1
Q
Investigations for anaphylaxis?
A
- Take blood to check FBC, U&Es, LFTs, calcium and glucose.
1
Q
Specific management for Broad/Narrow complex tachycardia with adverse features?
A
Synchronised DC shock
1
Q
Serum potassium level and ECG changes in hyperkalaemia?
A
Serum K+ > 5mmol/L ECG - tall tented T waves, small P waves, wide QRS complex becoming sinusoidal, VF.
1
Q
Definition of SIRS?
A
• Temp 38 • HR > 90 bpm • Tachypnoea > 20 breaths/min • WCC 12
2
Q
Management of pulmonary oedema?
A
- Treat any arrhythmias 2. Diamorphine 2.5mg IV slowly 3. Furosemide 40-80 mg IV slowly 4. Glyceryl trinitrate (2 sprays or 500 mcg tablet) 5. Consider CPAP 6. Salbutamol nebuliser if wheeze is predominant feature
3
Q
Investigations in NSTEMI?
A
• Take blood to check FBC, U&Es, calcium, magnesium, glucose and troponin) • Consider blood cultures if sepsis suspected • Serial ECGs
4
Q
Symptoms of acute asthma?
A
Dyspnoea, cough (often nocturnal), chest tightness
5
Q
Initial response to STEMI?
A
• ABCDE assessment • Give O2 via reservoir mask to maintain oxygen sats of 94-98% • Gain IV access
6
Q
General management for dysrythmias?
A
- Identify and treat underlying cause (e.g. electrolyte abnormalities) - Identify adverse features: • Shock (systolic BP
6
Q
Dose and function of salbutamol nebuliser in hyperkalaemia?
A
- Salbutamol 10-20 mg (5mg back to back nebulised) over 10-20 minutes. - Shifts potassium into cells temporarily.
6
Q
Features specific to a tension pneumothorax?
A
- Hypotension – must be present to make diagnosis of TP 2. Tracheal deviation away from the affected side 3. Distended neck veins
8
Q
Causes of airway obstruction?
A
- Most common - reduced conscious level - Foreign bodies - Secretions (vomit etc) - Swelling (anaphylaxis, angio-oedema)
8
Q
Specific management for bradycardia with adverse features?
A
ATROPINE 500 mcg IV Consider transcutaneous pacing
9
Q
Initial response to AKI?
A
• ABCDE approach • Obtain IV access
9
Q
Dose and function of insulin and glucose in hyperkalaemia?
A
- Short acting insulin 10 units in 50 mls of 50% glucose IV over 5-10 minutes. - Shifts potassium into cells temporarily. - Monitor BM regularly
10
Q
Sign of a near fatal asthma attack?
A
Raised PaCO2 (>6.0 kPa) and/or requiring mechanical ventilation with raised pressures.
10
Q
Investigations for acute asthma?
A
• Take blood to check FBC, U&E, glucose. Consider CRP, blood and sputum cultures if sepsis suspected. • Arterial blood gas
10
Q
Post renal causes of AKI?
A
• Obstruction (renal stones, retro-peritoneal fibrosis, bladder cancer, pelvic mass, enlarged prostate)
11
Q
Investigations in NSTEMI?
A
• Take blood to check FBC, U&Es, calcium, magnesium, glucose and troponin) • Consider blood cultures if sepsis suspected • Serial ECGs
13
Q
Recognition for ‘D’?
A
Patient response - AVPU GCS Pupils - size and reaction to light Blood glucose Focussed neurological exam Evidence of seizure activity? Check drug chart for reversible causes
14
Q
One other thing looking for in C?
A
Evidence of blood loss
15
Q
Management of NSTEMI?
A
- ANALGESIA – titrate MORPHINE 2.5-10mg slow intravenous bolus 2. GLYCERYL TRINITRATE (2 sprays or 500mcg tablet) sublingual or buccal 3. ASPIRIN 300mg orally 4. CLOPIDOGREL 300mg orally 5. Refer to cardiologist 6. FONDAPARINUX 2.5mg subcutaneously (after discussion with cardiologist)
15
Q
Pre-renal causes of AKI?
A
• Dehydration (vomiting, diarrhoea, burns, haemorrhage) • Hypotension • Sepsis • Cardiac failure
15
Q
Specific management for bradycardia without adverse features?
