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Asthma ddx
Ddx- acute infective exacerbation of COPD, pulmonary oedema, URT obstruction, PE, anaphylaxis.
Asthma monitoring in emergency care
repeat PEF 15-30mins after initiating t. Pulse ox- aim for >92%, check blood gases within 2h if PaCO2 was raised/normal or initial PaO2 was <8kPa or patient deteriorating. Record PEF before and after beta-agonist in hospital at least 4 times
Asthma emergency management
- Start tx before investigating
- Sit patient up and give high dose oxygen via non-rebreathing bag.
- Salbutamol 5mg (or terbutaline 10mg) plus ipratropium bromide 0.5mg nebulised with oxygen.
- Hydrocortisone 100mgIV or prednisolone 40-50mg orally or both if v. ill
- Chest x-ray to exclude pneumothorax.
- If life threatening add magnesium sulphate (bronchodilator) 1.2-2g IV over 20mins.
- Give salbutamol nebulisers every 15minutes, or 10mg continuously per hour.
- Monitor ECG- look for arrhythmias.
- If improving- 40-60% oxygen, prednisolone 40-50mg/24h orally for at least 5 days. Nebulised salbutamol every 4h. Monitor peak flow and oxygen sats.
- If not improving after 15-30mins: continue 100% oxygen and steroids. Hydrocortisone 100mg IV or prednisolone 300mg 30mg orally if not already given. Give salbutamol nebulizers every 15mins or 10mg continuously per hour. Continue ipratropium 0.5mg every 4-6h.
- If patient still not improving: repeat nebulisers every 15mins. MgSO4 1.2-2g IV over 20mins unless already given. Consider aminophylline (bronchodilator) if not already theophylline.
- If still no improvement transfer to ITU with doctor on hand to intubate.
COPD ddx
asthma, pulm oedema, URT obstruction, PE, anaphylaxis
Ix for COPD emergency
PEF, ABG, chest X-ray for pneumothorax and infection, FBC, U&E, CRP, ECG, blood culture if pyrexic, sputum culture
Emergency management of COPD
- Controlled oxygen therapy- start at 24-28% and vary according to ABG. Aim for PaO2 >8kPa with a rise in PaCO2<1.5kPa.
- Nebulized bronchodilators- salbutamol 5mg/4h and ipratropium 500micrograms/6h.
- Steroids- IV hydrocortisone 200mg and oral prednisolone 30-40mg (continue for 7-14d).
- Antibiotics- only if evidence of infection e.g. amoxicillin 500mg/8h oral. Can also use doxycycline or clarithromycin.
- If no response- repeat nebulisers and consider IV aminophylline. Give a loading dose (except to patients on maintenance methylxanthines e.g. aminophylline/theophylline) of 250mg over 20mins then infuse at a rate of ~500micrograms/kg/hr where kg is ideal body weight.
- If no response consider nasal intermittent positive pressure ventilation if RR>30 of pH<7. This is delivered by a nasal mask and a flow generator.
- Consider intubation and ventilation if pH<7.26 and PaCO2 is rising.
- Consider respiratory stimulant drug e.g. doxapram 1.5-4mg/min IV for patients not suitable for ventilation. Short term measure. Side effects include agitation, nausea, tachycardia and confusion. Not used as often now as NIPPV is available
symptoms of hypoxia
dyspnoea, restlessness, agitation, confusion, central cyanosis. If long standing- polycythaemia, pulm HT, cor pulmonale.
symptoms of hypercapnia
headache, peripheral vasodilation, tachycardia, bounding pulse, tremor/flap, papilloedema, confusion, drowsiness, coma.
mx of type 1 resp failure
- Treat underlying cause
- Give oxygen (35-60%) by facemask to correct hypoxia.
