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Medicine > Emergency Treatment > Flashcards

Emergency Treatment Flashcards

1
Q

ECG changes for STEMI?

A

ST elevation
New LBBB

Tall T waves
normalisation on ST segments
T wave inversion

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2
Q

STEMI acute treatment?

A
  1. ECG
  2. Aspirin 300mg
  3. Morphine (w/ metoclopramide), oxygen, GTN spray
  4. Angiography with PCI (ST elevation >2mm din 2 chefs leads or >1mm in limb leads) - if presenting within 12 hrs of symptoms and PCI can be delivered in 120 mins, offer prasurgrel with aspirin if not already on oral anticoagulant
  5. Fibrinolysis with alteplase/streptokinase - if presenting pithing 12 hours of symptoms and PCI not possible in 120 mins
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3
Q

STEMI secondary prevention?

A

Dual anti platelet - lifelong aspirin, ticagrelor (at least 12 months)
ACEi - indefinitely, titrated as high as possible eg. ramipril
BB - indefinitely, titrated a high as possible eg. atenolol or bisoprolol
Statin - atorvastatin 80mg OD
Lifestyle - stop smoking, cardiac rehab, no driving for 4 weeks, reduce alcohol, diet

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4
Q

ECG changes for NSTEMI?

A

No ECG changes
ST depression, T wave inversion

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5
Q

NSTEMI acute treatment?

A

BATMAN:
Beta blocker
Aspirin 300mg stat
Ticagrelor 180mg stat dose OR Prasugrel (clopidogrel 300mg if high bleeding risk)
Morphine
Anticoagulant - Fondaparinux
Nitrates - GTN

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6
Q

What is the GRACE score?

A

Assess for PCI in NSTEMIs - 6 month risk of death or repeat MI
<3% low risk
>3% intermediate/high risk - angiography with PCI within 72 hours (if indicated)

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7
Q

What is the definition of shock?

A

Acute circulatory failure with inadequate or inappropriately distributed tissue perfusion, resulting in generalised hypoxia and/or an inability of the cells to utilise oxygen

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8
Q

What are the different types of shock?

A

Hypovolaemic
Cardiogenic
Anaemic
Cytotoxic

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9
Q

What are the subgroups of hypovolaemic shock?

A

Haemorrhagic
Septic
Anaphylactic
Neurogenic

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10
Q

Clinical presentation: hypovolaemic shock

A

Skin - cold, clammy, pale
Drowsiness/confusion
Increased sympathetic tone
Tachycardia
Sweating

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11
Q

What are the 4 classes of hypovolaemic shock?

A

Blood loss:
I - 0-15%
II - 15-30%
III - 30-40%
IV - > 40%

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12
Q

Clinical presentation: cardiogenic shock

A

Signs of myocardial failure
Raised JVP
Gallop rhythm
Basal crackles and pulmonary oedema

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13
Q

Clinical presentation: septic shock

A

Pyrexia and rigors
Nausea and vomiting
Vasodilation and warm peripheries
Bounding pulse

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14
Q

What are the sepsis 6?

A

High flow oxygen, maintain sats >94%
Blood cultures
Measure serial lactate levels
IV antibiotics
IV fluids
Monitor urine output

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15
Q

Clinical presentation: anaphylactic shock

A

Profound vasoldilation
Warm peripheries
Low BP
Tachycardia
Bronchospasm
Pulmonary oedema

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16
Q

Treatment: neurogenic shock

A

Vasopressin and atropine

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17
Q

When is rhythm control 1st line treatment for AF?

A

Reversible cause
New onset < 48 hours
AF causing HF
Symptomatic despite rate control

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18
Q

What is usually 1st line treatment for AF?

A

Rate control
BB or rate limiting CCB (diltiazem or verapamil) monotherapy
Digoxin if non paroxysmal AF (if does no or little exercise or other rate drugs ruled out)

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19
Q

What is paroxysmal AF?

A

Intermittent episodes of AF that terminate within 7 days either spontaneously or with treatment

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20
Q

What type of drug is digoxin?

A

Cardiac glycoside

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21
Q

When is cardioversion used for rhythm control in AF?

