Emergency Flashcards
1
Q
Reversible causes sudden cardiac arrest
A
H’s
- hypoxaemia
- hypovolaemia
- hypo/hyperkaelaemia (metabolic)
- hypo/hyperthermia
T’s
- tamponade
- tension pneumothorax
- thromboembolism
- toxins
2
Q
causes of shock
A
Distributive (ABSENT)
- anaphylaxis
- burns
- sepsis/SIRS
- endocrine
- > addisons crisis
- > myxoedema
- neurogenic
- toxins/drugs
Cardiogenic
- cardiomyopathic
- arrhythmias
- valves
Hypovolaemia
- haemorrhagic
- nonhaemorrhagic
Obstructive
- pulmonary vasculature
- > PE
- > PTH
- mechanical
- > tamponade
- > restrictive pericarditis
- > tension pneumothorax
3
Q
Inotropes/pressors MOA, effects, uses
A
Adrenaline
- > MOA = beta>alpha
- > effect = B1 increase inotropy/dromotropy/chronotropy, B2 bronchodilation and vasodilation
- > use = cardiogenic shock, anaphylaxis
Noradrenaline
- > MOA = alpha>beta (cannot affect B2)
- > effect = increase TPR
- > use = distributive shock
Dopamine
- > MOA = d>B1>alpha
- > effect = dopaminergic increases renal/splanchnic vasodilation, B1 at high doses increase CO, alpha at very high doses increases TPR
Dobutamine
- > MOA = B1>B2
- > effect = B1 increases inotropy/dromotropy/chronotropy, B2 bronchodilation and vasodilation
- > use = cardiogenic shock
Phenylephedrine/metaraminol
- > MOA = alpha
- > effect = increase TPR
- > use = bridging tx for shock
Isoprenaline
- > MOA = B1>B2
- > effect = B1 increases inotropy/dromotropy/chronotropy, B2 bronchodilation and vasodilation
- > use = bradyarrhythmias causing shock
4
Q
ABG normal values
A
pH = 7.35-7.45 PaO2 = 80-100 PaCO2 = 35-45 HCO3 = 22-26 Base excess = -2 - +2 Anion gap = 8-16
Respiratory compensation =
- 1.5xHCO3 +8 +-2
- HCO3 + 15
Delta anion gap (AG-12/ 24-HCO3) :
in high anion gap metabolic acidos, should be >1 because some buffering takes place intracellularly, meaning that bicarb is not reduced proportionately.
-<0.4 = normal anion gap
-0.4-0.8 = combined normal and high anion gap
->1 = high anion gap
->2= previous metabolic alkalosis or compensation for respiratory acidosis (eg. COPD)
5
Q
acute asthma management pathway
A
- INITIAL ASSESSMENT
- IMMEDIATE INTERVENTION:
Life threatening
- continuous nebulised salbutamol
- ipratropium via intermittent nebuliser
- O2
Severe
- intermittent nebulised salbutamol or pMDI (with spacer)
- consider ipratropium via pMDI or intermittent neb
- 02 if below 95%
Mild
- salbutamol pMDI with spacer
- ipratropium not usually needed
- O2 as necessary
- SECONDARY SEVERITY SURVEY
- STABILISATION
Life threatening
- continuous salbutamol neb until dyspnoea improves
- ipratropium via intermittent neb every 20 mins
Severe
- repeat salbutamol pMDI or int/neb every 20 mins (or sooner)
- ipratropium pMDI or int/neb every 20 mins
- oral prednisone (IV methylpred) within 1st hour
Mild
- repeat salbutamol if wheeze returns
- consider ipratropium if not responding
- oral prednisone
- FORMAL REASSESSMENT AT 1 HR
Life threatening
- continuous neb until dyspnoea improves
- ipratropium every 4-6 hours
- consider
- > IV magnesium sulfate (muscle/resp weakness)
- > IV aminophylline (vom, sudden death)
- > IV salbutamol
- > IM adrenaline
- > positive pressure ventilation
Severe
- salbutamol every 20 mins (or sooner)
- ipratropium every 4-6
- consider IV magnesium sulfate
Mild
- attempt to increase salbuamtol dose interval in stepwise fashion
- ipratropium every 4-6 if needed
- POST ACUTE CARE/ARRANGE FOLLOW UP
6
Q
initial assessment asthma
A
risk stratification to determine initial management
Life threatening (COARSE)
- cyanotic
- O2<90%
- Altered level of consciousness
- Respiratory effort poor
- Soft or absent breath sounds
- Exhaustion
Severe (SOB)
- Sentences (can’t speak in full)
- O2 90-94
- Breathing (increased work)
Mild
- can walk and speak in full sentences
- O2 >94
7
Q
secondary assessment asthma
A
Life threatening = Any GASPing CORPSE
- altered level of consciousness
- gas (PaO2 <60, PaCO2 >50)
- auscultation (silent chest/reduced entry)
- speech (no full sentences)
- pulse (arrhythmia/bradycardia)
- cyanosis
- O2 <90%
- resp rate (bradypnea)
- posture (collapsed/exhausted)
- spiro (FEV1)
- effortful breathing
8
Q
acute asthma pharm treatment
A
