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Objectives Lots of topics requested – Acute cardiopulmonary disease – Anaphylaxis – Cardiac arrest – ALS and BLS – Septic shock – Paediatrics – Head injury – TIA and Stroke Acute respiratory distress 24 year old with history of asthma arrives in some distress with a respiratory rate of 32 and SaO2 of 94%. Speaking in phrases. – Moderate to severe exacerbation – Initial treatment Salbutamol 5mg x 3 q20min Ipratropium 500mcg x 1 Oral or IV steroids Reassess Asthma continued No improvement after 2 nebs with increasing resp distress, intercostal recession, speaking in words Urgent situation Continuous nebulised salbutamol Intravenous salbutamol IV Magesium CPAP/ BiPAP Intubation preparation IV adrenaline in small doses eg 0.1mg diluted (1ml of 1:10,000) Take home messages Severe asthmatic – Continuous oxygen driven nebulisers – Get to hospital – Small doses of IV adrenaline can buy time – Intubation last resort 82 year old man presents by ambulance with sudden shortness of breath, chest tightness. Chest sounds wheezy and rattly. Coughing frothy pink sputum. Obs: pulse 96, BP 200/130, RR 32, sats 96% on NRB Diagnosis? Treatment? Hypertensive and LVF – need to reduce afterload, increase preload Fluid overload not usual problem ECG to rule out STEMI, Monitoring, O2, IV access Nitrates +/- morphine BiPAP – Reduces work of breathing – Forces fluid out of alveolar space LVF plus hypotension – Too much nitrate? – Tachyarrhythmia? – Cardiogenic shock Fluid gently if inferior AMI Inotropic Cath lab urgently if AMI Pneumothorax Types: – Primary spontaneous – Secondary – underlying lung disease – Traumatic +/- rib fractures Primary Pneumothorax 18yo presents with sudden onset of left pleuritic chest pain. Some SOB when walking No past med hx Primary pneumothorax Risk factors: – Smoking – – – – 12% lifetime risk in men vs 0.1% non-smokers Pleural blebs and bullae Tall, thin males Asthma history 50% recurrence rate in 4 years Evaluation of size: – British Thoracic Society Guideline 2003 – Expiratory CXR not required – Small vs Large ptx – 2cm rim of air = 50% ptx Primary pneumothorax cont Options for treatment: – Leave vs aspiration vs chest tube Leave < 2cm rim of air on CXR and not breathless Attempt aspiration > 2cm rim of air and/or breathless- 70-80% success Unsuccessful aspiration – Try again – Small bore intercostal catheter, remove at 24 hours if fully reexpanded – High flow oxygen Surgical pleurodesis at 5 days if persistent leak Aspiration Re Xray 4 hours after procedure Home if reexpanded • Warn if increasing pain, breathlessness to seek help immediately Re X ray next day then at 1-2 weeks Same if conservatively treated Follow up Reabsorbs over weeks No flying till fully resolved (airline rules 6 weeks) No diving ever Resumption of sporting activity ? 2-4 weeks Secondary pneumothorax Age > 50, underlying pulmonary disease High rate of failure of conservative treatment – Only small apical asymptomatic, < 1cm ptx Usually need hospitalisation with a small bore chest drain until reexpanded BTS guideline: – < 50yo, < 2cm rim of air, not breathless – try aspiration and admit 24 hours – > 50yo or > 2cm air or breathless - ICC – Early surgical referral (3 days) Traumatic ptx Ptx on CXR usually requires ICC and admission Especially if requiring GA Traumatic ptx on CT scan less important Take home messages Asymptomatic ptx < 2cm can be treated conservatively – in under 50, – no underlying lung disease Many primary pneumothoraces can be aspirated – 70-80% success 60 year old with no known history of allergy eating an asian meal at a local restaurant. Within 2 minutes develops generalised erythema and itch, vomits, dizzy and collapses. Develops increasing of face and tongue and a hoarse voice, difficulty breathing Anaphylaxis Classified: – mild: skin and subcutaneous tissues only non-sedating antihistamines (cetirizine, loratidine) for symptoms – moderate: features suggesting respiratory, cardiovascular, or gastrointestinal involvement – severe: hypoxia, hypotension or neurological compromise Treatment of mod/severe anaphylaxis Emergency management of anaphylaxis: – Adrenaline – Adrenaline – Adrenaline 0.5ml of 1:1000 amp IM in the lateral thigh (0.1 ml/kg to maximum 0.5ml) ie half a 