Anaphylaxis
Discuss how to manage anaphylaxis.
What investigations may need to be done in anaphylaxis patients?
What us refractory anaphylaxis?
How is refractory anaphylaxis managed?
How should adrenaline be given in CPR?
How should pregnant women be managed in CPR?
What is biphasic anaphylaxis?
- Serum tryptase
- persisting respiratory or cardiovascular symptoms despite two appropriate doses of IM adrenaline
- Management of refractory anaphylaxis includes:
ABCDE approacvh
Seek expert input early
Maintenance adrenaline therapy with low-dose IV adrenaline infusion
Rapid IV fluid challenge with crystalloids - IV or intraoesseus
- Left lateral position, displace uterus manually to the left.
- Biphasic anaphylaxis: recurrence of symptoms within 72 hours after complete recovery of anaphylaxis, in the absence of further exposure to the trigger
Choking
How should choking be managed?
What should be examined after managing choking?
- If patient cannot speak suspect choking. Manage by seeing if they can cough. If they cannot cough its 5 back blows to the back and abdominal thrusts
- Check for any rib injuries
Asthma and COPD
What questions should be considered after managing an asthma patient?
- Are any further assessments or interventions required?
Does the patient need a referral to HDU/ICU?
Does the patient need reviewing by a specialist?
Should any changes be made to the current management of their underlying condition(s)?
Hypoglycaemia
1. What are the causes of hypoglycaemia.
2, What is the normal range for glucose.
3. Why might a reading above 4 be a concern
4. How should a conscious patient be treated with hypoglycaemia.
5. How should an unconcious patient be treated
6. How is a patient managed after the A-E?
- Insulin-dependent diabetes
Previous history of hypoglycaemic episodes or reduced hypoglycaemia awareness
Impaired renal function
Cognitive dysfunction/dementia
Alcohol misuse
Profound starvation
Increased exercise
Food malabsorption issues (e.g. coeliac disease, bariatric surgery, gastroenteritis) - Normal range is 4.0-5.8. Hypoglycaemia is defined as a plasma glucose of less than 3.0 mmol/l. In hospitalised patients, a blood glucose ≤4.0 mmol/L should be treated if the patient is symptomatic.
- Check previous reading as it may be unusual for the patient
- If conscious. Administer glucose gel by mouth (e.g. GlucoGel®).
Repeat capillary blood glucose after 10-15 minutes and if the patient is still hypoglycaemic, repeat administration of glucose gel a further 2-3 times. When the patient is fully alert, provide a longer-acting carbohydrate for the patient to eat (e.g. toast). - Administer intravenous glucose (e.g. 150-160 ml of 10% glucose).
If the patient then regains consciousness, switch to using oral glucose as above. If intravenous access is not able to be established rapidly, administer glucagon 1mg via the intramuscular or subcutaneous route - History, review, document, discuss, handover
Trauma
1. What management algorithm is used?
2. What does ATMISTER stand for?
3. How is a catastrophic bleed managed
4. What are some signs of airway compromise?
5. What are the c spine rules?
6. What are the canadian cspine rules?
7. When should the c-spine be examined>
8. What are the 6 life threatening breathing injuries?
9. What is major haemorrhage?
10. What is a useful tool for imaging in haemorrhage?
11. Why is JVP observed?
- Catastrophic bleeding A-E
- Age and sex of the injured person
Time of incident
Mechanism of injury
Injuries suspected
Signs, including vital signs, and Glasgow Coma Scale
Treatment so far
Estimated time of arrival
Special requirements - Encourage haemostasis. direct pressure, haemostatic dressing application, or tourniquets.
- These include significant facial trauma, facial burns, and haemorrhage. Check for stridor or inability to talk. Check c-spine as well. GCS . Call anaesthetic
- Spinal tenderness. Altered consciousness. Intoxication. Distracting injury. Age 65 or older
- Dangerous mechanism of injury (fall from over one metre or down five or more steps, or an axial loading injury)
Paraesthesia in any limb(s) - Before doing a head tilt. May require blocks and collars
- Tension pneumothorax
Open pneumothorax
Massive haemothorax
Cardiac tamponade
Airway injury
Tracheobronchial injury - Loss of more than one blood volume within 24 hours
50% of total blood volume lost in less than 3 hours
Bleeding in excess of 150 mL/minute - FAST ultrasound scanning
- Lethal triad
- Beck’s triad and pericardial effusion or cardiac tamponade
Tension pneumothorax
1. How is a tension pneumothorax managed?
- Needle decompression involves placing a needle or cannula into the 2nd intercostal space, mid-clavicular line (on the affected side) to immediately relieve the tension pneumothorax.
Rhabdomyolysis -
1. What are some signs?
2. What tests should be performed?
3. How does the creatinine kinase change
4. How is severe cases managed?
5. What else needs monitoring
6. What are complications of rhabdomyolysis
7. What are some non-specific symptoms?
8. What might precipitate rhabdomyolysis?
- Long lie and tea coloured urine
- Gas
Urea
Bone profile
Liver tests
Urinalysis
Electrolytes
Serum creatinine - markedly elevated (> 5x times), and myoglobin
- May escalate to IV bicarbonate or RRT
- Due to AKI also monitor potassium and if high ECG and treat
- DIC, AKI, electrolyte imbalances
- Muscle pain
- Triggers can be intense exercise
Traumatic head injury
1. What are some of the features?
- What are the complications of raised ICP?