Salbutamol
- dose
- > adult = 4-12 puffs/2x5mg nebuliser
- > paediatric = 2-6 puffs/2x2.5mg nebuliser
- frequency
- > every 20 mins or sooner
- > can be continuous neb
Ipratropium
- dose
- > adult = 8 puffs/500 micrograms nebuliser
- > paediatric = 4 puffs/250 micrograms nebuliser
- frequency
- > every 20 mins for 1st hour
- > every 4-6hrs thereafter
Predisone (within 1st hour)
- dose
- > adults = 50mg max
- > paediatric = 1mg/kg
- > children 1-5 = avoid unless severe
- frequency
- > adults = every day for 5-10 days
- > paediatric = every day for 3 days
*paediatric = 6yrs and over
9
Q
ALS algorithm
A
Unresponsive
- assess breathing and pulse simultaneously
- > pulse w/o breathing = rescue breathes, monitor pulse
- > no pulse and no breathing = CAB
Chain of survival
- CAB
- > begin compressions first
- > attempt airway manoeuvres
- > support breathing
- compression:ventilation
- > all adults 30:1
- > one rescuer in prepubescent = 30:1
- > two rescuers in prepubescent = 15:1
- check rhythm as soon as possible
Shockable rhythm (VF/pulseless VT)
- survival improved by
- > excellent, continuous CPR
- > early defib
- defibrillate as early as possible
- > only check rhythm after another 2 mins CPR
- adrenaline
- > after at least 1 defib and 2 mins of CPR
- > earlier administration has poorer outcomes
- > repeat every 3-5 mins/every 2nd loop
- amiodarone/lidocaine
- > if adrenaline is unsuccessful
- magnesium sulfate
- > if torsades
Non-shockable (Asystole/PEA)
- survival improved by
- > identification/correction of cause (4 H’s/T’s)
- > excellent, continuous CPR (ineffective in tamponade or tension pneumothorax)
- > adrenaline as early as possible (repeat every 3-5mins/every 2nd loop)
Safe defibrillating
- Continue compressions
- Oxygen away
- All others away
- Charging defib
- Hands off chest
- Evaluating rhythm
- Defib or disarm
10
Q
ALS treatment doses
A
Adrenaline
- adults
- > 1mg IV/IO every 3-5 mins
- paediatrics
- > 0.01mg/kg IV/IO every 3-5 mins
Amiodarone
- adults
- > 300mg then 150mg IV/IO
- paediatric
- > 5mg/kg may repeat 2 more times
Magnesium sulfate
- adults
- > 2g IV/IO bolus
- paediatrics
- > 25-50mg/kg in 5% dextrose solution infused over 2mins
Fluids
- hypovolaemia
- > adults = 20mL/kg (250-500mL) up to 2L
- > child = 10mL/kg up to 40mL/kg
- hypoglycaemia (<3mmol)
- > child = 10% glucose 2mL/kg
Defib
- adults
- > 200J
- paediatrics
- > first shock = 2J/kg
- > subsequent shocks = 4J/kg
11
Q
Initial assessment and management undifferentiated shock
A
When to suspect (Red flags)
- hypotension
- > SBP <90, MAP <65, orthostatic (SBP drop 20/DBP drop 10)
- > not always present (compensated shock)
- tachycardia
- oliguria
- abnormal mental status
- cool, clammy, cyanosed skin
- cap refill >3 seconds
- metabolic acidosis
- lactic acidosis
- tachypnea
Initial response
- secure airway
- support breathing
- gain IV/IO access (x2)
- > fluid bolus (adults=500mL, paeds=10mL/kg)
- > draw blood for lab
- risk stratify
- > brief hx and exam
Risk stratified response
- life threatening condition suspected
- > begin empiric life saving therapies
- > do not delay for results lab studies
- patient stable but undifferentiated
- > focused hx and exam
- > ECG
- > CXR
- > ultrasound (RUSH) or echo
- > lab studies
Lab studies for undifferentiated
- ABG
- CBC
- EUC
- LFTs
- Coags and D dimer
- Troponin and BNP
- Lactate
Empiric treatment
- IV fluid boluses
- > adults = 20mL/kg up to 1L (ICU)
- > paediatrics = 10mL/kg up to 40mL/kg (ICU)
- > smaller if cardiogenic suspected
- Inotropes/pressors
- > only use when fluid resus has failed (can worsen hypovolaemic shock)
- > pressor choice doesn’t matter
- > norad or metaraminol
12
Q
Assessment status epilepticus
A
Primary surgery
- Airway
- > patent
- > protected
- Breathing
- > pulse oximetry
- > ABG/VBG
- > provide oxygen
- Circulation
- > telemetry
- > BP
- > gain IV access
- Disability
- > rapid neurological exam (classify seizure)
- > time elapsed (>5mins/repeated w/o full recovery)
- Exposure
- > evidence of trauma
- Glucose
- > BGL
Secondary survey (occurs during concurrent with treatment)
- goal is to identify aetiology (SHITTED)
- hx
- > medications already given??
