

Causes of cardiogenic shock?

A

Pump failure –> LV dysfunction, aortic dissection, dysrhythmia

Inadequate filling –> PE, pneumothorax, tamponade

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5
Q

What is Beck’s triad of cardiac tamponade?

A

Low BP
Raised JVP
Faint heart sounds

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6
Q

Causes of hypovolaemic shock?

A

Haemorrhage

Salt + water loss

3rd space loss

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7
Q

ABG result in vomiting and haemorrhage?

A

Vomiting = alkalosis

Haemorrhage = acidosis

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8
Q

Definitions of respiratory failure?

A

Type 1 = PaO2 <8 kPa, PaCO2 <6.5 kPa

Type 2 = PaO2 <8 kPa, PaCO2 >6.5 kPa

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9
Q

Causes of type 1 respiratory failure?

A

V/Q mismatch

Obstructed airways = asthma, COPD
Block in blood flow = PE
Pulmonary oedema, ARDS

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10
Q

Why is CO2 normal in type 1 RF?

A

Because areas that are perfused and ventilated can blow it off by increasing RR

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11
Q

Causes of T2RF?

A

Alveolar hypoventilation - O2 can’t get in and CO2 can’t get out

Reduced ventilatory effort, increased dead space, increased CO2 production

Severe asthma –> exhaustion
Acute epiglottitis
Respiratory muscle paralysis

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12
Q

Signs of hypoxia?

A

Restlessness, confusion –> coma

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13
Q

Signs of hypercapnia?

A 
Drowsiness
Flapping tremor
Warm peripheries
Headaches
Bounding pulses
Papilloedema
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14
Q

Oxygen therapy in T1RF?

A

Unrestricted (35%+)

Repeat gases after 20 mins to ensure correction of PaO2 and absence of rise of PaCO2

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15
Q

Oxygen therapy in T2RF?

A

Controlled (start at 24% and titrate)

Monitor PaCO2 closely by repeat gases - if it rises by more than 1 kPa, consider NIV

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16
Q

Contraindications to NIV?

A 
Inability to protect airway
Cardiac/respiratory arrest
Upper airway obstruction
Pneumothorax
Haemodynamic instability
Maxillofacial surgery
Basal skull fracture
Intractable vomiting
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17
Q

When is CPAP used?

A

Acute pulmonary oedema
Asthma
Obstructive sleep apnoea

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18
Q

When is BIPAP used?

A

COPD
Weaning
Asthma
Neuromuscular disease

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19
Q

PCM OD dose associated with hepatic necrosis?

A

250 mg/kg

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20
Q

Clinical features of PCM overdose after 24h?

A

RUQ pain +/- evidence of liver failure

PT, ALT, AST - raised

PT/INR is best marker of synthetic function

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21
Q

Clinical features of PCM overdose after 3-5 days?

A

Recovery may begin, or fulminant hepatic failure

Cogagulopathy
Hypoglycaemia
Encephalopathy
AKI (hepatorenal syndrome)

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22
Q

ABG in PCM overdose?

A

pH <7.3 despite fluid resuscitation predicts mortality

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23
Q

Management of PCM overdose? (levels)

A

<4 hrs - take levels and wait

4-8hrs - take levels and treat if over treatment line

8-15hrs - treat before levels come back, stop if under treatment line

> 15hrs/staggered - treat

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24
Q

Doses of parvolex/NAC?

