Acute Treatment Of Emergent Conditions In Adults By Chris Krause

Front 1

Acute treatment of elevated intracranial pressure / traumatic brain injury.

Back 1

ICP above 20mmHg is abnormal.

1) PREVENT HYPOXIA: Maintain adequate oxygenation (O2 >95%), securing the airway early if necessary. Provide adequate sedation during and post intubation.

2) PREVENT HYPOTENSION: Adequately volume resuscitate and watch the BP carefully.

3) Elevate head of bed to 30 degrees, using reverse Trendeleburg if there are spinal precautions.

4) Mannitol 0.5-1g/kg IV. Starts working within 30 minutes and can last up to 6-8 hours.

5) Look for and correct coagulopathy.

6) Consider seizure prophylaxis with dilantin (20 mg/kg) or keppra.

6) Maintain pCO2 at 35-40 mmHg. DO NOT HYPERVENTILATE UNLESS THE PERSON IS CONING, and even then only go down to 30-35 mmHg.

Front 2

Acute treatment of acute angle closure glaucoma/elevated intraocular pressure.

Back 2

Step 1: Block production of aqueous humor using all of the following:
- carbonic anhydrase inhibitor, e.g. acetazolamide 500mg IV or PO
- topical beta blocker, e.g. timolol 0.5% one drop
- topical alpha agonist, e.g. apraclonidine 1% one drop

Step 2: Reduce volume of aqueous humor using:
- osmotic diuretic, i.e. mannitol 1-2g/kg IV

Step 3: shrink the pupil to allow outflow of aqueous humor (will only work once IOP is below 40) using:
- topical cholinergic agent, e.g. pilocarpine 1-2% two drops over 15 minutes then QID.

Front 3

What is a hypertensive emergency? Describe the acute treatment of hypertensive emergency.

Back 3

DEFINITION - A hypertensive emergency is acute hypertension (180/120 or greater) associated with end-organ damage. Examples of end-organ damage include:
--> Cardiovascular complications: Aortic dissection, acute pulmonary edema, acute MI/acute coronary syndrome.
--> Intracranial complications: Hypertensive encephalopathy, subarachnoid hemorrhage, cerebral hemorrhage, ischemic stroke.
--> Other organs/special cases: Acute renal failure, hypertensive retinopathy, severe pre-eclampsia/eclampsia/HELLP syndrome, sympathetic crisis (due to stimulant overdose or pheochromocytoma).

TREATMENT - Varies somewhat depending on cause. First, let's look at some specific considerations:

For sympathetic crisis - benzos, benzos, benzos. Phentolamine 5-10mg IV can also be used.

For aortic dissection - MUST start with a beta-blocker because it is critical to decrease heart rate as well as BP - decreases shear forces on the heart - labetalol 10-20mg q10min, or 1-2mg/min infusion.

For pulmonary edema - nitroglycerine - patch (0.4-0.8mg/hr) or infusion 10-100 mcg/min. AVOID B-blockers.

In pregnant patients - remember to add magnesium sulfate for seizure prophylaxis.

What about the generic hypertensive crisis?
1) Labetalol 10-20mg IV or 1-2mg/min gtt.
2) Hydralazine 10-20mg IV prn.
3) Nicardipine infusion. Start at 5mg/hr, can increase by 2.5mg/hr gradually, max dose 15mg/hr.

How much should BP be lowered?

Some targets:
- Aortic dissection: sBP less than 120 (and HR less than 60)
- Subarachnoid hemorrhage: MAP less than 130 (or restoration of patient's pre-hemorrhage BP)
- AAA: no target. Just maintain the BP, and avoid hypotension.
- Stroke patients WHO ARE THROMBOLYSIS candidates - less than 180/110. If not candidates for thrombolysis, don't treat.

If you don't know the target for a particular medical condition, just decrease it by 20% and see what happens.

