Emergency management Flashcards
(18 cards)
What is the management of SAH?
- urgent CT
- consider LP (>12h after headache onset)
- re-examine CNS often (BP, pupils, CNS)
- maintain perfusion by keeping well hydrated
- nimodipine -> reduce vasospasm
- surgery -> end-vascular coiling or clipping
Refer all proven SAH -> neurosurgery immediately
What is the emergency management of asthma?
- High flow O2
- Salbutamol 5mg nebs
- Ipratropium 0.5mg/6 h
- hydrocortisone 100mg IV or prednisolone 40-60 mg PO
- MgSO4 1.2-2g IV over 20 mins
- Refer ICU for consideration of ventilatory support /aminophylline/ IV salbutamol
Re-assess every 15mins
Later: Check inhaler technique, asthma plan, pred PO OD for 5-7 days, refer to GP for appointment within 2d
What is the emergency management of COPD exacerbation?
Ensure oxygenation then tx as greatest danger is hypoxia
- 24-28% O2 in COPD
- Salbutamol 5mg/4h and ipratropium 500mcg/6h as news
- Steroids: hydrocortisons 200 mg IV and prednisolone 30 mg PO (continue for 7-14d)
- Abx if evidence of infection: amoxicillin or clarithryomycin or doxycycline
- chest physio for sputum expectoration
If no response -> consider IV aminophylline
If still no response -> 1. NIPPV if RR>30/pH <7.35 or pCO2 rising
2. Considering respiratory stimulant e.g. doxapram 1.5-4mg/min in patient unsuitable for NIPCC
3. INtub and ventilation if pH <7.26 AND CO2 rising
What is the emergency management of anaphylaxis?
- secure airaway
- 100% O2
- remove cause
- raise feet
- adrenaline IM 0.5mg (0.5ml of 1:1000) and repeat every 5mins if needed (guided by BP/pulse)
- Chlorphenamine 10mg IV
- Hydrocortisone 200 mg IV - 0.9% 500 ml saline over 15min (titrate against BP)
- Consider admission to ICU
What is the emergency management of acute HF/pulmonary oedema?
- Sit patient upright, high flow O2, IV access and ECG
- Diamorphine 1.25mg-5mg IV slowly (caution in liver failure and COPD)
- Furosemide 40-80mg IV slowly (larger needed in renal failure)
- GTN spray 2 puffs SL or 2 x 0.3mg tablets SL
- If SBP >100 start nitrate infusion
If patient worsening
- further furosemide
- consider CPAP
If SBP <100 tx as cariogenic shock and refer to ICU
What is the emergency management of pneumonia?
- Treat hypoxia with O2
- Treat any hypotension or shock from infection
- Assess for dehydration -> consider fluids
Use CURB for tx
= 2 –> amoxicillin + clarithromycin
= 3 –> co-amoxiclav/cefuroxime + clarithromycin
Metronidazole + cef if aspiration. Gentamicin also if HAI
Analgesia for pleuritic CP
hypoxic despiteO2 -> cpap
hypercapnia -> NIV or invasive intubation
Discuss with ICU early if patient has rising cO2/no improvement.
What is the emergency management of bronchiectasis?
- airway clearance techniques + mucolytics (chest physio/flutter valve)
- antibiotics
- bronchodilators- if also asthma/COPD/CF/ABPA
- corticosteroids
- itraconazole for ABPA
- surgery may be indicated in localised disease or to control severe haemoptysis
What is the emergency management of PE?
If clinical suspicion start treatment before Ix. Risk stratify with Wells score.
Large PE:
- O2 if hypoxic (10-15L/min)
- Morphine 5-10 mg IV + anti-emetic
- LMWH/fondaparinux
- If low BP give IV fluid bolus. Get ICU input.
Haemodynamically unstable?
Yes = consider thrombolysis with altepase 10mg bolus then IVI 90mg/2h
No = consider vasopressors e.g. dobutamine
Then initiate LT warfarin (cont. LMWH until INR>2)/DOAC
Management of simple primary pneumothorax?
SOB +/or rim of air >2 cm on CXR?
Yes = aspiration (16-18G cannula), if not successful = chest drain
No = consider d/c + OP r/v in 2-4 weeks
Management of simple secondary pneumothorax?
(underlying lung disease/smoker >50yr)
SOB or rim of air >2cm on CXR?
Yes = chest drain
No (size 1-2) = aspiration, chest drain if aspiration unsuccessful
No = admit for 24 h ons and O2
If pneumothorax sue to trauma/mechanical ventilation/haem unstable -> chest drain
Management of tension pneumothorax?
Remove air by:
1. inserting a large bore (14-16G) needle with a syring, partially filled with 0.9% saline - 2nd ICS MC line
or
2. Large bore venflon in same location then chest drain
Management of pleural effusion?
If effusion is symptomatic = drainage and tx of underling cause.
Pleural aspiration - send off fluid for analysis:
- clinical chemistry [pH, LDH, amylase]
- bacteriology [M&C, TB stain]
- cytology
- immunology if indic [Rh. factor etc]
Transudates (<25g/L)
-increase venous P (HF) or hypoproteinaemia (cirrhosis, nephrotic syndrome), hypothyroid, Meig’s syndrome
Exudates (>35g/L)
- increase leakiness of pleural capillaries secondary to infection, inflammation or malignancy
- Blood [haemothorax]
- Pus [empyema]
- Chyle = lymph with fat [chylothorax]
What is the emergency management of metabolic acidosis e.g. DKA?
A-E approach, 2 large bore cannula
- 1l 0.9% saline over 1h
- give further 500ml bolus over 15 min if BP still low - Add 50u human soluble insulin to 50ml 0.8% saline. Infuse continuously at 0.1unit/kg/hour.
- Aim for fall in blood ketones of 0.5mmol/L - check BM and ketone hourly
- Add K+ after first bag of saline if it falls
- consider catheter
- Consider NG if vomiting or drowsy
- Start LMWH
- Avoid hypoglycaemia - when glucose >14mmol/L start 10% glucose alongside saline
Contine fixed rate insulin until ketones <0.6mmol/L, venous pH >7.3, venous bicarb>15mmol/L
Treat infection with abx
Emergency management of aortic dissection?
Type A = urgent cardiothoracic advice
Type B = definitive tx is less clear - can be managed medically
Take to ITY
Hypotensive: keep systolic at around 100mmHg (labetalol)
Immediate management of coma?
A-E
- Intubation if GCS <8
- circulation support (fluids, o2)
- protect C spine
- tx seizures
Check blood glucose - give 200mL 10% glucose
IV thiamine if suggestion of wernicke’s
IV naloxone or antidote
Emergency manage of of hypovolaemic shock?
ID and tx underlying cause
- raise legs
- give fluid bolus 10-15ml/kg crystalloid via large peripheral line
- If shock improves repeat and titrate to HR
- Aim: HR<100, SBP>90, UO>0.5ml/kg/hour
Emergency management of cardiogenic shock?
Manage in ITU - Ix and Tx may need to be done at the same time
- Consider CVP line and arterial line
- O2
- Diamorphine 1.25-5mgIV (for pain and anxiety)
- Correct: arrhythmias, U&E, acid base disturbance
- Optimise filling pressure -> aim MAP 70mmg
- Underfilled: plasma expander
- overfilled: inotropic support e.g. dobutamine 2.5mcg/kg/minIVI
- Look for and treat any reversible causes
What are some causes of cardiogenic shock?
MI, arrhythmia, PE, tension pneumothorax, cardiac tamponade, myocarditis, AD, valve destruction