- Assisted ventilation if PaO2<8kPa despite 60% oxygen.
mx of type 2 resp failure
- Treat underlying cause
- Controlled oxygen therapy- start at 24% O2
- Recheck ABG after 20minutes. IOf PaCO2 steady or lower, increase O2 conc to 28%. If PaCO2 has risen >1.5kPa and pt is still hypoxic consider respiratory stimulant e.g. doxapram 1.5-4mg/min IV or assisted ventilation e.g NIPPV.
- If this fails consider intubation and ventilation if appropriate.
signs and symptoms of PE
acute dyspnoea, pleuritic chest pain, haemoptysis, syncope, hypoT, tachycardia, gallop rhythm, raised JVP, right ventricular heave, pleural rub, tachypnoea, cyanosis.
Ix for PE emergency
U&E, FBC, baseline clotting, ECG, chest x-ray, ABG, serum D-dimer, CT pulmonary angiography.
Tx for PE emergency
- Oxygen 100%
- Morphine 10mg IV with antiemetic if patient is in pain or distressed.
- If critically ill with massive PE- immediate thrombolysis (50mg bolus alteplase) or surgery.
- IV access and start heparin either lmw heparin e.g. tinzaparin 175u/kg/24h subcut or unfractionated heparin ~10,000U IV bolus then ~18U/kg/h IV as guided by APTT.
- What is systolic? <90mmHg: start rapid colloid infusion, if BP still low after 500ml colloid, dobutamine 2.5-10micrograms/kg/min IV and aim for BP >90mmHg. If still low consider noradrenaline. If systolic BP<90mmHg after 30-60mins of standard tx, clinically definite PE and no CI, consider thrombolysis unless already given in step 3.
If BP>90mmHg start warfarin 10mg/24h orally and confirm diagnosis.
Clinical features of pneumothorax
: may be asymptomatic in young fit people with small pneumothorax or may be sudden onset dyspnoea and/or pleuritic chest pain. Reduced expansion, hyper-resonance on percussion, diminished breath sounds on affected side.
• With tension pneumothorax, the trachea will be deviated away from the affected side and patient will be very unwell.
Ix for pneumothorax
- Shouldn’t do a chest x-ray if suspected tension pneumothorax because it will delay treatment.
- Otherwise request expiratory film and look for area devoid of lung markings peripheral to edge of collapsed lung.
- Check ABG in dyspnoeic patient with chronic lung disease.
Tx for primary pneumothorax
SOB and/or rim of air>2cm on CXR? No- consider discharge, yes- aspiration. Successful? Yes- consider discharge. No- consider repeat. Successful? Yes-consider discharge. No- chest drain.
Tx for secondary pneumothorax
SOB and age>50 and rim of air >2cm on CXR? Yes- chest drain. No- aspiration. Aspiration successful? No- chest drain. Yes- admit for 24h.
Emergency management of tension pneumothorax
- Insert large bore (14-16G) needle with syringe, partially filled with 0.9% saline, into 2nd intercostal space in midclavicular line on side with suspected pneumothorax.
- Remove plunger to allow trapped air to bubble through the syringe until a chest tube can be placed.
- Alternately, insert large-bore venflon in the same location.
- Do this before requesting chest x-ray.
- Then insert chest drain.
clinical signs and symptoms of acute coronary syndrome/MI
- Diagnosis, increased then decreased troponin and symptoms of ischaemia, development of pathological Q waves or loss of myocardium on imaging.
- Symptoms: crushing central chest pain >20mins, nausea, vomiting, sweating, dyspnoea, anxiety, distress, pallor, tachycardia, HT, decreased 4th heart sound, raised JVP.
- May get MI without pain esp in elderly. Presents as syncope, pulm oedema, epigastric pain, vomiting , confusion
Ix for ACS
- Bloods: FBC, U&E, glucose, lipids.