A

150 mg/kg in 200ml over 1 hour

50 mg/kg in 500ml over 4 hours

100 mg/kg in 1000ml over 16 hours

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25
When to discontinue NAC?
If plasma concentration later reported to be below treatment line and patient is asymptomatic with normal LFTs, creatinine and PT.
26
Side effects of NAC?
20% have pseudoallergic (anaphylactoid) reaction stop infusion and give chlorphenamine
27
Pathophysiology of salicylate overdose?
Acid base disturbance Uncoupling of oxidative phosphorylation Disordered glucose metabolism
28
Signs/symptoms of salicylate overdose?
N+V, abdominal pain, tinnitus Deafness, hyperventilation, flushed skin, sweating, hyperthermia
29
Complications of salicylate overdose?
``` Aspiration Pulmonary oedema Cardiovascular instability Hypo/hyperglycaemia Hypokalaemia Hypoprothrombinaemia Thrombocytopenia DIC Renal failure ```
30
Salicylate levels?
Mild - <500mg/L Moderate - 500-750 mg/L Severe - >750 mg/L
31
ABG in salicylate overdose?
``` Metabolic acidosis (lactate) Respiratory alkalosis (hyperventilation) ```
32
ECG in salicylate overdose?
Widened QRS AV block Ventricular dystrhythmias
33
Bloods in salicylate overdose?
Glycaemic, Electrolytes, Bleeding, Renal ``` Hypo/hyerglycaeima Hypokalaemia Hypoprothrombinaemia Thromboyctopenia DIC Renal failure ```
34
Correcting acid-base, electrolyte, bleeding abnormalities in salicylate overdose?
Glucose infusion if hypoglycaemic Correct electrolytes Vitamin K if hypoprothrombinaemia Sodium bicarb for severe acidosis Dialysis in moderate-severe cases
35
Pathophysiolog and dose of TCA overdose?
TCA = sodium-channel blocking agent --> seizures and ventricular dysrhythmias 10mg/kg potentially life threatening, 30mg/kg --> severe toxicity Rapid deterioration within 1-2 hours of ingestion
36
CNS, CVS and anticholinergic features of TCA overdose?
Sedation/coma/convulsions/delirium - FIRST Sinus tachy + HTN --> hypotension Broad complex tachydysrhythmia --> broad complex bradycardia (pre-arrest) Agitation, restlessness, delirium, mydriasis, dry, warm flushed skin, urinary retention, tachycardia, ileus, myoclonic jerks
37
ABG/ECG findings in TCA overdose?
Metabolic acidosis Prolonged PR Wide QRS/QTc RAD of terminal QRS Ventricular dyshythmia
38
Management of TCA overdose?
Sodium bicarb IV - bolus every few minutes until BP improves and QRS narrows SEIZURES IV benzos, sodium bicarb, RSI/ventilation HYPOTENSION IV crystalloid bolus, vasopressors (ICU) CNS DEPRESSION Intubation - hyperventilate to pH 7.5-7.55
39
Effects of iron overdose? (Local and systemic)
LOCAL (GI) Corrosive injury to mucosa --> D+V, haematemesis, melena, fluid losses --> hypovolaemia SYSTEMIC Iron = cellular toxin, targets CVS and liver. Secondary CNS effects Metabolic acidosis due to hyperlactemeia and free proton production from hydration of free ferric ions Coagulopathy
40
Risk assessment of iron overdose?
<20 mg/kg = asymptomatic 20-60 mg/kg = GI symptoms only 60-120 mg/kg = potential for systemic toxicity >120 mg/kg = potentially lethal
41
Iron overdose presentation?
0-6 HOURS vomiting, diarrhoea, haemetemesis, melena, abdominal pain. Significant fluid losses --> hypovolemic shock 6-12 HOURS GI symptoms wane and the patient appears to be getting better. During this time iron shifts intracellularly from the circulation 12-48 HOURS Cellular toxicity becomes manifest as vasodilative shock and third-spacing, high anion gap metabolic acidosis (HAGMA) and hepatorenal failure 2-5 DAYS Acute hepatic failure, although mortality is rare 2-6 WEEKS Chronic sequelae occur in survivors –– cirrhosis and gastrointestinal scarring and strictures
42
Serum iron concentration levels in iron overdose?
Peak levels after 4-6 hours Levels fall after 6 hours due to intracellular shift 90 micromol/L = systemic toxicity
43
Blood gas in iron overdose?
HAGMA = high anion gap metabolic acidosis Useful marker of systemic toxicity
44
Managment of iron overdose?
ABCDE = priority --> restoration of circulating volume Decontamination - whole bowel irrigation or surgical/endoscopic removal if lethal ingestion
45
Antidote in iron overdose?
DESFERRIOXAMINE Chelates free ferric and ferrous ions --> water soluble complexes that can be renally excreted Cardiac monitoring mandatory when infusion running
46
ECG findings in hypothermia?
``` brady J wave 1st degree heart block Long QT Arrhythmias ```
47
Presentation of delirium?
New change in... ``` Cognition/concentration Physical function Social behaviour Appetite, sleep, mood Hallucinations Falls ```
48
Causes of delirium? DELIRIUM
Drugs (withdrawal/toxicity, anticholinergics)/Dehydration Electrolyte imbalance/Environmental factors Level of pain Infection/Inflammation (post surgery) Respiratory failure (hypoxia, hypercapnia) Impaction of faeces Urine retention Metabolic disorder (liver/renal failure, hypoglycaemia)/Myocardial infarction
49
General measures for delirium?
Calming environment Rationalise medications Hydrate (oral best) Monitor bowls/treat constipation Frequently reassure/reorientate Optimise sensory impairment (glasses, hearing aid) Look for and treat infection Don't argue/confront, move bays, restrain or do unnecessary procedures
50
Indications for sedation in delirium?
Carry out essential investigations Prevent danger to self or others Relieve patient distress
51
Sedation agents in delirium?
Haloperidol 0.5mg PO, 1-2 hourly, max 5mg daily Can add lorazepam - avoid due to hangover effect/dependence
52
When should benzos be first line for sedation?
Prolonged QRS, DLB, Parkinson's Seizures, rec drug intoxication/withdrawal, alcohol withdrawal
53
What is spinal shock?
Loss of sympathetic vascular tone --> dilation of arterioles/venous pooling --> low BP and low CO Loss of sympathetic drive to heart (T1-T4)
54
Causes of spinal shock?
Traumatic - transection of spinal cord at any level Iatrogenic - final spinal anaesthesia
55
Symptoms and signs of spinal shock?
Motor/sensory dysfunction below level of lesion (UMN lesion) + bladder/bowl dysfunction Low BP, warm peripheries, may not be able to mount tachycardia if lesion above T1-T4 Focal neurology +/- up going plantars, loss of anal tone
56
What are complications of shock?
PROLONGED HYPOTENSION --> HYPOPERFUSION Brain - low CNS/coma Kidneys - AKI/ATN Liver - ischaemic hepatitis Heart - myocardial ischaemia/MI
57
Definition of AKI?
Rise in serum creatinine >26µmol/L within 48hrs or rise in serum creatinine 1.5 x baseline value within 1wk or urine output <0.5ml/kg/hr for 6hrs.
58
AKI staging systems?
RIFLE AKIN KDIGO
59
AKI Management? ABCCDD
``` Assess (fluid balance) Bloods (K+, urea, cr) Catheter Cannula (IV fluids) Drugs (check chart) Dialysis? ```
60
Drugs to stop in AKI?
ACEi Metformin Diuretics NSAIDs
61
Indications for RRT in AKI?
Uraemic complications (enceph, pericarditis) Refractory Pulmonary oedema Refractory metabolic acidosis Refractory hyperkalaemia
62
HAGMA and NAGMA?
HAGMA = accumulation of organic acids/impaired H+ excretion (LKTR - lactate, toxins, ketones, renal) NAGMA = loss of HCO3- from ECF (hyperchloraemia, acetazolamide/addison's, GI losses)

- FINALS (24 decks)

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