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RRAPID Conditions and Management

Apr 27, 20248 min read

SAMPLE History Whilst Assessing Airway

  • Signs and symptoms
  • Allergies
  • Medications
  • Past medical history
  • Last oral intake
  • Events surround injury/illness

Acute Coronary Syndrome

  • Don’t forget troponin

STEMI

  • MOAN - morphine 5-10mg, oxygen 100%, aspirin 300mg & ticagrelor 180mg, nitrates GTN spray (metoclopramide 10mg)
  • PCI within 2 hours - if not possible thrombolysis with Fondaparinux

NSTEMI

  • MOAN - morphine 5-10mg, oxygen 100%, aspirin 300mg, nitrates GTN spray (metoclopramide 10mg)
  • Thrombolyse with LMWH - subcut as per local guidelines

High Risk on GRACE Score

  1. Fondaparinux (cannot give if immediate angiography)
  2. If Clinically Unstable: Immediate angiography. If Stable (not bleeding): Angiography within 72 hours (with follow-on PCI if indicated)
  3. Not on anticoagulation: Prasugrel/Ticagrelor + Aspirin - Only give prasugrel once PCI intended
  4. On previous Anticoagulation: Clopidogrel + Aspirin.

Low Risk on GRACE Score

  1. Fondaparinux
  2. Low Bleeding Risk: Ticagrelor + Aspirin
    Higher Bleeding Risk: Clopidogrel + Aspirin

Exacerbation of Heart Failure

Acute problems caused by pulmonary oedema

  • Troponin and BNP
  • IV furosemide 20-40mg
  • Do not offer: nitrates or opiates
  • Conside CPAP

Exacerbation of COPD

H. influenzae most common organism.

  • Give oxygen to meet requirements but take early ABG to identify retainers. Eg 28% Venturi mask at 4 l/min if risk/features of hypercapnia
  • Salbutamol 5mg neb - back to back
  • Ipratropium bromide 500 micrograms 4-6 hourly
  • 40mg oral pred or IV hydrocortosone 100mg.
  • IV theophylline may be considered.

Acute Kidney Injury

STOP AKI

  • Sepsis - complete 6 if suspected cause of AKI
  • Toxins - gentamicin, NSADs, iodine contrast
  • Optimise - blood pressure and volume status
  • Prevent - treat complications - acidosis, hyperkalaemia, pulmonary oedema

Monitor fluid balance

Asthma

  • <33% of predicted or best, < 92% ORA < 8kPa life PEFR life-threatening.
  • Confusion automatically means life threatening.
  • Raised is near fatal
  • Oxygen 100%.
  • 5mg back to back salbutamol nebs ± ipratropium (if no response to salbutamol).
  • Prednisolone 40mg oral or IV hydrocortisone 100mg
  • Consider magnesium sulphate

Oh
Shit,
I
Hate
My
Asthma

  1. Oxygen
  2. Salbutamol nebulisers
  3. Ipratropium bromide nebulisers
  4. Hydrocortisone IV or Oral Prednisolone
  5. Magnesium Sulfate IV
  6. Aminophylline / IV salbutamol

Patients after an exacerbation can be discharged after:

  • been stable on their discharge medication (i.e. no nebulisers or oxygen) for 12-24 hours
  • inhaler technique checked and recorded
  • PEF >75% of best or predicted

Anaphylaxis

  • Maintain airway
  • IV fluid challenge

IM adrenaline - 1:1000 repeat every 5 minutes

GroupDose
Adults (12+)500 micrograms
Children (6-12)300 micrograms
Children (<6)150 micrograms

Arrhythmias

Only if things are “adverse”

Bradycardias

  • IV atropine 500 micrograms - repeat up to 3mg
  • or transcutaneous pacing
  • Get a pace maker fitted asap

Tachycardias

Tip

‘Amiodarone’ is broader than ‘Adenosine’
Give amiodarone in broad complex tachy and Adenosine in narrow complex tachy

Supraventricular tachycardia
  • Vagal/valsalva manoeuvers
  • If they don’t work IV adenosine
Broad complex tachycardia
  • DC cardioversion
  • IV amiodarone if adverse features not present
Polymorphic ventricular tachardia
  • Subtype of this is torsades de pointes - precipitated by prolongation of the QT interval
  • IV magnesium