FOR ALL OF THE ABOVE MEDICATIONS, IF PATIENT IS ELDERLY OR MEDICALLY FRAIL - CUT THE INITIAL DOSE IN HALF.

Front 4

What are the 3 guiding principles when treating a patient with sepsis?

Back 4

The foundation of sepsis treatment is based on three principles:
1) Early goal-directed therapy
2) Lung-protective ventilation
3) Broad-spectrum empiric antibiotic coverage.

Front 5

In sepsis, define and describe early goal directed therapy (EGDT).

Back 5

EGDT is a strategy to guide the early (initial 6 hours) management of patients with severe sepsis (meaning sepsis with end-organ dysfunction) or septic shock (meaning sepsis with hypotension).

It has 3 components: 1) Optimization of oxygenation, ventilation, and circulation; 2) Initiation of drug therapy, including antibiotics; and 3) Source control.

TARGET #1: SpO2 > 90%.
Administer supplemental oxygen to achieve target O2. Intubate, sedate, and paralyze if necessary to decrease oxygen consumption (once intubated, ventilate at 6 ml/kg ideal body weight).

TARGET #2: MAP > 65mmHg. Start with aggressive administration of IV crystalloid. May take 4-6L or more. If still hypotensive after 3-4 L of fluid, consider inotropes.

TARGET #3: CVP 8-12 mmHg.

TARGET #4: Sv02 > 70%. If too low despite adequate oxygenation and blood pressure, consider intubation or transfusion.

TARGET #5: Hemoglobin 70-90.

TARGET #6: Urine output 0.5-1cc/kg/hr.

WHAT ABOUT SHOCK REFRACTORY TO ALL THE ABOVE MEASURES? Give hydrocortisone 100mg IV q8h (or 50 mg IV q6h).

Front 6

What does lung-protective ventilation mean?

Back 6

It means two things:

1) Limiting plateau pressures to less than 30 cmH20.

2) Targeting tidal volumes to 6 cc/kg of ideal body weight.

Front 7

Acute treatment of vaginal bleeding.

Back 7

First, determine if the woman is pregnant or not. If pregnant, it depends on whether it's first or third trimester.
If not pregnant:

1) Resuscitation and blood transfusion if indicated.

2) Ideally, endometrial biopsy would be done prior to initiating treatment.

3) Unstable women will likely need D&C, which is diagnostic and therapeutic. Uterine artery embolization should be done for uterine AVM.

4) Stable women can be treated with high dose estrogen (always give anti-emetics with high dose estrogen):
- Estrogen 25mg IV, if effective, will stop the bleeding within 6 hours.
- Birth control pills can be given, 4/day for 4 days, 3/day for 3 days, 2/day for 2 days, then 1/day until 21 days total.
- OR Premarin 2.5 mg qid until the bleeding stops, followed by medroxyprogesterone acetate 10mg daily x 10 days - this will be followed by a heavy period, which is normal.

5) Anovulatory bleeding can be treated just with medroxyprogesterone acetate 10mg daily or twice/day x 10 days (without the need for estrogen).

Front 8

Acute treatment of asthma exacerbation.

Back 8

1) IV, O2, monitors. Assess work of breathing, consider PEF or FEV or other test of pulmonary function. In children, consider using the PRAM score to assess severity.

2) Give short acting bronchodilators:
If giving nebulized meds, give salbutamol 2.5-5mg neb, with ipratropium 0.25-0.5mg neb - may give q15 minutes up to 3 times.
If giving MDI, give salbutamol and ipratropium 4-8 puffs q 15 minutes up to 3 doses.

3) Systemic corticosteroid, e.g. prednisone 1 mg/kg, or dexamethasone 0.6mg/kg.

4) Magnesium 1-2g IV (75mg/kg in children)

5) IV fluid bolus 20 cc/kg.

6) IV salbutamol (like hell I'm going to try that).

7) IM epinephrine (0.3-0.5mg IM), or inhaled epinephine (5mL of 1:1000 = 5mg via nebulizer).