- Cardiac enzymes: troponin (T and I are most sensitive) are used for cardiac necrosis. Serum level increased 3-12hrs post onset of chest pain, peak at 24-48h and decrease to baseline after 5-14 days. Creatinine kinase- increased CK-MB within 3-12h after onset of chest pain, peak within 24h and baseline after 48-72h. Myoglobin- rise within 1-4h from onset of pain- highly sensitive but not specific.
DDx for ACS
angina, pericarditis, myocarditis, aortic dissection, PE, oesophageal reflux/spasm.
Tx for ACS
- Attach ECG monitor and do 12 lead ECG
- Oxygen 2-4l aim form SaO2>95%- caution if COPD
- IV access- bloods for FBC, U&E, glucose, lipids and cardiac enzyme.
- Brief assessment- hx, risk factors, CIs to thrombolysis, vitals (BP from both arms), JVP, cardiac murmurs, upper limb pulses, look for scars from previous surgery.
- Aspirin 300mg unless already given
- Morphine 5-10mg IV and antiemetic e.g. metoclopramide 10mg IV
- GTN sublingual 2puffs or 1 tablet as required
- Primary PCI or thrombolysis?
- Beta-blocker e.g. atenolol 5mg IV unless asthma or left ventricular failure
- Chest xray- do not delay thrombolysis while waiting unless suspected aneurysm e.g. interscapular pain or BP different in each arm.
- Consider DVT prophylaxis
- Consider mediation except calcium channel antagonists.
- Bed rest for 48h
- Daily examination of chest, lungs and legs for complications, 12 lead ECG, U&E
- Consider warfarin for 3 months as prophylaxis.
- Aspirin e.g. 75mg
- Continue ACEi
- Statin e.g. simvastatub 40mg.
- Address modifiable risks
- Conduct exercise ECG
- General advice
Signs and symptoms of acute circulatory shock
- General: cold and clammy suggest cardiogenic shock or fluid loss.
- Anaemia or dehydration e.g. skin turgor, hypoT.
- Warm and well perfused with bounding pulse septic shock.
- Any features of anaphylaxis
- CVS- usually tachycardic and hypoT- not always, young, fit, pregnant women.
- JVP or CVP- of raised cardiogenic shock.
general management of acute circulatory failure
- ABCDE- high flow oxygen
- Raise the foot of the bed- UNLESS CARDIOGENIC SHOCK
- IV access- 2x wide bore cannulas, if this takes longer than 2 minutes get help.
- ID and treat underlying cause
- Get expert help
- Investigations: FBC, U&E, glucose, CRP, x-match blood, check clotting, blood cultures, urine cultures, ECG, lactate, echo, abdo CT
- Consider arterial line, central venous line and catheter
- Fluid replacement as indicated by BP, CVP and urine output. Don’t overload with fluids if cardiogenic shock. If persistently hypoT consider inotropes.
management of anaphylactic shock
- Secure airway- 100% oxygen. Intubate if respiratory obstruction.
- Raise feet and remove cause of obstruction
- IM adrenaline 0.5mg- 0.5ml of 1:1000, repeat every 5mins if needed- guided by observations.
- Secure IV access.
- Chlorphenamine 10mg IV and hydrocortisone 200mg IV
- IV fluids- 0.9% saline 500ml over 15minutes up to 2l. titrate against BP.
- If wheeze- treat for asthma. May require ventilatory support
- If still hypotensive ITU and IV adrenaline may be needed with or without aminophylline and nebulised salbutamol GET EXPERT HELP- IV adrenaline requires different doses.
- Admit to ward- monitor ECG, continue chlorphenamine 4mg/6h, suggest medic alert bracelet, epipen, allergy testing.
mx of cardiogenic shock
- Oxygen- titrate to maintain levels
- Diamorphine 2.5-5mg IV for pain and anxiety
- Investigations and close monitoring GET SENIOR AT BEDSIDE. Pericardiocentesis, x-match blood.
- Correct arrhythmias, U&E abnormalities or acid-base disturbance.