1ml amp for an adult May be repeated every 3-5 minutes depending on response Beware of using IV adrenaline Adjunctive treatment Lie patient flat Oxygen IV access/ NS 20mg/kg Salbutamol neb for bronchospasm Neb adrenaline for upper airway obstruction Atropine for bradycardia Glucagon for beta blocked patients Steroids, antihistamines - H1 and H2 blockers (eg ranitidine) Keep for 4 hours minimum post Adrenaline – should be observed in ED Follow up with allergy specialist if severe – RNSH OPD If severe provide EpiPen (0.3mg) and instructions Cardiology Acute coronary syndromes – ETAMI – High sensitivity troponins ETAMI - Emergency Treatment of AMI Ambulance paramedics do an ECG on patients with chest pain Across Northern Sydney transmitted to RNSH ED 24 hours ECG Read by EM specialist/registrar call back to ambulance via mobile – STEMI: transport to RNSH/ Cath lab alerted – others: to local hospital ETAMI Pioneered at RNSH from 2004 Front door to needle time of 18 minutes Sydney wide system from August to cath labs at major hospitals High sensitivity troponins 6-7% patients present to ED with chest pain – about 3,500 pa. Half have ACS. Over 10,000 troponins a year Until end 2009 using 3rd gen trop test: – NR < 0.03 mg/L, 0.03 – 0.2 equivocal Now 4th generation troponin assay – < 14ng/ml negative, 13-100ng/mL equivocal What does this mean? – Many more false positives – How do you interpret a low positive test? High sensitivity troponins cont. Patients need to be clinically risk stratified – Good ACS story plus N trop = admission for Ix – Poor ACS story plus low N trop may be able to go home Change in serial troponin important – We are using 30% change in 6 hours – 3 hour trop for high risk patients Be aware of other diagnoses causing rise in troponin Non ACS causes of raised troponin Pulmonary embolism Acute cardiac failure Myocarditis Aortic dissection Acute decompensated AV disease Renal insufficiency BLS and ALS changes BLS – New literature emphasising minimal interruptions to ECM questioning role of early breathing interventions – compression only CPR? – ARC: "ANY ATTEMPT AT RESUSCITATION IS BETTER THAN NO ATTEMPT" and if a rescuer is unwilling to do rescue breaths then chest compressions are better than nothing.” – Revised ARC guidelines due Dec 2010 – www.resus.org.au/ BLS – Rate of compression to breath 30:2 – 2 initial rescue breaths – ECM 100/min (5 cycles in 2 minutes) – Frequent rotation of rescuers – every 2 minutes – Don’t interrupt CPR to check for signs of life – Use AED as soon as available ALS for VF /pulseless VT Early defibrillation for VF Look for alternative reversible causes Witnessed arrest – Precordial thump – Stacked shocks x 3 - 200J biphasic defib – AEDs will only deliver a single shock – Commence CPR ASAP ALS for VF/pulseless VT Further DC shocks for VF/VT: – Given every 2 minutes Adrenaline (1mg) IV – 10mls of 1:10000 – Given every 3 minutes Securing airway – no more than 20 seconds break in CPR ALS - other drugs Antiarrhythmics – Amiodarone drug of choice for prolonged VF/pulseless VT – 300mg (5mg/kg) Atropine, Calcium, Bicarbonate, Magnesium – No evidence of benefit except in specific circumstances Patient in non-shockable rhythm Asystole/Pulseless Electrical Activity – CPR / Rescue breathing 30:2 – Adrenaline every 3 minutes – Search for a reversible cause: 4 H’s and 4T’s: Hypoxia Hypovolaemia Hypo/hyperkalaemia Hypo/hyperthermia cardiac Tamponade Tension ptx Toxins / drugs Thrombosis – pulm or Paediatric resus Rare! Shocks: first 2J/kg then subsequent 4J/kg Importance of CPR/rescue breathing Ratio for advanced providers 15:2 Using IO access Take home messages Don’t interrupt chest compressions – 100/min – change regularly Place of rescue breathing being questioned but still in guidelines – Ratio 30:2 DC shocks 2 minutely for VT/VF Adrenaline 1mg IV q3min 70 year old man presents with a week of left loin pain, difficulty passing urine, poor oral intake. Now confused and febrile. At triage vital signs: – P 120, BP 90/60, – RR 28/min, sats 98% room air, – T39.2 EGDT in septic shock Early 2000’s US study (Rivers) – aggressive early resuscitation, – Early ICU care, – maintenance of blood pressure with inotropes, – Hb/haematocrit optimisation, – Careful monitoring of oxygenation via CVC – improved