Trauma - Lecture Note

Common F1 acute situations • • • • • • • • • • • • Cardio-respiratory arrest Acute coronary syndrome Severe sepsis Allergy/Anaphylaxis Infective exacerbation of asthma / COPD Acute Asthma Hypo/Hyperglycaemia Overdose Status epilepticus Massive blood loss Acute confusion Dysthrhythmias ALS Life Support Algorithm Unresponsive Open Airway Check for signs of life Call for Resus Team CPR 30:2 Until ECG/defib monitor available Assess Rhythm Shockable (VF / pulseless VT) During CPR • • 1 Shock • 150-360J biphasic or 360J monophasic • Resume 30:2 for 2 minutes • • Check reversible causes Check electrode positions and contacts Establish IV access and start O2 Uninterrupted compressions once airway secure Adrenaline every 3-5 minutes Consider amiodarone/ atropine/Mg Not Shockable (PEA / Asystole) Resume 30:2 for 2 minutes Reversible Causes Hypoxia Hypovolaemia Hypo/hyperkalaemia (metabolic) Hypothermia Tension Pneumothorax Tamponade Toxins Thrombosis (cardiac/PE) Acute Coronary syndromes Septicaemia • • • • • • • • • Give high flow O2 Start vigourous fluid resus Blood tests – routine, lactate and cultures Monitor ECG, BP and SaO2 Catheterise bladder and monitor urine output & fluid balance Look for infection source (chest, abdo, soft tissue in DM, brain) Start broad spectrum antibiotics – if no obvious cause give broad spectrum B-lactam (piperacillin) + tazobactam Refer to inpatient/ICU team Low dose steroids may help Anaphylaxis Upper airway obstruction Summon skilled anaesthetic and ENT help Adrenaline Administer adrenaline parenteral Consider nebulised adrenaline if less acute Give IV hydrocortisone (300mg) and IV chlorphenamine (10mg) Bronchospasm Anaesthetic help in severe cases Nebulised bronchodilator (salbutamol 5mg) IV hydrocortisone (300mg) and IV chlorphenamine (10mg) Consider IV salbutamol or parenteral adrenaline if severe Shock Due to vasodilatation and maldistribution of fluid Rapid IV fluids (20ml/kg) IV hydrocortisone (300mg) and IV chlorphenamine (10mg) Consider parenteral adrenaline in severe cases Infective exacerbation of COPD/Asthma Increased dyspnoea Purulent sputum Increased sputum volume Ix PEFR – PEF<100l/m = severe exacerbation Pulse-Ox – of little use as many COPD have sats below 90% normally Blood Gases – hypoxia with rising hypercapnia & respiratory acidosis – Repeat after 30-60 mins of Rx FBC & Electrolytes CXR ECG If on regular theophyllines à plasma theophylline Sputum sent for microscopy and culture Rx Sit up and give O2 to keep sats above 90% Bronchodilators Nebulised B2 adrenoceptor agonists (salbutamol 5mg / terbutaline 10mg made up to 5 ml with normal saline). Ipratropium bromide may also be helpful – 30 minute delay in action but lasts 36hours IV aminophylline if poor response to nebulisers – loading does 5mh/kg over 20mins with ECG monitoring à 500 μg / kg / h. ALWAYS check if already on as narrow therapeutic range Oxygen Is the patient known to have previous episodes of hypercapnic respiratory failure? Is the patient drowsy IF NO TO BOTH – give 100% O2 IF YES TO EITHER – give 24-35% O2 until more info available, keep SaO2 =90-92% Steroids Prednisolone 30mg daily for 1-2 weeks, or 200-300mg IV if unable to swallow tablets in ED Antibiotics If purulent sputum H.Infulenzae, Strep pneumoniae and Moxarella caterrhalis are typical pathogens Amoxycillin 500mg tds or tetracycline 250mg qds are suitable 1st line Other if resistance include trimethoprim 200mg bd, co-amoxiclav or quinolones (ciprofloxacin) Admission Difficulty coping at home Poor/deteriorating physical health Poor activity / confined to bed Long term O2 therapy Significant co-morbidity (esp cardiac disease or IDDM) Rapid onset exacerbation Severe breathlessness / cyanosis Acute confusion / impaired consciousness SaO2 < 90%, pH < 7.35 or PaO2 < 7kPa CXR changes