8) IV epinephrine.

9) NIPPV, e.g. CPAP or BiPAP.

10) Intubation with ketamine (due to bronchodilator properties).

11) What to do if an intubated asthmatic codes: disconnect ventilator, squeeze the air out of their chest, bilateral needle decompression, bilateral chest tubes, fluid bolus.

Front 9

Describe the management of status epilepticus.

Back 9

1) Attach monitors, check for hypoxia and hypoglycemia (treat as appropriate).

2) If IV access - lorazepam 0.1mg/kg up to adult dose, which is 4 mg IV - or other benzo of your choice.
If no IV access and unable to start IO - Midazolam buccal (0.5mg/kg) or intranasal (0.3mg/kg).

3) If still seizing, repeat lorazepam 0.1mg/kg IV up to adult dose of 4mg.

4) If still seizing, phenytoin 20 mg/kg IV (must be infused slowly, 50mg/min).

5) ADULTS: If still seizing, start IV propofol and intubate (loading dose 2 mg/kg, and infusion at 2-10 mg/kg/hr).

SPECIAL CASES:
- Consider pyridoxine 100mg IV/PO for seizures due to Vitamin B6 deficiency.
- Consider sodium bicarbonate 1 amp IV prn for toxic seizures, e.g. TCA overdose.

Front 10

Acute treatment of anaphylaxis.

Back 10

1) IV, O2, monitors (do not delay administration of epinephrine in order to establish IV access or monitoring).

2) Epinephrine IM.
Adult dose is 0.3-0.5mg IM.
*CAN BE GIVEN q5-15min.*

3) IV fluid 20 ml/kg bolus. This should be started at the first signs of shock or if intubation is imminent.

4) Antihistamines:
Give an H1 antagonist, e.g. Benadryl 1mg/kg IV or IM, up to adult dose of 50mg.
Give an H2 antagonist e.g. ranitidine 1mg/kg IV up to adult dose of 50mg.

5) Corticosteroids.
If able to take oral - prednisone 1mg/kg po up to 50 mg.
If GI symptoms or more severe reaction - methylprednisolone 1mg/kg IV up to 125mg.

6) Inhaled medications - e.g. ventolin or nebulized epinephine - can be give for wheezing, or stridor, respectively.

7) For hypotension that persists despite repeated IM epinephrine and IV fluid boluses:
--> Start an IV epinephrine infusion, start at 0.1 mcg/kg/min and titrate up.

8) For patients on beta blockers who are not responding to the epinephrine:
--> glucagon 1mg IV is adult dose. For peds can divide by 50 and give 20 mcg/kg IV.

9) Discharge medications should include:
- a new epipen
- 3 days of antihistamines and steroids (limited data to support)
- teaching regarding biphasic reactions

Front 11

Acute treatment of hyperkalemia.

Back 11

3 steps: Stabilize the cardiac membrane, shift the K+ into the cells, and enhance excretion of the K+.

1) Stabilize the cardiac membrane:
- Give one amp (10 mL) of calcium chloride (preferred if you have a central line) or 1-3 amps of calcium gluconate (better if you only have a peripheral line).

2) Shift the K+ intracellularly. Can give:
- Ventolin 2.5-5mg neb (works the fastest)
- Sodium bicarbonate one amp (50mL) IV
- Insulin 10 units IV (give with one amp (50mL) of D50 to prevent hypoglycemia).

3) Excrete/eliminate the K+. Can try:
- Furosemide 40mg IV.
- Kayexelate (sodium polystyrene sulfonate) 15-30mg PO or PR.
- Hemodialysis.

Front 12

Acute treatment of heart failure/pulmonary edema.

Back 12

1) Oxygen and positioning (sitting up).

2) Nitro, either SL, patch, or infusion.

3) Start IV lasix - IF there is volume overload. Initial dose 40mg IV, or give their current PO dose IV.