- > description of event
- > previous seizures
- > seizure medication/adherence
- > other medications/substances
- > predisposing medical condition
- > family hx
- investigations
- > BGL
- > electrolytes/CMP
- > FBC
- > toxicology screen
- > anti-seizure drug levels
- post acute
- > EEG
- > CT
13
Q
Treatment algorithms status epilepticus
A
Adults 1. IV access -yes = 0.1mg/kg midazolam IV -no >40kg= 10mg midazolam IM <40kg= 5mg midazolam IM or 5-10mg midazolam buccaly/nasal 2. still seizing -sodium valproate 40mg/kg IV/IO over 5 mins -contact senior/anaesthetist/ICU 3. still seizing -transfer to ICU -intubation -EEG
Paediatric 1. IV access -yes = 0.15mg/kg midazolam IV -no 0.15mg/kg midazolam IM or 0.3mg/kg buccal/nasal midazolam 2. still seizing after 5 more mins -repeat midazolam dose 3. still seizing after 5 more mins -contact senior/anaesthetist/ICU -levetiracetam 40mg/kg IV over 5 mins or -phenytoin 20mg/kg IV (monitor ECG/BP) 4. still seizing 5 mins after infusion finished -repeat with alternate anti-seizure med 5. still seizing -intubation -transfer to ICU -EEG
14
Q
Neonatal resus
A
Routine management if born
- > at term
- > breathing or crying
- > with good muscle tone
If not, initial steps
- protect airway
- > neutral or slightly extended
- > suction mouth and nose
- stimulate
- > often drying/suctioning is enough
- > slap or flick feet
- maintain temperature
- > dry and swaddle in warmed blankets
- > radiant heater
- > polyurethane bags for preterm
HR <100/gasping or apnea
- PPV
- > CPAP at 5-8cmH20
- > initial breaths may require approx 30cmH20
- > rate is 40-60
- SPO2 monitoring
- > pre ductal (right arm)
HR<100
- Review airway
- > patent?
- > leaks?
- Escalate PPV
- > increase pressure
- > increase O2
- Consider intubation/LMA
HR<60
- begin CPR
- > 3 compressions to 1 breath
- > 100% O2
- intubation/LMA
- obtain venous access
HR <60
-IV adrenaline
Still <60
-volume resuss
Lower limit SPO2
- add 5% each minute up to 5
- 1 min = 60
- 5 min = 80
- 10 min = 85%
15
Q
Sepsis mangement
A
Initial response
- severe or neonate
- > call MERT
- > A’s and B’s
- > attach cardiorespiratory monitoring
- possible sepsis
- > clinical review
- > hx and exam
- > consult senior
A -assess ->patency ->air entry -maintain patency B -assess ->resp rate ->sats ->examine chest -maintain SPO2 >95% C -gain IV access -antibiotics within hour ->empiric or targeted if possible -obtain bloods before antibiotics if possible -fluids ->adults = 250-500mL ->kids = 10-20mL/kg -reassess ->HR ->pulses ->cap refill -repeat if no response ->adult = up to 2L ->kid = 40mL/kg -max fluid dose ->transfer to ICU ->consider pressor (adrenaline) support D -AVPU E -locate source of infection -treat if possible F -insert catheter -monitor urine output G -monitor glucose
Monitor for deterioration
- SBP <100
- tachypnea
- altered level of consciousness
- urine output <0.5mL/kg/hr
- lactate >2