A

Immediate - if < 48 hours or haemodynamically unstable
Delayed - if > 48 hours and stable

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22
Q

What medication needs to be given for delayed cardioversion?

A

Antiocoagulate for min 3 weeks prior
Consider amiodarone 4 weeks prior and 12 weeks after

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23
Q

What treatment is used for AF if monotherapy fails?

A

Combination therapy: any 2 of:
- BB
- diltiazem
- digoxin

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24
Q

What antiarrhythmic drug is contraindicated in patients with known IHD or structural HD?

A

Class 1c
eg. flecainide and propafenone

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25
Q

Long-term rhythm control:

A
  1. BB
  2. Dronedarone - 2nd line for rhythm control after successful cardioversion
  3. Amiodarone - LV impairment or HF
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26
Q

When is ‘pill-in-pocket used? and which drug?

A

Paroxysmal AF
Flecainide - take when episode starts

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27
Q

When is left atrial ablation considered in AF?

A

Drug treatment not tolerated/not suitable/unsuccessful in symptomatic paroxysmal or persistent AF
3 months of antiarrhythmic drugs after

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28
Q

What is CHA2DS2VASc?

A

Calculates stroke risk in patients with AF

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29
Q

Chadvasc score of 2 or more - action?

A

Anticoagulate with DOAC - apixaban, dabigatran, edoxaban, rivaroxaban
Men can have if score of 1 or more
Warfarin if DOAC contraindicated

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30
Q

What is the ORBIT score?

A

Predicts risk of major bleeding in patients on anticoagulation for AF

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31
Q

ORBIT score criteria:

A
  1. Haemoglobin - 2 points
    - Male - Hb < 13 or haematocrit < 40%
    - Female - Hb < 12 or haematocrit < 36%
  2. Age > 74 - 1 point
  3. Bleeding history - 2 points
    - GI, intracranial, haemorrhagic stroke -
  4. GFR < 60ml/min - 1 point
  5. Antiplatelet treatment - 1 point
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32
Q

ORBIT score outcomes:

A

Low risk - 0-2
Intermediate risk - 3
High risk - 4 or more

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33
Q

Acute management of stable SVT?

A

Valsalva manoeuvre
Carotid sinus massage
Adenosine 6mg IV bolus -> 12mg -> 12mg (verapamil as alternative)

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34
Q

Acute management of unstable or unsuccessful management SVT?

A

Direct current cardio version with amiodarone 100J -> 200J -> 300J
Amiodarone loading dose of 300mg over 20 mins -> 900mg over next 23 hours

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35
Q

Long term management of paroxysmal SVT?

A

Meds - BB. CCB, amiodarone
Radiofrequency ablation

36
Q

What is status epilepticus?

A

Seizure lasting longer than 5 minutes or 2 or more seizures without regaining consciousness

37
Q

Treatment of status epilepticus

A
  1. Benzodiazepine = IV lorazepam 0.1mg/kg, diazepam
  2. Further dose after 10 minutes
  3. No response still –> phenytoin/levetiracetam
  4. Intubation and GA
38
Q

Raised ICP presentation?

A

Headaches –> worse leaning forward/coughing
Vomiting
Papilloedema
Focal neurological deficit
Drowsiness
Seizures

39
Q

Management of raised ICP?

A

Treat underlying cause
Neuroprotective ventilation
Mannitol (1g/kg) or hypertonic saline
Radiotherapy
Dexamethasone - 8-16mg daily titrated down

40
Q

What is role of mannitol in raised ICP management?

A

Reduced ICP short term

41
Q

What score is used to diagnose PE?

A

Wells Score

42
Q

Well’s score <4 next steps?

A

PE unlikely
D-dimer (1), proximal leg US (2/3)
Interim therapeutic anticoagulation

43
Q

Well’s score > 5 next steps?

A

PE likely
CTPA and interim therapeutic anticoagulation

44
Q

Investigations for PE

A

FBC, U&Es, LFTs, PT, APTT
Can have raised troponin
ECG can look like MI

45
Q

What is the PESI score?