4) If dyspnea is severe, begin non-invasive ventilation (i.e. BiPAP).

Front 13

What is the approach to acute, significant bleeding in a patient with a bleeding disorder?

Back 13

FIRST, EVERYONE SHOULD GET:
1) IV, O2, monitors
2) Apply direct pressure to the source of bleeding, if possible (e.g. nose, scalp, etc).
3) Draw labs for CBC, PTT, INR, fibrinogen, and type & screen with cross-match.

THE NEXT STEP DEPENDS ON WHAT DISEASE THEY HAVE
1) If you have absolutely no clue what they have, but you're pretty sure it's something:
Give FFP 4 units IV (adult dose) or 10mL/kg (peds dose).
This has got all the clotting factors in it so somehow they should get whatever they are lacking.

2) If they have Hemophilia A, they should theoretically be getting Factor VIII. But ASK THEM what they get, hopefully they know or it's in the old charts.
Also: ASK THEM if they have an inhibitor (i.e. antibody against factor VIII), in which case it will be useless or even dangerous to give them the factor.
(Alternatives include Factor VIIa, FEIBA, PCCs such as Octaplex - but don't memorize these).

3) If they have Hemophilia B, they should get Factor IX. But again, ASK THEM what to do and ASK THEM about inhibitors.

4) If they have vWD, again you can ASK THEM. The treatment depends on what type of vWD they have.
Options include:
- DDAVP (aka desmopressin) causes vWF and factor VIII to be released from endothelial cells, temporarily increasing the amount in the blood and allowing clots to form (because it causes release of Factor VIII it may also work for Hemophila A).
- Tranexamic acid (TXA) may be helpful for mucosal bleeding.
- Cryoprecipitate, which contains Factor VIII, vWF, and fibrinogen, would be a good choice for any serious bleeding.

Front 14

Acute treatment of priapism.

Back 14

Only low-flow (i.e. ischemic) priapism needs to be treated. This is the painful kind.

1) Provide narcotic analgesia and/or benzodiazepines for anxiolysis.

2) Can try pseudoepherine 60-120mg po - but it never works.

3) Next step is to aspirate the corpus cavernosum - this may not be necessary if the erection has lasted less than 4 hours.
First, perform a penile block with local anaesthetic.
Then, insert a 19g butterfly needle at 2 or 10 o'clock and gently suction anywhere from 5 to 20cc of blood.

4) After aspiration, inject phenylephine 100 to 500mcg into the same butterfly syringe. It can be diluted so the volume matches the volume of blood withdrawn, or, if the patient presented early, this can be done without first aspirating.

5) Repeat q5mins for up to an hour.

Some patients will require surgical intervention.

Front 15

Acute treatment of hypercalcemia.

Back 15

Treat symptomatic patients with a calcium >3, or ANY patients with a calcium >3.5. The treatment is fluid, calcitonin, and a bisphosphonate.

1) Volume repletion with normal saline at 2-3 times maintenance. CAUTION! No need to give excessive fluid, just titrate to a urine output of 2cc/kg/hr or so. Avoid volume overload, which can occur due to hypercalcemia-induced renal dysfunction.

2) Calcitonin 4 units/kg SC/IM (NOT intranasal) q12h.

3) Pamidronate 90mg IV.

Front 16

Acute treatment of hyponatremia.

Back 16

Treat any patient with sodium below 120 or who is symptomatic.

Hypovolemic patients generally need fluid, and euvolemic patients generally need fluid restriction.

The fluid you give will usually be normal saline, and the rate can be estimated using the sodium deficit.

Sodium deficit can be calculated with the formula:
Sodium Deficit = (Target [Na] - Actual [Na]) x Total Body Water
(TBW = weight in kg x 0.6L/kg)

Target an increase of less than 0.5mEq/hr, i.e. less than 12mEq in 24 hrs.