A
- Assess for risk of asystole (recent asystole, mobitz type 2 block, complete heart block, ventricular pause >3s) - Observe if no risk of asystole - If risk of asystole treat as for bradycardia with adverse features.
15
Definition of severe sepsis?
Sepsis + organ dysfunction
17
Signs of airway obstruction?
- Paradoxical chest and abnormal movements - Grunting, gurgling - Foreign body visible? - Fully obstructed airway will be silent
17
Symptoms of hyperkalaemia?
muscle weakness, palpitations, paraesthesia etc.
19
Initial response for acute asthma?
• ABCDE assessment – sit patient up • O2 – 15 L/min via a reservoir mask • Obtain IV access
20
What does GCS include?
Eye opening, voice, movement - 3-15
20
Initial response to hyperkalaemia?
- ABCDE assessment • IV access – take bloods to check FBC, U&Es, LFTs, glucose • Attach to cardiac monitor • Monitor BP and O2 saturations. Immediate treatment required if potassium \> 6 mmol/L with ECG changes OR potassium \> 6.5 mmol/L regardless of ECG changes.
20
CXR findings in pulmonary oedemea?
Cardiomegaly Fluffy bilateral shadowing with peripheral sparing (bats wings) Kerley B lines Pleural effusions
20
Initial response to pulmonary oedema?
• ABCDE assessment • IV access – take bloods to check FBC, U&Es, LFTs, glucose • Attach to cardiac monitor • Monitor BP and O2 saturations.
22
Management of acute asthma?
1. SALBUTAMOL 5mg NEBULISED WITH O2 (repeat 15-20 minute intervals) 2. IPRATROPIUM BROMIDE 500 mcg NEBULISED WITH O2 (4-6 hourly) 3. HYDROCORTISONE 200mg IV or PREDNISOLONE 40mg ORALLY 4. MAGNESIUM SULPHATE 2g IV (over 20 minutes) 5. Chest X-ray to exclude infection and pneumothorax
25
Risk factors for acute coronary syndrome?
increasing age, male sex, family history of IHD, smoking, hypertension, DM, hyperlipidaemia, obesity, sedentary lifestyle.
27
Recognition of 'A'?
- Is the patient talking? - Look, listen, feel - Signs of airway obstruction - Cyanosis/hypoxia is late sign
28
Definition of bradyarrythmia?
- ECG rate less than 50 BPM
28
When is RRT indicated in hyperkalaemia?
In intractable cases of hyperkalaemia
29
Recognition of 'C'?
Look at and feel peripheries: - Pulse rate and character - BP - Cap refill - JVP - Auscultate heart sounds
30
Recognition for 'E'?
Expose patient (maintain dignity and minimise heat loss) to assess for injuries, infection sites, bleeding etc Check temperature Focussed history and examination Chart review Drug chart Investigation results
31
Response to sepsis?
BUFALO (Septic six) - WITHIN 1 hour B - Blood cultures should be drawn prior to Abx administration U - Measure urine output hourly via urinary catheter F - Fluid resuscitation to treat hypotension – 500ml or Hartmann’s/saline. A – Administer broad spectrum Abx intravenously as per hospital guidelines. L – Measure serum lactate and haemoglobin O – 15 L/min O2 via a reservoir bag
33
What else for 'E'?
Consider removal and culture of potential sources of infection (catheters, cannulae) Review all sources of information - history from patient/relative/witness, patient notes, obs, drug charts, investigations, imaging
34
Recognition of 'B'?
Look listen feel... Is the patient breathing? Signs of respiratory distress? - sweating, central cyanosis, use of accessory muscles - RR, depth and rhythm - Equal air entry - Added sounds - Percussion note - Trachea central?
35
Temporary management of hyperkalaemia?
1. Calcium Gluconate 2. Insulin and glucose 3. Salbutamol Nebuliser 4. Calcium Resonium 5. Renal Replacement Therapy
36
Response for 'B'?
Sit patient up Give O2 15 L/min via reservoir bag - aim for 94-98% sats (88-92 if at risk of TII RF) PEFR ABG CXR If not breathing - ventilate with bag and mask
38
What should you look for in 'E'?
Bleeding (GI bleeding), evidence of DVT, infection sites, injury, rashes, hypothermia or fever
39
Specific management for irregular narrow complex tachycardia without adverse features?
- Treat for AF - DIGOXIN or BETA BLOCKERS for rate control - AMIODARONE for chemical cardioversion and rate control
39
Response to a tension pneumothorax?