- Optimise filling pressure- if available measure pulmonary capillary wedge pressure (PCWP)
• If PCWP<15mmHg fluid load- give plasma expander, 100ml every 15mins IV, aim for PCWP 15-20mmHg.
• If PCWP>15mmHg, inotropic support e,g. Dobutamine 2.5-10micrograms/Kg/minute IV. Aim for systolic BP >80mmHg. - Consider renal dose dopamine- 2-5 micrograms/kg/min IV initially via central line only.
- Consider intra-aortic balloon pump if you expect the underlying condition to improve, or you need time before surgery.
- Look for and tx any reversible cause e.g MI or PE.
mx of septic shock
- See general management
- Give antibiotics within 1h (preferably after blood cultures). If source unknown give co-amoxiclav 1.2g/8h IV or meropenem 1g/8h IV.
- Give colloid or crystalloid by IV
- Aim for CVP 8-12mmHg, mean arterial pressure >65mmHg, urine >35ml/h.
- Low dose steroids may help continuous hypoT despite fluids and vasopressors.
Ix for AF
Tests: absent p wave on ECG, irregular QRS, blood tests- U&E, cardiac enzymes, thyroid function. Echo for L atrial enlargement, mitral valve disease.
symptoms of AF
May be asymptomatic, chest pain palpitations, dyspnoea, faintness, irregularly irregular pulse, apical pulse>radial rate.
Mx of acute AF
- If very ill or haemodynamically unstable o2, U&E, cardioversion (shock), if unavailable try IV amiodarone. Don’t delay treatment to start anticoagulation
- Treat associated illnesses
- Control ventricular rate- good first choice is diltiazem 60-120mg/8h PO. 2nd line- digoxin and amiodarone.
- Start full coagulation with low molecular weight heparin.
Mx of chronic AF
- Main goals are rate control and anti-coagulation.
- Beta-blocker or rate limiting calcium channel blocker.
- If this fails- digoxin as monotherapy is acceptable but only in sedentary patients.
- Rhythm control- cardioversion, do echo first. Pretreat with 4wks amiodarone
- Anticoagulation
ddx for ventricular tachycardia
SVT, pre-excited tachycardia e.g. atrial flutter
Mx of ventricular tachycardia
- Pulse? No- arrest protocol, yes oxygen and IV access
- Adverse signs? Systolic BP<90mmHg, chest pain, heart failure, HR>150.
- YES: get expert help, sedation, synchronised DC shock- 200J300J360J, amiodarone (potassium channel blocker) 300mg IV over 20minutes, then 900mg over 24h, ensure K and Mg are correct, cardioversion if necessary.
- No: correct electrolyte problems esp low K, assess rhythm. If regular- amiodarone 300mg IV over 20-60minutes, then 900mg over 24h OR lidocaine IV 50mg over 2mins, repeat every 5 mins to a total of 200mg. If irregular- diagnosis is usually AF with bundle branch block, pre-excited AF or polymorphic VT.
ddx for acute pulmonary oedema
asthma, COPD, pneumonia and pulmonary oedema are hard to distinguish. Do not treat all simultaneously.
symptoms of acute pulmonary oedema
dyspnoea, orthopnoea, pink frothy sputum.
signs of acute pulmonary oedema
- distressed, pale, sweaty, tachycardia, raised JVP, fine lung crackles, wheeze, usually sitting up leaning forwards.
Ix for acute pulmonary oedema
CXR: cardiomegaly, shadowing, small effusions at costophrenic angles, ECG, U&E, cardiac enzymes, ABG, consider an echo, plasma BNP.
emergency management of acute pulmonary oedema
- Sit patient upright
- Oxygen 100% if no existing lung disease
- IV access, ECG, treat arrhythmias
- Investigations while continuing treatment
- Diamorphine 2.5-5mg IV slowly- caution in liver failure and COPD
- Furosemide 40-80mg IV slowly- larger doses required in renal failure
- GTN spray 2 puffs S/L or 2x0.3mg tablets S/L- don’t give if systolic BP<90mmHg
- Necessary investigations, examination, hx
- If systolic BP>100mmHg start nitrate infusion e.g. isosorbide dinitrate 2-10mg/h IV and keep systolic >90mmHg
- If the patient is worsening further dose of furosemide 40-80mg. consider ventilation or increasing nitrate infusion. Alternately venesect 500ml blood- rarely done
- If systolic <100mmHg, treat as cardiogenic shock.