- What needs to be suspected?
- Headache
Nausea and vomiting
Restlessness, agitation or drowsiness
Slow slurred speech
Papilloedema
Ipsilateral sluggish dilated pupil which then becomes fixed (“blown pupil”)
Cranial nerve palsy (e.g. CN III palsy with ‘down and out’ pupil)
Seizures
Reduced GCS
Abnormal respiratory pattern
Abnormal posturing, initially decorticate and then decerebrate - CPP = Mean Arterial Pressure (MAP) – ICP
Cushing’s triad
CN palsy and herniation - Bradycardia and dyspnoea due to Cushing’s reflex or due to opioids
Upper GI bleed
1. How should patients be managed?
2 large bore cannulas
IV fluids + consider major haemorrhage protocol + cross match
Antibiotics
Terlipressin
Upper GI endoscopy
Drug chart review
A-E
1. What are the steps?
- What needs to be done if no signs of life?
- What is a MET call?
Airway - talking? stridor? facial burns? / Catastrophic bleeding? C-spine
Breathing - wheezing, breath sounds, oxygen, percussion, chest expansion
Cardiovascular - CRT, cannula, cuff, JVP, heart sounds, JVP raised
Disability - glucose, pupils, AVPU, drug chart
Everything else - lacerations, source of infection
- Puts out a crash call
- Medical emergency call
Give an example of an SBAR
Hello, my name is Sam Jacobs, I am a junior doctor on the wards, can I clarify who I am speaking to.
Clarify patient details, name, date of birth and hospital number
I need your advice on
The patient deteriorated 10 minutes ago
The patient was admitted because
Their date of admission is the
Current diagnosis is
Allergies are.
Symptoms, signs
Investigations
Recommendations
Suggest how to do an A to E for breathlessness.
Safe to approach
Airway – is the patient able to talk? Any signs of angioedema? Is the airway patent? Any stridor or stertor? (PAST X 4)
Breathing – oxygen sats, pursed lip breathing, accessory muscles tracheal deviation, chest expansion, chest sounds (x6) (POTACS)
Circulation – CRT, pulse (count), cuff, cannula – cultures first, FBCs, U and E’s, LFTs, CRP, cyanosis, cardiac monitoring, catheterise (x8) (7 C’s – CRT, counting HR, cuff, cannula, cyanosed, cardiac monitoring, catheterise)
Disability – AVPU, DEFG, PEARL, temperature (x4)
Everything else
Suggest how to take an infertility history
PC
HPC:
- How long have you spent trying to conceive?
- Any pain, any bleeding, any discharge
- Any dyspareunia
Gynaecology:
- Any contraception
- Normal menstrual cycle
- Smears
- STIs and sexual history
- Obstetric history - sensitive issue - miscarriages, terminations
- Partner’s health
- Surgeries
Past medical history
DHx
FHx
SHx
Testing - semen analysis, FSH, LH, oestrogen
STI testing
Councelling and IVF
What questions can be asked in a gynaecological history for AUB?
Rectal symptoms
Urinary symptoms
Discharge
Dyspareunia
IMB, PCB
Time and amount of bleeding
Amount/ abdominal pain
PMB
Secretions
What questions could be asked in a infertility history?
Dyspareunia, dysuria
Abdominal pain
Menstruating
Itching or discharge
AUB
New changes - acne
Get - Growth
P - Puberty
Contraception –> obstetric history (miscarriages and terminations) –> smears and STIs
How should you counsel a patient on a new medication?
Check prior understanding and any concerns
In today’s consultation I’d like to tell you what the drug is, what the drug does, how to take it, any side effects and benefits.
Does this sound OK.
What do you already know about the medication?
What ideas and concerns do you have?
What are the causes of palpitations?
What are some causes of breathlessness?
What should you ask in a respiratory history?
Pain
Palpitations
Any blood
Any cough
Weight loss
Wheeze
Secretions
Sweats
What should you ask in a gastrointestinal history?
Pain
Urine
Dysphagia
Dysuria
Icterus
Itchiness
Nausea and vomiting
GORD
Skin changes
What should you ask in a cardiovascular history?
Breathlessness
Orthopnea
Pain
Palpitations
Positional
Inspiration
Nausea
What should be asked in a urinary history?
Frequency
Output
Urgency
Nocturia
Dysuria
Bleeding
LUTS
ood
What should be asked in a gynaecological abnormal bleeding history or dysmenorrhea history?
Rectal pain
Urinary pain
Dyspareunia
Discharge
IMB and PCB
Time of menstrual cycle
Amount of blood - clotting - 50p
Pruitis
Sweats
Give differentials for abdominal bloating.
Ovarian cancer
Liver cirrhosis and ascites
Bowel obstruction (i.e. sigmoid volvulus)
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