1. ABCDE assessment 2. Give O2 15 L/min via a reservoir mask 3. Do not delay management by waiting for a chest X-ray 4. Needle decompression – large bore needle (14-16G) 2nd intercostal space mid-clavicular line (leave in place before insertion of chest tube) 5. Insertion of chest tube
41
What is the clinical presentation of poor tissue perfusion (shock)?
Cold peripheries (except septic shock) Prolonged cap refill time Inability to get pulse oximeter trace Tachycardia Reduced JVP Tachypnoea Poor urine output Adgitation/Obtundation Lactic acidosis Hypotension
41
Investigations for AKI?
• FBC, U&Es, bicarbonate, LFTs, calcium, phosphate • Consider blood cultures in sepsis suspected • Urine dipstick (presence of blood and protein suggests infection or vasculitis) • CXR – pulmonary infiltrates could indicate fluid, infection or haemorrhage • Renal tract ultrasound – assess renal anatomy and exclude renal tract obstruction.
43
Which cardiac biomarker is raised in ACS?
Troponin (after 12 hours)
44
Definition of septic shock?
Sepsis + persistent hypotension despite adequate fluid resuscitation
46
Signs of acute asthma?
Use of accessory muscles, wheeze
47
Dose and function of calcium resonium in hyperkalaemia?
- Calcium resonium 15g orally every 6-8 hours. - Removes potassium from GI tract. Co-prescribe with lactulose.
48
What are you looking for in top to toe examination?
Rashes Cellulitis Cannula sites (infection) Sources of bleeding Wound infection Peripheral oedema Evidence of trauma Swollen, inflamed joints Swollen or tender legs indicative of DVT
49
Features of acute severe asthma?
(any one of): • Inability to complete sentences in one breath • Respiratory rate \> 25 breaths/minute • Heart rate \> 110 beats/minute • PEFR 33-50% of predicted
50
What is hypoglycaemia?
Glucose under 4 mmol/L
52
CXR signs in ACS?
May show pulmonary oedema or cardiomegaly
52
Management of STEMI?
1. ANALGESIA – titrate MORPHINE 2.5-10mg slow intravenous bolus 2. NITRATES (buccal/sublingual/spray glyceryl trinitrate) 3. ASPIRIN 300mg orally 4. CLOPIDOGREL 300mg orally 5. PRIMARY PERCUTANEOUS INTERVENTION (PCI) is treatment of choice if on-going ischaemia and within 12 hours of onset. 6. THROMBOLYSIS if PCI not available 7. Refer to cardiologist
53
ECG changes in ACS?
1. STEMI – ST elevation or new left bundle branch block. 2. NSTEMI or unstable angina – ischaemic changes (ST depression, T wave inversion) may be present.
55
Features of AKI?
- Hypovolaemia – assess volume status (cap refill, pulse, BP, JVP, skin turgor, pulmonary oedema, peripheral oedema, urine output, weight) - Palpable bladder? - Signs of vasculitis (weight loss, fever, rash, uveitis, haemoptysis, joint swelling) - Bruits (renal artery stenosis)
56
Features of anaphylaxis?
- Airway problems - Stridor, bronchospasm, laryngeal oedema, respiratory distress. - Rash - Urticaria - Angio-oedema - Hypotension and shock - Nausea, vomiting or diarrhoea
57
Definition of AKI?
• Rise in serum creatinine greater than 26 µmol/L within 48 hours OR • Rise in serum creatinine 1.5 × baseline value within 1 week OR - Urine output less than 0.5 ml/kg/hr for 6 consecutive hours
58
Investigations for dysrythmias?
- Take blood to check FBC, U&Es, LFTs, calcium, magnesium and glucose - Consider blood cultures if sepsis suspected - Attach to cardiac monitor - Perform 12 lead ECG - Monitor BP and O2 saturations
59
Definition of sepsis?
SIRS + evidence of infection
60
Management of AKI?
1. Treat underlying cause – i.e. IV fluids for hypovolaemia and ABx for sepsis 2. Treat complications of AKI (e.g. hyperkalaemia, pulmonary oedema, acidosis, peridcarditis) 3. Review of drug chart (dose adjustments and avoid nephrotoxins) 4. Renal replacement therapy if indicated 5. Monitor (daily volume assessment, fluid balance, U&Es, bicarbonate).
62
Signs of poor end organ perfusion?