Mx of cardiorespiratory arrest
- Airway: head tilt if no spine injury and chin lift/jaw thrust. Clear the mouth.
- Breathing: check breathing and give 2 breaths after 1st set of compressions for 1s. Use specialised equipment if available and two resuscitators present, if not give mouth to mouth.
- Chest compression: 30 compressions to 2 breaths. Uninterrupted unless shocking or intubating. Use heel of hand with straight elbows centrally over lower third of sternum, aim for 5-6cm depression at 100-120/min.
- Place defibrillator pads on ASAP and assess rhythm
• VF/VT- defibrillation must occur without delay 360J
• Asystole and electromechanical dissociation: poorer prognosis. Obtain IV access and intubate. Look for reversible causes and treat. - Find patients notes to look for cause.
- If IV access fails can give intraosseous route
- If spontaneous circulation occurs consider therapeutic hypothermia.
Causes of cardiopulmonary arrest
- MI
- PE
- Tension pneumothorax
- Electrocution
- Shock
- Hypoxia
- Hypercapnia
- Hypothermia
- U&E imbalance
- Drugs e.g. digoxin
what is an acute abdomen?
sudden onset severe abdo pain
Ix for acute abdomen
- Urine dipstick: infection or haematuria
- ABG- sepsis, lactate indicates hypoperfusion
- Routine bloods- FBC, U&E, LFT, CRP, amylase, serum calcium in suspected pancreatitis
- Imaging- ultrasound of kidneys, ureters and bladder, biliary tree and liver, ovaries, fallopian tubes and uterus.
- Radiological- CXR, CT
Basic management of acute abdomen
- A- Give oxygen
- B
- C- IV- start fluids and monitor fluid balance
- D- analgesics, antiemetics
Causes of GI bleeding
- Peptic ulcer
- Mallory-Weiss tears
- Gastroduodenal erosions
- Oesophagitis
- Varices
- Malignancy
- Vascular malformations
- Facial trauma
Mx of GI bleeding- if shocked
- Protect airway and keep nil by mouth.
- Insert 2 large bore cannulas
- Bloods- FBC, U&E, LFT, glucose, clotting screen, cross match 6 units
- Give high flow O2
- Rapid IV crystalline infusion up to 1l
- If remains shocked, give blood
- Otherwise give slow saline infusion to keep lines open
- Transfuse as dictated by haemodynamics
- Correct clotting abnormalities- vitamin K, FFP, platelets
- Set up CVP line to guide fluid replacement.
- Catheterise and monitor urine output. Aim for 30ml/h
- Monitor vitals every 15mins until stable
- Notify surgeons
- Urgent endoscopy for diagnosis +/- control of bleeding
Mx of GI bleeding- not shocked
- Insert 2 big cannulas
- Start slow saline IV to keep lines patent
- Check bloods and monitor vitals + urine output
MOA of DKA
- Lack of insulin+ decreased glucose uptake into cells
- Decreased production of pyruvate by glycolysis.
- Acetyl CoA is generated by fat breakdown to make up the deficit.
- Excess of 2C acetyl CoA which is converted to ketone bodies.
presentation of DKA
- Gradual drowsiness
- Hyperglycaemia
- Ketosis
complications of DKA
- Cerebral oedema
- Aspiration pneumonia
- Hypokalaemia
- Hypomagnesaemia
- Hypophosphatemia
- Thromboembolism