Aaqid Akram MBChB (2013) Clinical Education Fellow
ACC - C Week Aaqid Akram MBChB (2013) Clinical Education Fellow Objectives Recognise and manage shock IV fluid management
Recognise and manage ACS Recognise and manage acute LVF Recognise and manage diabetic complications Recognise and manage upper GI bleeds Be able to interpret ECGs Case 1 40 year old male 2 day history of diarrhoea and vomiting
Sudden onset haematemesis Now light headed BP 80 systolic Mallory weiss syndrome acute upper GI bleed - ABCDE Upper GI bleed Peptic ulcer disease Oesophageal varices
Oesophagitis / gastritis / duodenitis Malignancy Mallory-Weiss tear Vascular malformations Risk Factors Alcohol Chronic Renal Failure NSAID use Age
Lower socio-economic class Previous UGIB H Pylori Bleeding Haematemesis Haematochezia Coffee ground vomit Malaena
Fresh red blood ACTIVE BLEEDING Haematochezia Passage of fresh/altered blood per rectum Colonic bleeding Profuse upper GI bleeding Coffee ground vomit Ceased bleeding Relatively modest bleeding Malaena Black tarry stools Digestion of upper GI bleed If signs of shock or haemodynamic compromise manage that first. Management non variceal
Resuscitation Fluid Challenge Blood Transfusion PPI only after endoscopy If Unstable - Interventional radiology / Surgery Blatchford Bleeding Score Hb Urea BP Pulse Malaena Syncope Hepatic disease Cardiac Failure Endoscopy Mechanical (clips) +/- adrenaline Thermal coagulation + adrenaline Fibrin/Thrombin + adrenaline Proton Pump Inhibitor If failed first attempt Repeat endoscopy Interventional radiology Surgery Blatchford bleeding score will guide to urgency of endoscopy required. >0 is high risk >6 is 50% mortality Rockall score may be used pre and post endoscopy: Pre - Age / shock / co-morbidity Post Diag / major stigmata of major haemorrhage Blatchford score Management - variceal Resuscitation Fluid Challenge Blood Transfusion Terlipressin/octreotide Abx If Unstable - Interventional radiology / Surgery Blatchford Bleeding Score Hb Urea BP Pulse Malaena Syncope Hepatic disease Cardiac Failure Endoscopy Band ligation Stent Insertion Transjugular intrahepatic portosystemic shunts (TIPS) Gastric: N-butyl-2-cyanoacrylate injection Balloon tamponade for temporary salvage treatment of uncontrolled variceal haemorrhage IV fluids Resuscitation Routine maintenance Replacement Redistribution
Fluid Homeostasis Resuscitation Routine maintenance Replacement Redistribution Reassessment 5 Rs Fluid status BP Pulse JVP Postural Hypotension Oedema CRT NEWS
Fluid balance chart Weights FBC U+E Abnormal losses Thirst Initial Assessment ABCDE Fluid Resuscitation Systolic BP < 100
HR > 90 CRT > 2 seconds RR > 20 NEWS > 4 Passive leg raise (if positive then likely fluid responsive) Fluid Resuscitation Fluid Resuscitation Initiate Treatment: Identify cause of deficit
500 ml crystalloid (15 mins) Reassess (ABCDE) If more fluid needed: Give up to 2000ml in 500ml boluses Signs of shock Senior Help Routine maintenance Only use if insufficient oral intake
Initial prescription (24 hours) Water: 30ml/kg/day Sodium/Potassium/ Chloride: 1mmol/kg/day Glucose: g/day Limit starvation ketosis Not enough for total nutritional need Further prescription Reassessment Alter as per electrolytes / renal function NG/enteral feed preferable if more than 3 days needed Think about refeeding syndrome Sodium chloride 0.18% in 4% glucose (Dextrose) + 27 mmol/L Potassium Replacement Existing fluid/electrolyte deficits or excess
Dehydration Fluid Overload Hyperkalaemia/hypokalaemia Abnormal Distribution Ongoing losses Ongoing losses Liver / cardiac / renal failure Hypo / hypernatraemia
Redistribution Gross oedema Severe Sepsis Liver / cardiac / renal failure Hypo / hypernatraemia Post Operative fluid retention Malnutrition / refeeding Case 2 50 year old male Sudden onset central, crushing chest pain
Radiating down left arm SOB + sweating PMH: Hypertension Hypercholesterolaemia Anteroseptal MI - LAD LBBB (new) STEMI / New LBBB ABCDE Call PCI centre (Keep YAS there if possible)
If no PCI - Thrombolysis Clopidogrel / Ticagrelor Aspirin (Make sure YAS not already administered) Nitrates (GTN) Morphine + antiemetic Oxygen, if required Call PCI centre (Keep YAS there if possible) ABCDE ABCDE LGI PCI 15L NRB Morphine IV titrate 10mg Antiemetic IV cyclizine/ondansetron/metoclopramide/levopromazine GTN 300mcg SL Aspirin 300mg Clopidogrel 300mg / ticagrelor 180mg CI active bleeding / previous IC bleed / moderate + hepatic impairment / CYP3A4 inhibitors (ketoconazole / clarithromycin / antiretrovirals) Caution major surgery 30 days / gi bleed 6 months / severe thrombocytopenia / NSAIDs / fibrinolytics / anticoagulants / bradycardia Thrombolysis similar exclusion criteria to ticagrelor IV Fonda (2.5mg) IV TNK (Tenectoplase) SC Fonda (2.5mg) TNK unless >75yo female then consider streptokinase Case 3 18 year old female GCS 8 Collateral Hx: Unwell for 2 days
Vomiting Very tired for 6 months polyuria Variable Value O2 15L NRB SpO2 98% RR 30 HR 120 Temp 37.5 BP 88/60 DKA Variable Value Variable Value Range
Na 140 K 5 Creat 100 Urea 16 Cl WCC 15 Neuts 13 Variable Value Range pH 7.29 pCO2 3.0 pO2 20 11-13 cHCO3 14 22-26 BE -9 -2 / +2 SaO2 60 >95% Lactate 1.8 320 mosmol/kg Glucose + urea + (2 x Na) Hyperglycaemia >30 mmol/L Hypovolaemia No significant ketones in urine/blood No significant acidosis There may be a mixed HHS and DKA picture consult senior Treat underlying precipitant as required
IV Fluids 0.9% NaCl 1L over 1 hour (Potassium supplementation as required) IV insulin infusion (Fixed rate) ONLY if ketones present 0.05units/kg/hour Clinical Assessment Sepsis Vascular event Change in DHx Dehydration Mental State Exam Investigations Blood glucose U+E Measure osmolality VBG Ketones (Urine/blood) ECG / CXR / Urine MC+S Urinary catheterisation Measure Urine Output (minimum 0.5 ml/kg/Hr) Calculate fluid balance Alert diabetes specialist team Give LMWH unless CI Treat underlying precipitant as required IV Fluids Aim positive balance 6 hours: 2-3L 12 hours: 3-6L
If any complications of Rx: fluid overload / cerebral oedema / extra pontine myelinolysis seek senior help immediately Osmolality Measure every 2 hours (1st 12 hours) Glucose + Urea + 2Na
Reduce by 3-8 mosmol/kg/Hr Declining appropriately Continue on 0.9% NaCl Declining 8 mosmol/kg/Hr Reduce rate of IV fluid +/- Insulin (if commenced) Glucose Measure at least every 2 hours (1st 12 hours)
Aim for minimum 5 mmol/L/Hr decrease Declining