Agitation Reduced consciousness Urine output
63
What's a fluid challenge?
Fluid blolus of 500ml of crystalloid fluids (Hartmann's or 0.9% saline)
63
Causes of hyperkalaemia?
• Oliguric AKI • Postassium sparing diuretics • Drugs (ACEi) • Rhabdomyolysis • Metabolic Acidosis • Iatrogenic • Addison’s disease • Massive blood transfusion • Artefact (haemolysis)
64
Symptoms of ACS?
chest pain, tight, heavy, crushing, radiating to the jaw or left arm. Shortness of breath, sweaty, nausea, palpitations.
66
Response for 'D'?
Protect the airway Endotracheal tube if GCS
67
Response to airway obstruction?
Call for help Head tilt, chin lift Jaw thrust Oropharyngeal/Nasopharyngeal airway Suction secretions Give Oxygen Call anaesthetist for definitive airway management
69
Definition of broad complex tachycardia?
- ECG rate greater than 100 BPM - QRS complex \>0.12s - Presence of a pulse (if no pulse start ALS)
71
Response for 'C'?
Treat underlying problem 2 large bore cannulas (14G or 16G) Bloods (routine haem, biochem, coag and group/save) 12 lead ECG Fluid challenge and assess response
72
Initial response to dysrhythmias?
- ABCDE assessment - Give O2 15 L/min via reservoir mask - Obtain IV access
73
Initial response for anaphylaxis?
- ABCDE assessment - Secure the airway – give O2 15 L/min via a reservoir mask – CALL AN ANAESTHETIST IF AIRWAY COMPROMISED. - Obtain IV access.
76
What examination should you do in 'E'?
Abdominal examination and top to toe examination
77
Specific management for broad complex tachycardia with no adverse features?
1. AMIODARONE 300mg loading dose IV over 1 hour 2. Followed by AMIODARONE 900mg IV over 24 hours.
78
Dose and function of calcium gluconate?
- 10% CG 10 ml IV over 2 minutes OR 10% calcium chloride 10 mls over 10 minutes. - Provides cardio-protection, does not alter serum potassium level.
79
What are you looking for in recognition of anaphylaxis?
acute onset of illness, life-threatening airway and/or breathing and/or circulation problems, skin changes (usually present).
80
Definition of narrow complex tachycardia?
- ECG rate greater than 100 BPM - QRS complexes
81
Intrinsic renal causes of AKI?
• Prolonged hypo-perfusion • Nephrotoxins • Glomerulonephritis • Vasculitis • Interstitial nephritis
82
Causes of pulmonary oedema?
Left ventricular failure Fluid overload Neurogenic
83
Features of pneumothorax?
• Shortness of breath (sudden onset) • Pleuritic chest pain • Unilateral reduced chest pain • Unilateral decreased breath sounds • Unilateral hyper-resonance to percussion • Chest X-ray confirmation
84
Features of pulmonary oedema?
• Dyspnoea; orthopnoea; pink frothy sputum; pale, sweaty, distressed; elevated JVP; inspiratory crackles; wheeze (cardiac asthma); triple/gallop rhythm.
85
Specific management for regular narrow complex tachycardia with no adverse features?
- Treat for SVT - Use vagal manoeuvres - ADENOSINE
86
Signs of heart failure?
dyspnoea, raised JVP, crackles at lung bases
87
Features of life threatening asthma attack?
• Altered conscious level • Exhaustion/poor respiratory effort • Silent chest • PEFR
88
Initial response to NSTEMI?
• ABCDE assessment • Give O2 via reservoir mask to maintain oxygen sats of 94-98% • Gain IV access
89
What else do you want to assess for C?
Assess circulation, fluid status and look for signs of hypovolaemia
90
Management of anaphylaxis?
1. Remove the antigen if identified 2. Raise legs to help restore circulation 3. ADRENALINE 0.5mg (i.e. 0.5ml of 1:1000) intramuscular – repeat adrenaline as necessary every 5 minutes 4. CHORPHENAMINE 10mg IV 5. HYDROCORTISONE 200mg IV 6. Fluid challenge - (500mls HARTMANN’S SOLUTION or 0.9% SALINE) 7. May need INOTROPES/VASOPRESSORS to maintain blood pressure 8. If audible wheeze present, treat as for asthma 9. If patient remains unstable consider transfer to ICU 10. CONTINUALLY REASSESS ABCDE
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