A

Risk of mortality and severity of complications in PE

46
Q

Management of PE - haemodynamically unstable?

A

Thrombolysis with streptokinase/alteplase

47
Q

Management of PE - haemodynamically stable?

A

Apixaban or rivaroxaban for 3 months (6 if unprovoked and active cancer)
If unsuitable - LMWH 5 days then dabigatran/edoxaban for at least 3 months
Renal impairment (eGFR < 15ml) - LMWH then UFH/VKA

48
Q

Long term PE management?

A

Compression stockings
IVC filters an option if repeat DVT/PE despite anticoagulation

49
Q

Pneumothorax: No SOB and <2cm rim of air on CXR. Treatment?

A

None - resolves spontaneously
Follow up 2-4 weals

50
Q

Pneumothorax: SOB and/or >2cm rim of air on CXR. Treatment?

A

Aspiration
Chest drain
Surgery if drain fails - abrasive pleurodesis, chemical pleurodesis, pleurectomy

51
Q

Tension pneumothorax. Treatment?

A

Large bore cannula into 2nd intercostal space in mid-clavicular line

52
Q

Upper GI bleed presentation

A

Haematemesis -> coffee ground vomit
Malaena
Hameodynamic instability

53
Q

What is the Blatchford score?

A

Likelihood of having upper GI bleed

54
Q

What is the Rockall score?

A

Risk of rebreeding or death after upper GI bleed

(do after endoscopy)

55
Q

Management of upper GI bleed?

A

ABCDE resuscitation
Bloods -> Hb (FBC), urea (U&Es), coagulation, LFTs, crossmatch
Transfuse
Endoscopy
Depends on source of bleeding
After endoscopy - PPI, repeat endoscopy if rebelled
stop NSAIDs, anticoagulants

56
Q

When is an endoscopy needed for upper GI bleed?

A

Immediately after resuscitation in unstable patient with severe acute upper GI bleed
Within 24 hours otherwise

57
Q

Upper GI bleed management: non variceal bleed

A

Mechanical method (clips) +/- adrenaline
Thermal coagulation with adrenaline
Fibrin or thrombin with adrenaline

58
Q

Upper GI bleed: variceal bleed

A

Terlipressin at presentation
Prophylactic abx
Band ligation
Transjugular intrahepatic portosystemic shunts (TIPS) if bleed not controlled by band ligation

59
Q

What transfusions are required for massive upper GI bleed?

A

Blood
Platelets - if actively bleeding and count < 50
Clotting factors - FFP if actively bleeding and PT or APTT > 1.5x normal
Prothrombin complex concentrate - if on warfarin and actively bleeding

60
Q

What is the definition of an AKI?

A

Acute drop in kidney function, diagnosed by measuring serum creatinine

61
Q

What is the criteria for AKI diagnosis?

A
  1. Rise in creatinine > 25 micromol/L in 48 hours
  2. Rise in creatinine > 50% in 7 days
  3. Urine output < 0.5ml/kg/hour for 6 hours
  4. eGFR fallen by >25% in children and young people in 7 days
62
Q

Risk factors for AKI:

A

CKD, HF, DM, liver disease, old age, cognitive impairments, nephrotoxic medications (NSAIDs, ACEI), contrast medium use

63
Q

3 types of causes of AKI?

A

Pre renal, renal, post-renal

64
Q

Pre renal causes of AKI

A

Inadequate blood supply - dehydration, hypotension (shock), HF

65
Q

Renal causes of AKI

A

Intrinsic disease - glomerulonephritis, interstitial nephritis, acute tubular necrosis

66
Q

Post renal causes of AKI

A

Obstruction to outflow - kidney stones, masses/cancers, ureter/ureteral strictures, enlarged prostate

67
Q

Investigations for AKI

A

Urinalysis:
- leucocytes and nitrates - infection
- protein and blood - acute nephritis
- glucose - diabetes

US - look for obstruction

68
Q

Management of AKI?

A

Stop nephrotoxic meds
Pre-renal - fluid rehydration
Renal - biopsy and specialist treatment
Post-renal - obstruction relief with nephrostomy to stunting within 12 hours of diagnosis

69
Q

When is dialysis needed for AKI management?

