Emergency Medicine Flashcards
Reversible causes of cardiac arrest
Hypoxia
Hypovolaemia
Hyperkalaemia/hypokalaemia, hypoglycaemia, hypocalcaemia
Hypothermia
Thrombosis
Tension pneumothorax
Tamponade
Toxins
Treatment of hypoxia in cardiac arrest
patient adequately ventilated with maximal inspired O2 (15L/min)
Treatment of hypovolaemia in cardiac arrest
o look for haemorrhage and restore volume with fluids and blood products
o Activate major haemorrhage protocol where required
Treatment of thrombosis in cardiac arrest
o Urgent angiography ± PCI
o Thrombolyse if PCI not available or PE
Treatment of tamponade in cardiac arrest
pericardiocentesis
Initial assessment in cardiac arrest
- Assess for response and signs of life
- Call for help and make bed flat
- Open airway using head-tilt chin-lift
- ABCDE
Chest compressions in cardiac arrest
- Ratio chest compressions to ventilation 30:2
Ventilation in cardiac arrest
- Bag-valve mask
- Airway adjuncts used where required
- Continuous with LMA, I-gel or endotracheal intubation
- 10 breaths per minute
Defibrillation in cardiac arrest
- Shockable rhythms: Ventricular fibrillation, pulseless ventricular tachycardia
- Single shock followed by 2 mins of CPR
Adrenaline in cardiac arrest
- Adrenaline 1mg ASAP for non-shockable rhythms (PEA, asystole)
- Shockable rhythms give adrenaline once chest compressions have restarted after 3rd shock
- Repeat adrenaline every 3-5 mins
Amiodarone in cardiac arrest
- 300mg given to patients after 3 shocks
- Further 150mg given after 5 shocks
- Lidocaine used as alternative if amiodarone
Peri-arrest bradycardia adverse signs
- Shock hypotension, pallor, sweating, cold, clammy extremities, confusion, impaired consciousness
- Syncope
- MI
- HF
Management of peri-arrest bradycardia
- 1st line = 500mcg IV atropine
- Continue atropine up to max 3mg
- Transcutaneous pacing
- Isopredaline/adrenaline infusion titrated to response
Risk factors for asystole
- Complete heart block with broad complex QRS
- Recent asystole
- Mobitz type II AV block
- Ventricular pause >3s
Management of peri-arrest tachycardia
- If adverse signs present then synchronised DC shocks (up to 3)
- Broad complex (regular)
o Assume VT (unless previously confirmed SVT with BBB)
o Loading dose of amiodarone followed by 24 hr infusion
o Lidocaine use with cuation in severe LV impairment
o Procainamide
o Electrophysiological study
o Implantable cardioverter-defibrillator - Broad complex (irregular)
o Seek expert help
o AF with BBB
o AF with ventricular pre-excitation
o Torsade de pointes - Narrow complex (regular)
o Vagal manoeuvres
o IV adenosine
o Atrial flutter BB - Narrow complex (irregular)
o AF
o Onset <48 hr consider electrical or chemical cardioversion
o BB
Causes of hypothermia
- Primary hypothermia environmental exposure with no underlying medical condition
- Secondary hypothermia
o Decreased heat production hypothyroidism, hypoadrenalism, malnutrition
o Increased heat loss vasodilation, burns, erythroderma
o Impaired thermoregulation CNS trauma, stroke, sepsis, pancreatitis
Presentation of hypothermia
- Mild (32-35 degrees)
o Shivering
o Lethargy
o Confusion
o Tachycardia
o Vasoconstriction
o Loss of motor coordination - Moderate (28-32)
o Dysrhythmias
o Bradycardia
o Hypotension
o J waves (frosty Jacks)
o Reduced reflexes
o Reduced GCS
o Dilated pupils - Severe (<28)
o Agitation/delirium
o Arrhythmias
o Apnoea
o Non-reactive pupils
o Coagulopathy
o Oliguria
o Pulmonary oedema
Investigations of hypothermia
- Rectal/ear temp
- ECG J waves or other arrhythmias
- Bloods U&Es, plasma glucose, amylase, TFTs, FBC, coagulation studies, blood cultures
- ABG
- CXR
Management of hypothermia
- ABCDE
- Aim for temp rise of 0.5 per hour using warm IV fluids, warm O2 and blankets
- IV drugs avoided use to risk of drastic response
- IF cardiac arrest, warming as quickly as possible
o Warmed fluids infused into all orifices with access (IV, catheter, NG) - Patients not dead until warm and dead
- If <30 and in arrest no more than 3 shocks administered until rewarmed
- Cardiac monitoring
- Catheterise
- Abx for prevention of pneumonia in patients <65 with temp <32
Management of haemorrhage
- Major haemorrhage protocol
- Call for help
- Try to limit bleeding
- Call blood bank
- Bloods and 2x Group and Save
- Two large bore cannulas
- IV fluid bolus (no more than 1L)
- 2 units of O- blood
- Crossmatched blood
- Additional blood products – platelets, FFP, cryoprecipitate
- Definitive management
Causes of burns
- Thermal Solids, liquids, gases, smoke, fire
- Chemical Acid, alkali, toxins
- Electrical
Severity classification of burns
- Superficial epidermal (1st degree)
o Red and painful, dry, no blisters
o Blanching on pressure
o Will heal without scarring
o Don’t calculate total body surface area
o E.g. sunburn - Partial thickness – superficial dermal (2nd degree)