Patients who are comatose or seizing may need hypertonic (3%) saline:
- Give 100mL of hypertonic saline IV.
- This should increase the serum Na by about 2.
- Repeat q1h up to three doses.
- This will raise the Na about 6 mEq which is more than half a day's worth; if the seizures stop, the Na should probably be kept fairly constant for the next 24 hrs.

Front 17

When treating afib/aflutter/SVT, what is the dose of diltiazem? What is the dose of metoprolol?

Back 17

Diltiazem: 0.25mg/kg IV (max dose 20mg) slow IV push.
Can repeat after 15 minutes if no response.
Then start infusion at 4-20mg/hr for up to 24 hrs.

Metoprolol: 2.5-5mg IV q5min, up to max of 15mg IV.

Front 18

What is the treatment of afib or SVT associated with WPW?

Back 18

1) NARROW complex SVT - Can be treated the same as regular SVT.
2) WIDE complex SVT - DC cardioversion, or procainamide 17mg/kg IV over 30 minutes.

FOR AFIB -
1) DC cardioversion or procainamide 17mg/kg IV over 30 minutes.

In wide complex SVT and afib associated with WPW, the following medications are contraindicated:
- Adenosine, B-blockers, CCBs (possibly also digoxin?)

Front 19

Management of an acutely ischemic limb.

Back 19

FIRST, determine how bad the ischemia is:
1) Check distal pulses in both limbs (affected and unaffected) with a hand-held Doppler - if no pulse detectable, determine the lowest level that a pulse CAN be detected.
2) If a distal pulse can be detected, check an ABI with the Doppler.
- Greater than 1.3: non-compressible
- Greater than 0.9: normal
- Less than 0.25: Potentially limb-threatening ischemia

SECOND, initiate treatment.
1) ASA 81mg po.
2) IV unfractionated heparin 80 units/kg bolus followed by 18 mg/kg/h.
3) Place the limb in a dependent position.
4) Call vascular surgery - therapy choice of angioplasty vs. surgery vs. anticoagulation only will depend on comorbid conditions, presence of collateral vessels, etc.

Front 20

What are the indications for urgent endoscopy to remove an esophageal foreign body?

Back 20

1) Ingestion of sharp or elongated object.
2) Multiple foreign bodies.
3) Button battery.
4) Evidence of perforation.
5) FB present for more than 24 hrs.
6) Airway compromise.
7) Coin at the level of the cricopharyngeus muscle in a child.

Front 21

What is the treatment for acute malaria?

Back 21

Quinine + doxycycline, or atovaquone-proguanil.

Another option would be mefloquine + doxycycline.

Front 22

What is the treatment for meningitis in adults?

Back 22

1) Ceftriaxone 2g IV q12h PLUS Vancomycin 15mg/kg IV

2) Add Ampicillin 2g IV q6h if age over 50 (to cover Listeria)

3) At or before antibiotics, dexamethasone 10mg IV can decrease morbidity and mortality if there is strong suspicion of S. pneumoniae as the causative agent (e.g. grossly purulent CSF).

Front 23

What is the treatment of DKA in adults?

Back 23

1) If the patient is in shock, give NS boluses of 10-20mL/kg until the patient stabilizes.
If no shock, start NS at 500mL/hr for 4 hours.

2) Draw stat labs including osmolality, VBG, and electrolytes.

3) Once the K is back, your actions depend on the results: If below 3.3, add K+ at 40mEq/L. Do not start insulin yet.
If between 3.3 and 5 (and the patient is peeing), add K+ at 20 mEq/L and start insulin at 0.1 units/kg/hr.
If over 5, start insulin and repeat K+ stat.

Front 24

What is the treatment of autonomic dysreflexia?

Back 24

1) Sit the patient upright (to help lower blood pressure by gravity).

2) Remove all tight clothing.

3) Search for and correct any noxious stimuli including plugged catheter, urinary retention, constipation (do a rectal), etc.

4) If necessary, use IV anti-hypertensives such as labetalol, hydralazine, etc.