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Flashcards in Management Deck (49)
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1

Investigations for Severe Pulmonary Oedema

Chest x-ray: Cardiomegaly, Signs of pulmonary oedema: bilateral shadowing, small effusions at costophrenic angles, fluid in fissures, kerly b lines (septal linear opacities)

ECG: signs of MI, dysrhythmia

Bloods: Troponin, U&Es
BNP
ABG

Echo

Signs on examination: distressed, pale, sweaty, tachycardia, tachypnoea, pink frothy sputum, pulsus alterans, increased JVP, fine crackles, triple gallop, wheeze (cardiac)

2

Management of Severe Pulmonary Oedema/Acute Heart Failure

A through to E approach

Sit the payment up

High-flow O2

IV access and ECG
Treat any arrhythmias

Diamorphine 1.25-5mg IV slowly

Furosemide 40-80mg IV slowly
Increase dose in renal failure

GTN spray or sublingual (2 x 0.3mg)
Only if SBP >90mmHg

If SBP >100mmHg start nitrate infusion


If worsening
Repeat dose of furosemide
Consider CPAP
Increase nitrate infusion whilst maintaining SBP

3

Investigations for Cardiogenic Shock

Investigations: ecg, u&e, troponin, abg, cxr, echocardiogram. If indicated, ct thorax (speak with radiologists, this can be protocolled for both aortic dissection and pe)

Monitor: cvp, bp, abg, ecg, urine output. Keep on cardiac monitor/telemetry. Record a 12-lead ecg every hour until the diagnosis is made. Consider a cvp line and an arterial line to monitor pressure, if these are in situ consider measuring cardiac output and volume status. Catheterize for accurate urine

4

Management of Cardiogenic Shock

Oxygen - maintain O2 at 94-98%

Diamorphine 1.25-5mg IV slowly (1mg/minute)

Investigations and monitoring

Correct arrhythmias, abnormalities and acid-base disturbance

Optimise filling pressure
Under filled --> plasma expander every 15 minutes

Over filled --> dobutamine 2.5-10 micrograms/kg/min

Aim for MAP 70mmHg

Treat reversible causes: pulmonary embolism, MI, valve failures

Manage in acute coronary care unit

5

Beck's Triad

Muffled heart sounds

Raised JVP

Hypotension with narrowed pulse pressure


Indicative of cardiac tamponade

6

Signs of Cardiac Tamponade

Beck's Triad
Hypotension with narrowed pulse pressure
Raised JVP
Muffled heart sounds

Increased JVP on inspiration (Kussmauls)

Pulsus paradoxus (pulse fades on inspiration)

Echo

CXR: globular heart, left heart border convex or straight, right costophrenic angle >90%

ECG: electrical alterans

7

Management of Pericardial Effusion

Get a senior to come now

Pericardiocentesis

While you wait, monitor ECG and give O2

Take bloods, with cross-match

8

Pericardiocentesis

Subxiphoid approach

Long 18-22 G needle attached to syringe

Insertion: between xiphisterum and left costal margin direct towards the left shoulder at 40 degree angle to skin continual aspiration as needle approaches RV once pericardial fluid aspirated, can insert cannula into pericardial space attach a 3 way tap and remove fluid with improvement in haemodynamics

9

Management of Broad Complex Tachycardia

>100bpm QRS >120ms

Pulse? No ---> arrest protocol

Yes

Give O2 if data <90%
IV access
12-lead ECG

Check for adverse signs?
Shock SBP <90mmHg
Chest pain/ ischaemia on ECG
Heart failure
Syncope

No
Correct electrolyte abnormalities
Assess rhythm
300mg IV amiodorone

Yes
Get expert help
Sedation
3 synchronised DC shocks
Check and correct electrolyte abnormalities
300mg IV amiodorone (>20 minutes)