mortality 50% to 35% Clinical Excellence Commission Sepsis Review Recent NSW study showed septic shock markedly over represented in major reported incidents – Across all types of hosp. – Non-recognition of sepsis – Delays in starting treatment ABx Treatment of poor organ perfusion – Poor monitoring of vital signs – Over 65 yo and after hours over represented – Oliguria, hypotension, tachycardia +/- fever = septic shock until proven otherwise ARISE trial attempting to study role of EGDT in Australian population - RNSH lead hospital Patients who present with: – sepsis (T >38 or < 34 with evidence of an infection) – BP < 90 systolic not responding to 1000mls IV fluid or – Lactate > 4 All get early antibiotics Randomised into trial for EGDT vs normal treatment ADULT Sepsis / SIRS Guideline* 0 Hrs Does the Patient meet the SEPSIS CRITERIA? SEPSIS CRITERIA Known or Suspected Infection PLUS: ≥ 2 SIRS criteria Temp ≤ 36.0 or ≥38.0°C Heart Rate > 90 Resp Rate >20 or PaCO2 <32 mmHg WCC >12 or <4 + Triage to Resuscitation Room or acute area Category 2 YES Initiate Initial management Insert IV line Bloods / ABG & lactate Blood Cultures / Urine MC&S / Swabs & CXR Consider LP IV fluids IV Antibiotics Reassess in 1 Hr For Surgical causes contact the Surgical Team NO ORGAN DYSFUNCTION Pale / Clammy skin Tachycardia / Tachypnoea Systolic < 90 or > 40mmHg drop from baseline in hypertensive pt Acute change in mental status Oliguria (<0.5 ml/kg/hr) Lactic Acidosis – Lactate 4 (For Elderly/ Frail patients, more frequent reassessment may be required) Exit Guideline Refer to admitting team NO SEPTIC SHOCK CRITERIA Acute Circulatory failure and Persistent hypotension despite fluid resuscitation & not explained by other causes EVIDENCE OF ORGAN DYSFUNCTION or SEPTIC SHOCK O YES Inform Registrar in charge Transfer to Resus room Insert second IV line Second set of Blood Cultures Coags/DIC screen Bolus 500mls Crystalloid over 10 mins / Reassess & repeat up to 2litres Crystalloid as required + Broad Spectrum IV Antibiotics Insertion of IDC & hourly U/O monitoring Early Treatment goals (2hrs) Capillary Refill < 2secs U/O > 0.5 ml/kg/hr MAP >65 Contact ED Consultant for: ICU referral and Admission Ongoing Fluid Resuscitation 500mls Crystalloid over 10 mins / Reassess & Repeat Consideration of CVP Line Placement Arterial line Vasopressors 2 Hrs NO Is the Patient achieving the Early Treatment goals within 2 hrs? YES Continue to monitor and reassess patient. Aim to maintain vital signs. Admit to appropriate Inpatient team / ICU as necessary *This is a general guideline only – it is always important to consider the individual requirements of the patient and to give consideration to other clinical causes Adapted from Manly Hospital Sepsis guideline, Drs Phipps, Rochford, Franks & LKirkwood 70 yo patient with urosepsis: – Recognition at triage – resus bed – Aggressive fluid resuscitation to restore BP > 90 systolic – may need 2-4 litres – After 1000mls NS if BP< 90 or lactate > 4 entered into ARISE trial – Early antibiotics essential – broad spectrum ABx should be given within one hour – Early inotropic support eg noradrenaline – Look for a source – urine, abdominal, chest, cannulas, cellulitis, others Take home messages Think about sepsis as a diagnosis – subtle early signs Urosepsis, hypotension dangerous combination Early antibiotics and resuscitation Paediatrics - dehydration DOH CPG: Management of Children with Gastroenteritis http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_009.pdf Major themes: – Rehydration: Less use of IV fluids More emphasis on oral rehydration – If child requires IV: Use of NS + 2.5% glucose rather than hypotonic solutions Oral rehydration Oral rehydration solutions – Hydralyte, Gastrolyte (no sports drinks, fruit juice, soft drinks) Parent should offer 0.5mls/kg every 5 minutes eg with a syringe – Charted by parent including vomits, U/O Parental attention, persistence encouraged by staff Rapid rehydration via NGT an option – ORS via Kangaroo pump @ 10mls/kg/hr x 4hrs Medications in gastroenteritis Antiemetics: – Ondansetron: some evidence of benefit – No evidence for prochlorperazine or metoclopramide Antidiarrhoeals – No evidence Antibiotics: – Rarely required / antimotility agents IV therapy Who for? – Mild (3%) - Reduced UO, Thirst, Dry mucous membranes, mild tachycardia – Oral only required – Moderate (5%) - Dry mucous membranes, tachycardia, abnormal respiratory pattern, lethargy, reduced skin turgor, sunken eyes – try oral first if fails go to IV IV therapy – Severe (10%) – all of above, poor perfusion: mottled, cool limbs/Slow capillary refill/Altered consciousness Shock: thready peripheral pulses with marked tachycardia and other signs of poor perfusion – IV or IO therapy, 20mls/kg bolus NS Which IV solution? NS plus 2.5% or 5% glucose Reduced risk of hyponatraemia All get an EUC, BGL Low BGL < 3.5 or formal BSL < 2.6 – extra glucose bolus IV Rehydration: rapid over 4 hours or standard over 24 hours Who gets admitted? Go home Most Mild Dehyd – Must have passed urine, able to take some fluid – occasional social admission – GP review in 24-48 hours Moderate who pass TOF go home Admitted Mild < 6mths Moderate who fail TOF any severe get admitted for IV therapy Any question about diagnosis RNS doesn’t do acute paed abdo surgery < 14yo eg appendicitis, torsion testis Red flags Gastroenteritis = V + D + fever – Beware vomiting in the absence of diarrhoea Differential diagnosis large: – Appendicitis – Intussusception < 2yo Beware: Abdominal distension Bile-stained vomiting Fever >39ºC Blood in vomitus or stool Severe abdominal pain Headache n n n n n n n Reintroduction of diet BF should continue with ORS supplement if needed Resume N diet as soon as vomiting stops Fact sheet on CHW website Some evidence probiotics helpful 2yo, presents in the late evening, 2 days of upper respiratory symptoms, barking cough Tonight increasing, cough, agitation, stridor Immunised On exam sitting forward, alert but not interacting much, insp. stridor at rest, intercostal recession, accessory muscle use Not toxic looking Hopefully hear the cough! Moderate/severe croup Straight into resus area Monitor pulse and saturations P140, RR 36, sats 99% Nebulised adrenaline - 5mg of 1:1000 – Rapid action, lasts 2 hours Dexamethasone mg/kg – IM (or po) 0.3 Paeds - croup New DOH clinical practice guideline in Aug 2010: http://www.health.nsw.gov.au/policies/pd/2010/pdf/PD2010_053.pdf Mostly 6-36 months Mostly viral - RSV, parainfluenza Spasmodic croup – atopic group, sudden onset, improve quicker, recurrent Worry if: Rising pulse, RR Less interactive, more agitated/anxious, sleepy More respiratory distress Cyanosis/pallor or low O2 sats a late sign Disposition • If settle after neb Adrenaline – 4 hours obs and home – Expect illness last 4-5 days – GP review – Mostly only need one dose steroids - Use of steroids has dramatically decreased admission and intubation rates Admit – If further neb Ad needed – Age < 6 mths – Any uncertainty about dx Differential diagnosis: – Less than 3 months think ? Structural /congenital problem – Foreign body – Epiglottitis – Bacterial tracheitis Croup – take home messages Nebulised adrenaline 0.5mls/kg to 5mls of 1:1000 (5mg) for mod or severe. At least 4 hours obs needed. Steroids – one (or two) doses only has reduced admission/complication rates A 4 month old child presents snuffly for the last couple of days, occasional coughing, low grade fevers. Breast feeding poorly, decreased wet nappies. Today mum has noticed breathing rapidly, seems to be working hard. On exam: pulse 160, RR 40, nasal flaring, intercostal recession, sats 92% room air Chest auscultation: fine crackles on inspiration, occasional exp wheeze. Most likely diagnosis? Management? Paeds - bronchiolitis DOH CPG available Mostly children less than 12 months RSV causes > 90% Clinical diagnosis – No CXR unless another dx eg bacterial pneumonia suspected Differential dx in this case? Acute asthma – less than 12 months, not recurrent episodes Pneumonia – not toxic, URTI sx Bronchial foreign body – infective history, not sudden onset in well child Pertussis – cough not prominent, no contacts Cardiac failure – usually earlier, well child till now, normal growth Management of bronchiolitis Self limiting viral illness – red flags: – Less than 3 months, preterm/small – risk of apnoeas – Underlying heart or lung disease – Feeding poorly/dehydrated – Apnoeas – Resp distress – tiring, marked chest wall retractions, grunting, low O2 sats Treatment mainstays: – Oxygen, adequate