CPR

  • DRS ABC

  • 100-120 BPM 5-6cm depth

  • 30:2 CPR:Rescue breaths in adults

  • Switch person every 2 minutes

  • If in VF/ pulseless VT give 1 shock followed by 2 mins of CPR

  • If the arrest was witnessed give up to 3 shocks before starting CPR

  • Adrenaline 1mg immediately in non-shockable rhythms

  • In VF/pulseless VT give adrenaline once CPR have restarted after 3rd shock

  • Repeat adrenaline every 3-5 minutes whilst ALS continues

  • Give 300mg amiodarone after 3 shocks then 150mg (ideally through a central line)

Reversible causes of cardiac arrest:

The ‘Hs’The ‘Ts’
- Hypoxia
- Hypovolaemia
- Hyperkalaemia, hypokalaemia, Hypoglycaemia, Hypocalcaemia, acidaemia and other metabolic disorders
- Hypothermia		- Thrombosis (coronary or pulmonary)
- Tension pneumothorax
- Tamponade - cardiac
- Toxins

Delirium

Cause:

  • Pain

  • Infection

  • Nutrition

  • Constipation

  • Hydration

  • Medication

  • Environment/electrolytes

Consider Sepsis 6

If a danger to themselves or others:

  • Haloperidol 1st line - contraindicated in those with prolonged QTc, ventricular arrythmias or Parkinson’s disease
  • Lorazepam 2nd line

Diabetic ketoacidosis

Metabolic acidosis with Anion gap

  • Raised blood glucose >11 mmol/L
  • Capillary ketones >3 mmol/L
  • Venous pH <7.3 or bicarb <15 mmol/L

Management:

  • Fixed rate insulin infusion 0.1 units/kg/hour
  • Continue long acting insulin - short acting insulin should be stopped
  • Repeat IV fluids 1L 0.9 NaCl over 1hr - add potassium as required. Most patients with DKA are deplete around 5-8 litres
  • Potassium cannot be given faster than 20mmol/hour
  • Once blood glucose is <14 mmol/L add an infusion of 10% dextrose

GI Bleed

Fluid resuscitation:

  • Fluid challenge of 500ml over 15 minutes

  • Aim not to over fill due to increased bleeding with higher pressure

  • If massive haemorrhage - active Major haemorrhage protocol calling blood bank.

    • 4 units of RBC and 4 units of FFP 1:1 transfusion ratio
    • Consider TXA
    • Correct any clotting abnormalities
    • If bleed from varices patient needs terlipressin and prophylaxic antibiotics

  • Urgent OGD once resusitated

Head Trauma

  • worst and first/thunderclap Subarachnoid haemorrhage.

  • N&V - 2 or more episodes of vomiting urgent head CT

  • Panda eye - basal skull fracture

  • Cushing’s triad of signs brain herniation

    • Cheyne-Stokes breathing
    • Hypertension
    • Bradycardia

  • Correct any coagulopathies

  • Refer to neurosurgery esp if ICP

Hyperkalaemia

Causes

  • K sparing diruetics - amiloride, spiro

  • ACEi

  • NSAIDs

  • Rhabdomyolysis

  • Addison’s Disease

  • Metabolic acidosis

  • Mild - K+ 5.5 - 5.9 mmol/L

  • Moderate - K+ 6.0 - 6.4 mmol/L

  • Severe - K+ ≥ 6.5 mmol/L

ECG changes:

  • Tall tented T waves
  • loss of P waves
  • broad QRS

All patients with severe hyperkalaemia or with ECG changes should have emergency treatment:

  • IV calcium gluconate - stabilise myocardium
  • Insulin/dextrose infusion - shift potassium into cells
  • Other - salbutamol nebs

Pneumonia

CURB-65 - one point for each

  • Confusion - AMTS 8
  • Urea - >7 mmol/L
  • RR - 30
  • Blood pressure < 90 systolic or <60 diastolic
  • Age 65 (soft score)

Management 0-1 - low risk home management - 500mg amoxicillin TDS for 5 days 2 - intermediate risk - short in-patient stay 3 - high risk - severe pneumonia

