PACES acute

Question 1

Anaphylaxis management

Answer 1

1. Secure the airway- give 100% O2. Intubate if respiratory obstruction
2. Remove the cause, raise the feet of the bed
3. Adrenaline IM 0.5mg, every 5mins as guided by BP/pulse/resp function
4. Secure IV access
5. Chlorphenamine 10mg IV and hydrocortisone 200mg IV
6. IVI 0.9% saline over 15mins (up to 2L may be needed); titrate against BP
7. If wheeze, tx for asthma; may require ventilator support
8. If still hypotensive, admit to ITU and give IVI adrenaline +/- aminophylline and nebulized salbutamol; get expert help
9. Admit to ward. Monitor ECG
10. Continue chlorphenamine 4mg/6h PO if itching
11. Medic Alert bracelet
    Refer to allergy clinic
12. Teach about Epipen
13. Skin prick tests to identify cause

Tryptase 12hours post to confirm

Question 2

ACS with STEMI

Answer 2

1. ABCDE
2. Attach ECG monitor and 12 lead ECG (hyper acute T. waves, St elevation, t wave inversion, q waves LBBB)
3. O2 2-4L aim for SaO2>95% (mask or nasal prongs)
4. IV access- bloods for FBC, U&E, glucose, lipids, cardiac enzymes- measure at presentation and 12 hours
5. Brief assessment:
   i. Hx of CV disease; risk factors for IHD, contraindications to thrombolysis? Examine: pulse, JVP, cardiac murmurs, signs of heart disease, scars from previous surgery
6. Aspirin 300mg PO, +/- clopidogrel
7. Morphine 5-10mg IV + antiemetic e.g. metoclopramide 10mg IV
8. GTN sublingually or 2 puffs or 1 tablet PRN
9. Primary PCI (best if ongoing ischaemia and presentation within 12h) or thrombolysis

BB, ACEi, statin, dual AP

Admission with continuous ECG

Question 3

ACS with NSTEMI

Answer 3

1. ABCDE
2. Attach ECG monitor and 12 lead ECG
3. O2 2-4L aim for SaO2>95% (mask or nasal prongs)
4. IV access- bloods for FBC, U&E, glucose, lipids, cardiac enzymes
   Morphine + meto + aspirin and GTN

GRACE score
age
heart rate, blood pressure
cardiac and renal function (serum creatinine)
cardiac arrest on presentation
ECG findings
troponin levels

Low risk- aspirin and ticagrelor
High risk- PCI and ticagrelor

Question 4

Pulmonary oedema Mx

Answer 4

2. ABCDE
3. 100% oxygen
4. IV access and monitor ECG; treat any arrythmias
5. Invx: CXR, ECG, U&E, ‘cardiac’ enzymes, ABG, consider ECHO
6. (during treatment monitor progress with BP/pulse/cyanosis/resp rate/JVP/urine output/ABG)
7. Diamorphine 2.5-5mg IV slowly- caution in liver failure and COPD
8. Furosemide 40-80mg IV slowly- larger doses in renal failure
9. GTN 2 puffs SL or 2 x 0.3mg tablets SL (NOT if BP<90)
10. If patient is worsening: further dose of furosemide 40-80mg. Consider ventilation (invasive or non-invasive
11. If systolic BP<100mmHg, tx as cardiogenic shock i.e. insert Swan Ganz catheter and inotropic support
12. Daily weights; BP and pulse/6h. Repeat CXR

Long term- ACEi, BB, spirono, SGLT2i,
Entresto
Biventricular pacing
Specialist nurse

Question 5

Cardiogenic shock

Answer 5

1. ABCDE
2. Oxygen titrated to adequate arterial saturations
3. Diamorphine 2.5-5mg IV for pain and anxiety
4. Invx- ECG, U&E, cardiac enzymes, ABG, CXR, ECHO. IF indicated do CT thorax or V/Q scan
5. Monitor- CVP, BP, ABG, ECG, urine output. 12 lead ECG hourly until diagnosis. Consider Swanz-Ganz catheter for pulmonary wedge pressure and cardiac output, and an arterial line to monitor pressue. Catheterise for urine output.
6. Correct arrhythmias, U&E abnormalities or acid-base disturbance

If available measure pul capillary wedge pressure - swanz
IF low- fluid bolus
If high-inotropic support- dopamine

Question 6

Shock management

Answer 6

A-E
Call for help
Raise feet- unless cardio

IV access- 2 large bore

ECG
Cold, JVP

Septic- warm, no JVP, fever- sepsis 6- broad antibiotics, fluids ect

Hypovolaemic- no JVP, cold- fluids, transfusion

Question 7

Broad complex tachycardia

Answer 7

A-E
Check pulse
2222
O2, ECG, IV access

Cardiac monotor and defib pad

No signs- correct cause, amiodarone, torsades- MgSo4
Adverse signs- experts, sedation, DC shock, amiodarone

Question 8

Acute severe asthma

Answer 8

A-E
100% O2
Salb 5mg, Ipra 0.5mg- bedulised
HC IV or pred PO

ABG, CXR, FBC, U+E
O2 sats, HR, RR, PEF

Life threatening- IV magnesium

Continue nebulisers every 15 mins
and magnesium
Aminophylline IV

Seniors

Before discharged- stable on meds for 24 hours, technique, PEF >75, management plan, GP in 1 wk, resp clinic in 4

Question 9

Acute COPD Mx

Answer 9

A-E approach
High flow- titrate down
Or 24-28%

Nedulised salbutamol and ipratropium
Steroids

ABx if think infection

Physio- remove sputum

IV aminophylline

BPAP- if <7.35 pH
<7.25- ITU and intubation

Discharge- GP steroids reduction, smoking, vaccines,
Rehab, LTOT

Question 10

Pneumothorax mx

Answer 10

A-E
tracheal deviation or signs of tension
CXR
Tension- large 14G with syringe
After air- CXR and chest drain

1- >2cm- aspirate
Admit for 24 hours if successful

2- <2cm aspirate, >2cm chest drain

If bilateral, lung fails to expand after drain, multiple past on same side- surgery

Question 11

PE management

Answer 11

100 O2

IV access- FBC, UE, clotting, ECG, CXR, ABG, D dimer, CTPA
Analgesia
Unstable- thrombolyse
CI_ unfractionated heparin

Senior help

Wells score- >4- CTPA- DOAC
<4- doppler

Question 12

Acute upper GI bleed

Answer 12

A-E

Shocked- 2 large bore cannulas- draw blood- FBC, UE, LFT, fluids, X match 6 units
Protect airway, NBM

Fluids and blood

Clotting- check INR

Rockall score- age, comorbidity, liver disease, haemodynamic disturbance, continued bleeding, elevated blood urea

Vital signs monitor- 15 mins

Endoscopy urgent- same day

If variceal- terlipressin and ABx before= banding
Massive- Sengstaken Blakemore tube

Non- high dose PPI

Question 13

Status epilepticus mx

Answer 13

Maintain airway- recovery position

Oxygen
IV access- take bloods- BM test, Ca, toxicology
Thiamine- alcohol