Give amiodarone through central line

10

Dose of Amiodarone

300mg IV over >20 minutes

Then 900mg through central line

11

Dose of Adenosine

6mg IV bolus

Then 12mg

Second 12mg

Move onto verapamil

Warn about transient chest tightness, dyspnoea, headache and flushing

12

Dose of Verapamil

2.5-5mg

Over 2 minutes IV

Contraindicated in patients taking beta blockers

13

Management of Narrow Complex Tachycardia

QRS <120ms
Rate >100

O2 if SaO2 <90%
Achieve IV access
12-lead ECG

Adverse signs?
-shock
-chest pain
-heart failure
-syncope

--->yes
Seek expert help
Sedation
Three synchronised DC
Check electrolytes and correct
300mg Amiodarone
DC cardio version
900mg Amiodarone via central line

--->no
Continuous ECG
Vagal manoeuvres

Then
Adenosine 6mg IV bolus
Then Adenosine 12mg
Then Verapamil 2.5-5mg

14

Management of AF

Metoprolol 1-10mg IV
Give small increments to slow rate

Rate-limiting Ca2+ channel blocker e.g. verapamil 5-10mg IV

If heart failure, can use digoxin as alternative
Load dose with 500micrograms

Amiodarone can be used to control rhythm

Anticoagulant therapy to reduce risk of stroke
DOAC: Apixabam 5mg BD

If onset <48 hours ---> DC cardioversion
Anti coagulated for 3 weeks ---> DC cardioversion

Chemical cardioversion
Flecanide 2mg/kg IV slow over 10-30 minutes with ECG monitoring



15

Cushing's Triad

Bradycardia
Hypertension
Irregular breathing

Indicative of raised ICP

16

Beta-blocker overdose antidote

Glucagon

17

Management of Bradycardia

Give O2 if SaO2 <90%
Manual BP
IV access
ECG

Identify reversible causes (e.g. Hypothermia, electrolyte abnormalities)

Adverse signs?
Shock
Heart failure
Syncope
Myocardial ischaemia

Yes adverse signs present
Atropine 500micograms IV every 3-5 minutes
Maximum of 3mg (6 doses)
If fails, Transcutaneous pacing (under sedation)

Isoprenaline
Adrenaline
Dopamine
Aminophylline
Glucagon

If no adverse signs, assess risk of asystole
Recent asystole
Mobitz II AV block
Complete heart block
Ventricular pauses >3s
If risk --> commence management above of atropine

18

Management of Acute Asthma

Assessment - Severity
If severe/life-threatening notify ICU

Supplement O2 to achieve sats of 94-98%

Salbutamol 5mg in oxygen-driven nebuliser

If severe, add in ipratropium bromide 0.5mg/6 hours to nebuliser

Prednisolone 40-50mg PO OR. Hydrocortisone 100mg IV

Reassess every 15 minutes
If PEF<75%, repeat salbutamol nebuliser every 15-30 minutes
Monitor ECGs, watch for arrhythmias

Consider single dose of IV magnesium sulphate 1.2-2g over 20 minutes in those with severe/life-threatening features without good response to initial therapy

If not improving ---> ICU
Normocapnia
Worsening acidosis
Low pO2
Exhaustion, feeble respiration
Drowsiness, confusion
Respiratory arrest

19

Management of Acute Exacerbation of COPD

A--->E

Nebulised bronchodilators
Salbutamol 5mg /4h
Ipratropium bromide 500micrograms /6h

Controlled oxygen therapy
Indicated if SaO2<88% or PaO2 <7 kP
Start using Venturi mask 24-28% FiO2
Aim for PaO2 >8 with a rise in PaCO2 <1.5

Steroids
IV hydrocortisone 200mg
And
Oral Prednisone 30mg OD

Antibiotics
Amoxicillin 500mg QDS
Clarithromycin or Doxycycline

Physiotherapy to aid clearance

If no response to nebulisers or steroids ---> IV aminophylline

No response ---> consider Non-invasive positive pressure ventilation (NIPPV)
If RR>30, pH<7.35, or rising PaCO2