o Pale pink, painful, blistered, slow cap refill
o Blanching - Partial thickness – deep dermal (2nd degree)
o Typically white but may have patches of non-blanching erythema
o Reduced sensation
o Painful to deep pressure - Full thickness (3rd degree)
o White/brown/ black in colour, leathery appearance
o No blisters, non-blanching
o Loss of sensation no pain
Assessing extent of burn
- Total Body Surface Area
o Wallace’s rule of 9s
o Lund and Browder chart (Paeds)
o Palm rule palm is 1% TBSA
Immediate management of burns
- Stop the burn
o Remove burning/source
o Electrical burns switch of power supply, cardiac monitoring
o Chemical burns Brush any powder off then irrigate with water (do not try to neutralise) - ABCDE
o Airway issues get worse quickly with oedema
o Oxygen and measure CO
o 2x wide bore cannulae fluid resus
o Careful exposure
o Monitor urine output
General burns management
o Within 20 mins, irrigate burn with cool water for 10-30 mins
o Cover burn using cling film, layered, rather than wrapped around limb
o Symptomatic relief – analgesia, emollients
o Tetanus
o Cleanse wound
o Leave blister intact
o Non-adherent dressing
o Avoid topical creams
o Review in 24 hrs
Referral to secondary care for burns
- All deep dermal and full-thickness burns
- Superficial dermal burns of >3% TBSA in adults or >2% in children
- All circumferential burns
- Unhealed burns >2/52
- Need for HDU/ITU
- Pregnancy
- Any inhalation injury
- Suspicion of non-accidental injury
- Discussion
o Superficial dermal burns involving face, hands, feet, perineum, genitalia, or any flexure
o Any electrical or chemical burn injury
o Cold injury
o Febrile/unwell children
Management of more severe burns
- Assess airway
o Smoke inhalation can result in airway oedema
o Look for singed nose hairs, facial burns, oropharyngeal burns, voice hoarseness, stridor
o History of burns in enclosed space
o Consider early intubation as oedema can make intubation more difficult later - Breathing
o ABG Carbon monoxide levels, lactate, oxygenation, cyanide poisoning
o High flow O2 - IV fluids
o Children with burns >10% total body surface area
o Adults with burns >15% total body surface area
o Parkland formula: total body surface area of burn % x weight (kg) x4 (adults) or x3 (children)
o Half of fluid administered in first 8 hrs - Urinary catheter monitor urine output
- Transfer to burns unit
o Complex burns
o Burns involving hand perineum and face
o Burns >10% in adults and 5% in children
o Laser doppler imaging - Deroof blisters
- Escharotomy
o Divide burnt tissue in circumferential burns affect limb or severe torso burn impeding respiration
o Relieve pressure to prevent compartment syndrome - Excision/debridement and skin grafting for complex burns
o Remove necrotic tissue and aim to create viable tissue bed for healing
o Autologous harvest of healthy skin
o Meshed, fixed in place
Short term complications of burns
o Inhalation injury/poisoning
o SIRS
o Shock
o DIC
o Compartment syndrome
o Multi-organ failure
o Corneal ulceration
Medium term complication of burns
o Burn-associated infection
o Paralytic ileus
o Curling’s ulcer (acute gastric ulcer develop in response to severe physiological stress)
Long term complication of burns
o Contractures
o Marjolin ulcer
o Heterotopic ossification
o PTSD, depression
Causes of airway obstruction
- Coma loss of protective airway reflexes
- Blood or vomit
- Direct trauma
- Haematoma
- Oedema (following burns)
- Choking
Airway maintenance
- Chin lift or jaw thrust manoeuvres
- Airway control by holding mask onto face; inserting laryngeal mask airway; or intubation
- Look in mouth and pharynx for foreign bodies, blood and vomit
- Remove any obstruction with Magill’s forceps or Yankauer sucker
Management of choking
- Severe patient cannot speak or breathe, attempts at coughing are silent
- Mild patient can speak, cough and breathe
- Encourage to cough if mild
- Cycle of 5 black blows (heel of hand between scapulae) and 5 abdominal thrusts (from behind, placing clenched hand under xiphisternum and pulling upwards and inwards
- If lose consciousness, commence ALS protocol and try to retrieve object with foreceps/suction
Risk factors for sepsis
- Extremes of age
- Immunosuppression chemo, splenectomy, steroids, immunosuppressant meds, pregnancy
- Recent trauma, Invasive procedure, Surgery in past 6 weeks
- IVDU
- Indwelling lines, drains or catheters
NICE criteria for sepsis
- 1 red criteria or 2 yellow criteria + symptoms, fever
- Red = objective altered mental state, RR >25 or increased O2 requirement, HR >130, SBP <90 or >40 below normal, urine output <0.5ml/kg/hr or no output for >18h
- Yellow = history of altered behaviour, RR >20, HR >100, SBP <100, urine output <1ml/kg/hr or no output for >12h, deterioration in function, rigors, immunosuppression, recent surgery