A

Persistent hyperkalaemia, refractory pulmonary oedema, symptomatic uraemia (encephalopathy, pericarditis), severe metabolic acidosis, poisoning (aspirin)

70
Q

Presentation of DKA?

A

Recent diabetic symptoms -> polyuria, polydipsia, WL
Abdominal pain, N+V
Dehydration
Lethargy, drowsiness
Kassmaul sign -> tachypnoea, acidotic breathing

71
Q

What is Kassmaul sign?

A

Increased JVP on inspiration

72
Q

Precipitating factors for DKA?

A

Infection
Inadequate insulin or non-adherence with insulin treatment
New onset DM or other psychological stress -> trauma, surgery
Other conditions -> hypothyroidism, pancreatitis
Drugs -> steroids, diuretics, atypical antipsychotics, salbutamol

73
Q

Diagnosis of DKA:

A

Acidosis = pH < 7.3 (+/- HCO3 < 15mM)
Hyperglycaemia = > 11.1
Ketonuria = urinary > 2mM, capillary blood > 3mM

74
Q

Management of DKA:

A

Resuscitation, IV access, catheter

Fluids:
- avoid fluid boluses
- 0.9% normal saline = 1l stat
- add potassium in 2nd bag if K < 5.5mM = 4L over 12 hours

Insulin infusion:
- actrapid at 0.1 units/kg/hour
- started after 1st hour

Monitor glucose to prevent hypoglycaemia:
- swap fluid to IV dextrose once blood glucose < 14mmol/L

Treat underlying triggers, monitor for signs of cerebral oedema, monitor glucose, monitor ketones, monitor pH

75
Q

Most likely patient for hyperosmolar hyperglycaemic state?

A

Often T2DM and elderly

76
Q

Diagnosis of hyperosmolar hyperglycaemic state

A
  • Hypervolaemia/marked dehydration
  • Marked hyperglycaemia (>30mmol/L) without significant hyperketonuria or acidosis
  • Osmolality >320mosmol/kg
77
Q

Management of HHS:

A

0.9% normal saline –> replace 50% of loss in first 12 hours, remained in next 12 hours

Low dose IV insulin (0.05units/kg/hr) - only when blood glucose no longer falling

Treat precipitant

Prophylactic anticoagulant in most patients –> LMWH during admission at least

78
Q

Hypoglycaemia definition?

A

Blood glucose levels < 3.5mmol/L

79
Q

Presentation of mild hypoglycaemia:

A

Hunger, anxiety, irritable, palpitations, tremor, sweating, tingling lips

80
Q

Presentation of moderate hypoglycaemia:

A

Headache, drowsiness, difficulty concentrating, impaired vision, confusion, impaired cognitive function (<3.0)

81
Q

Presentation of severe hypoglycaemia:

A

severe cognitive impairment, convulsions, LOC, coma

82
Q

Precipitating factors for hypoglycaemia?

A

Insulin regime
Sulfonylurea SE

83
Q

Management of hypoglycaemia:

A

10-20g fast acting carbohydrate - fresh fruit juice, glucose tablets, dextrose tablets, jelly babies, glucose gel (0.3g/kg children)

Recheck blood sugars after 10-15 mins
Repeat oral intake
Recheck sugars after 10-15 mins

If restored - long-acting carbs eg, bread, potatoes, pasta

If unconscious/unable to swallow:
- IM glucagon 1mg (child <8 years or <25kg = 500micrograms)
- if no response within 10 mins or no glucagon available call 999
- if restored -> oral carb
- IV dextrose if access

84
Q

Anaphylaxis management - hospital:

A

IM adrenaline, repeat after 5 mins
If respondents/cardio problems persisting - IV fluid bolus + IV adrenaline (expert guidance)

After stabilisation:
- non-sedating oral antihistamine
- serum tryptase levels

85
Q

Where is IM adrenaline administered?

A

anterolateral aspect of middle third of thigh

86
Q

Anaphylaxis management - home:

A
87
Q

What is the most common ECG change in PE?

A

Sinus tachycardia

Medicine (14 decks)

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