hydration – No role for bronchodilators, steroids or antibiotics How sick is this child? A 4 month old child presents snuffly for the last couple of days, occasional coughing, low grade fevers. Breast feeding poorly, decreased wet nappies. Today mum has noticed breathing rapidly, seems to be working hard. On exam: pulse 160, RR 40, nasal flaring, intercostal recession, sats 92% room air Chest auscultation: fine crackles on inspiration, occasional exp wheeze. How sick is this child? A 4 month old child presents snuffly for the last couple of days, occasional coughing, low grade fevers. Breast feeding poorly, decreased wet nappies. Today mum has noticed breathing rapidly, seems to be working hard. On exam: pulse 160, RR 40, nasal flaring, intercostal recession, sats 92% room air Chest auscultation: fine crackles on inspiration, occasional exp wheeze. Moderate bronchiolitis Admit for: – O2 to keep sats > 95% – Look at child feed: IV fluids vs oral rehydration – Close observation for apnoeas – NPA for RSV – no CXR Home when normal feeding, little or no resp distress, not hypoxaemic Head Injury – Case 1 18yo who presents after a having a few drinks, falling with a short LOC less than a minute. Now alert and orientated but complaining of dizziness and a headache, vomited once. Haematoma over forehead. Does he need to come to hospital? Does he need a CT scan? Follow up needed? Time off sport? Head Injury – Case 2 72 year old on warfarin for chronic AF. INR 2.3 last week. Simple fall at home with a scalp lac needs suturing. Possible short loss of consciousness, amnesic for event. Does he need to come to hospital? Does he need a CT scan? Follow up needed? Mild head injury Low Risk Factors LOC < 5 minutes Amnesia < 30 min GCS 15 at 2 hours No focal neuro deficit No evidence for skull fracture No seizure post event Nausea or single vomit Mild headache Age < 65 No coagulopathy Isolated HI No drug or alcohol ingestion High Risk Factors LOC > 5 minutes Amnesia > 30 min GCS < 15 Focal neuro deficit Possible skull fracture Post event seizure 2 or more vomits Severe headache Age > 65 Coagulopathy Multiple injury/ dangerous mechanism Drugs or alcohol Representation Indication for CT scanning and prolonged observation Mild head injury 4 hours observation and home if: - normal cognition and alertness - N CT or no indication for a CT - should be a responsible person at home - given HI advice sheet - be able to return Keep in hospital if: - clinical symptoms not improving at 4 hours - abnormal CT scan - use judgement - elderly - coagulopathy - intoxicated - social issues Case 1 - 18yo – 4 hours obs and home if well to parents with HI advice card Case 2 - CT scan head, check INR, observe. May need overnight stay. CT radiation effective dose Chart giving effective dose in mSv/CXRs/cigarettes/hours of plane travel Eg CT head = 2.3 mSv = 115 CXR = 1 yr of background radiation = 920 cigs = 329 hours of plane travel CT radiation effective dose Lumbar spine XR = 65 CXR CT chest = 400 CXR CT abdo/pelvis = 500 CXR Increase in cancer risk under 40yo Head CT on a 1yo may give lifetime cancer risk of 1:1000 1 mSV = 500CXR = smoking 400 cigs = 1:17,000 ca risk 74 year old presents with a episode of left arm weakness lasting 30 minutes which has now resolved. P 72 regular, BP 145/95 Not diabetic, no cardiac history You diagnose a TIA. What is his risk of having an early acute stroke? ABCD2 Score for TIA Age ≥ 60? Yes +1 BP ≥ 140/90 mmHg at initial evaluation? Yes +1 Clinical Features of the TIA: – Unilateral Weakness – Speech Disturbance without Weakness +2 +1 Duration of Symptoms? 10-59 minutes ≥ 60 minutes Diabetes in Patient's History? +1 +2 Yes +1 High risk TIAs Score of 3 or above: – Start aspirin (as with all TIA) – Early specialist investigation in next 24 hours ie hospitalisation – TIA clinic Why? – New onset TIA - 10% risk of stroke in next 90 days however half will have their stroke in the first week Acute stroke management at RNSH IV TPA is offered for acute thrombotic/embolic stroke able to be investigated and treated within 3 hours IA thrombolysis is offered up to 6 hours Time is from the time last seen normal ED arranges CT, rings stroke team, neurologist makes decision and administers Stroke unit/HDU bed after procedure That’s All Folks!