Broad spectrum antibiotics empirically - co-amoxiclav or ceftriaxone plus marcolide (clarythromycin)

Poisoning

Opioid

  • Pin point pupils
  • N&V
  • Reduced GCS
  • Bradycardia
  • Reduced RR

Naloxone - repeat doses or infusions may be required as cleared faster than opioids

Benzodiazepines

  • Pale
  • Clammy
  • Cool peripheries
  • Confused
  • Unsteady gait
  • Reduced RR

Flumazernil used to reverse - sudden withdrawal may causes seizures arrhythmias and hypotension

Tricyclic anti-depressants

TCA examples: amitriptyline, clomipramine, dosulepin, imipramine, lofepramine and nortriptyline

  • Dilated pupils
  • Fever
  • Dry skin
  • Urinary retention
  • Widening QRS

Give sodium bicarbonate - cardioprotective + lowers amount of active form of the drug

Paracetamol

  • RUQ pain
  • Jaundice
  • Deranged LFTs
      • ↑ AST
    • ↑ PT and INR
    • normal ALP and other factors not for hepatocyte damage
  • Coagulopathic
  • Renal failure ↑ creatinine
  • Lactic acidosis
Management

Immediate to <1 hour since ingestion: Activated charcoal to prevent absorption into the bloodstream

1 to 8 hours: Plot paracetamol concentration on concentration curve and determine if N-acetylcystine is required

8-24 hours: Calculate weight and start N-acetylcysteine if ingestion is > 150 mg/kg (or if Paracetamol concentration is not available).

24 hours+: Start N-acetylcystine or any time if they are clearly jaundiced or have hepatic tenderness, their ALT is above the upper limit of normal

Unsure or staggered overdose: Always give N-acetylcystine if unsure of the timeline or if there was more than 1 hour between taking all of the tablets

pulmonary embolism

Calculate risk with Well’s Score

Non-specific signs:

  • Tachypnoeic
  • Low SpO2
  • Tachycardic
  • Hypotensive
  • Raised JVP

Management

  • Well’s 4+ perform a CTPA or alternative

  • <4 perform a D-dimer and if positive get a CTPA

  • DOAC - apixaban or rivaroxaban first line

  • LMWH main alternative (e.g. in Kidney Failure patients)

Pneumothorax

  • Iatrogenic
  • Trauma
  • Ventilated patients

Deviated trachea with absence breath sounds & reduced chest expansion. Chest XR

Management:

  • Needle decompression (large bore cannula in 4th or 5th intercostal space anterior to mid axillary line just superior to following rib - NOT INFERIOR)

Sepsis

  • Blood cultures
  • Urine output - monitor hourly, U&Es, urine culture
  • Fluid resuscitation 500ml over 15 minutes
  • Antibiotics IV broad spec - LTHT guidelines (tazocin 4.5 g every 8 hours; increased if necessary to 4.5 g every 6 hours)
  • Lactate measurement - from arterial or venous blood gas
  • Oxygen to correct hypoxia

Status Epilepticus

  • Alcoholism
  • Drug use
  • Hypoxic episodes
  • Space occupying lesions
  • Trauma
  • Metabolic causes

Different classifications:

  • Generalised tonic-clonic
  • Focal - isolated muscle group twitching with intact consciousness
  • Non-convulsive - impaired awareness, absence, aware

Difficult to obtain obs

Management

  • IV lorazepam 0.1mg/kg - may be repeated once after 5-10 minutes
  • If status is ongoing can give second line agent - levetiracetam, Phenytoin or sodium valporate
  • Consider IV thiamine and glucose for Alcoholism
  • If refractory status (45 minutes from onset) RSI with anaesthesiologist

Ischaemic Stroke

  • Aspirin 300mg - as soon as hemorrhagic been excluded
  • Within 4.5hr = thrombectomy + thrombolysis (alteplase)
  • Within 6-24hrs = thrombectomy only
  • Wake up Stroke (unknown) = thrombectomy only

Discharge medications

  • Dual antiplatelet - 2 weeks 300mg then Aspirin 75mg + Clopidogrel 180mg
  • ACE inhibitor - reduce blood pressure
  • Beta blocker - reduce blood pressure
  • Statin 80mg

Graph View

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