Doxaparam in those not suitable for mechanical ventilation (1.5-4mg/min)


Consider intubation and ventilation




20

When to seek surgical advice for pneumothorax

Bilateral pneumothoraces
Lung fails to expand within 48hours of intercostal drain insertion
Persistent air leak
2 or more previous pneumothoraces on same side
History of pneumothorax on opposite side

21

Management of tension pneumothorax

Large bore needle with saline in syringe as water seal
Or cannula
2nd intercostal spade mid-clavicle line

Once aspirated

Chest X-ray

Then chest drain

22

CURB-65

Confusion (abbreviated mental test score < or equal to 8)

Urea (>/7mmol/L)

Respiratory rate (>/30/min)

Blood pressure <90/60mmHg

Age >\ 65 years

Curb score
1- treatment at home
2- treatment in hospital
3- severe pneumonia and consider ICU
4
5

23

Pneumonia management by CURB-65

1- treat at home
2- treat in hospital
3- severe, consider ICU

2- Blood cultures
2-Sputum cultures (has not yet commenced antibiotics)
2- urine pneumococcal antigen
2- Consider pleural fluid aspiration
3-Sputum cultures (irrespective of commencement of antibiotics)
3- legionella antigen

Everyone gets chest X-ray and ABG if SaO2<92%

24

Antibiotics for Mild/Moderate Pneumonia

Mild not previously ℞ (curb 0–1)
Streptococcus pneumoniae
Haemophilus influenzae

--->
Oral amoxicillin 500mg–1g/8h or clarithromycin 500mg/12h or doxycycline 200mg loading then 100mg/day (initially 5-day course)


Moderate (curb 2)
Streptococcus pneumoniae
Haemophilus influenzae
Mycoplasma pneumoniae


--->
Oral amoxicillin 500mg–1g/8h + clarithromycin 500mg/12h or doxycycline 200mg loading then 100mg/12h If iv required: amoxicillin 500mg/8h + clarithromycin 500mg/12h (7-day course)

25

Antibiotics for Severe Pneumonia

Severe (curb >3)

Co-amoxiclav 1.2g/8h iv or cephalosporin iv (eg cefuroxime 1.5g/8h iv) and clarithromycin 500mg/12h iv (7 days)

Add flucloxacillin ± rifampicin if Staph suspected; vancomycin (or teicoplanin) if mrsa suspected. Treat for 10d (14–21d if Staph, Legionella, or Gram −ve enteric bacteria suspected)

Panton-Valentine Leukocidin-producing Staph. aureus (pvl-sa)

Seek urgent help. Consider adding iv linezolid, clindamycin, and rifampicin

26

Antibiotics for Atypical Pneumonia

Atypical
Legionella pneumophilia
Fluoroquinolone combined with clarithromycin, or rifampicin, if severe. See p[link]

Chlamydophila species
Tetracycline


Pneumocystis jirovecii
High-dose co-trimoxazole

27

Antibiotics for Aspiration Pneumonia

Aspiration
Streptococcus pneumoniae
Anaerobes

Cephalosporin iv + metronidazole iv



28

Antibiotics for Neutropenic Pneumonia

Neutropenic patients
Gram-positive cocci
Gram-negative bacilli

Aminoglycoside iv + antipseudomonal penicillin iv or 3rd-generation cephalosporin iv

29

Antibiotics for Hospital-Acquired Pneumonia

Hospital-acquired
Gram-negative bacilli
Pseudomonas
Anaerobes

Aminoglycoside iv + antipseudomonal penicillin iv or 3rd-generation cephalosporin iv (p[link])

30

Signs of PE on ECG

Commonly normal
Or sinus tachycardia

Can have:
Right ventricular strain pattern v1–v3
Right axis deviation
RBBB
AF
May be deep s waves in I, q waves in III, inverted t waves in III (‘sI qIII tIII’).