A&E Flashcards
1
Q
How do you calculate GCS?
A
2
Q
Describe an A-E
A
A = see if they reply, check for obstruction in mouth
B = resp exam, resp rate
C = cardio exam, hr, bp, put in 2 large bore IV access cannula (take bloods, give fluids etc), abg/vbg
D = avpu (alert, responds to voice, pain, unresponsive), pupil size, glucose, temperature, GCS
E = exposure
3
Q
What would you do if you suspect Sepsis?
A
Sepsis
- Investigations
- Take Bloods (cultures, fbc, u&es, crp, lfts, clotting)
- Serial abgs or vbg for lactate
- Sputum and urine mc&s, swab wounds, lp?
- Monitor urine output
- Start broad spectrum antibiotics within 1 hour
- Fluids if sbp<90, aki, lactate>2
- 500mls 0.9% NaCl over 15 mins
- O2 until 94-98% or 88-92% for copd
- Speak with critical care early
4
Q
How would you manage anaphylaxis?
A
Anaphylaxis management
- Secure airway or intubate if necessary – inform ITU
- Raise feet to help restore circulation
-
Adrenaline IM 0.5mg (1:1000)
- Repeat in 5 mins if needed
- Get IV access and give Chlorphenamine 10mg IV and Hydrocortisone 200mg IV
- Give 500ml 0.9% NaCl over 15 mins IV, give up to 2L
- If still hypotensive refer to ICU
- Ivi adrenaline may be needed +/- aminophylline and neb salbutamol (consult senior!!!)
- Monitor with ecg
- Continue chlorphenamine if still itching
- Serum tryptase 1-6 hours after anaphylaxis
- Educate about self injecting adrenaline
- Skin prick IgE test to identify allergens and educate to avoid
5
Q
How would you manage a STEMI initially?
A
ACS (STEMI) Management
- 12 lead ecg + hx!!!
- U&E, troponin, glucose, cholesterol, fbc, CXR
BNF Initial Management
- O2 if necessary
- Sublingual Glyceryl Trinitrate
- 5-10mg IV Morphine
- 10mg IV Metoclopramide
- Aspirin 300mg + Ticagrelor 180mg
- Refer for PCI
- Give unfractionated heparin or LMWH (enoxaparin)
6
Q
How would you manage a STEMI long term?
A
BNF Long term Management
- Aspirin + clopidogrel
- B Blockers eg. propranolol
- Diltiazem or verapamil if BB not appropriate
- ACE I or ARB
- Nitrates if angina
- Statins
7
Q
How would you manage pulmonary oedema? (initially)
A
Pulmonary Oedema
Initial Management
- Sit patient upright
- High flow o2 if necessary
- IV access
- Monitor ECG
- Run investigations (Cxr, ecg, U&Es, troponins, ABG, echocardiogram, BNP)
- 5mg Diamorphine IV slowly
- 40-80mg Furosemide IV slowly
- 2 puffs GTN spray
- Can give further doses of 40-80mg furosemide
- CPAP can help improve ventilation (get senior help)
- Can start nitrate infusion if sbp>100mmhg
8
Q
How would you assess asthma severity?
A
- Severe =
- RR>25
- HR>110
- PEF33-50%
- unable to complete sentences
- Life threatening =
- PEF<33
- silent chest, cyanosis, confusion
- high pCO2 on abg
9
Q
How would you manage severe asthma?
A
- Warn ICU if severe or life threatening
- O2 until 94-98% (88-92 if copd)
-
5mg salbutamol nebs with o2 (SE = tremor, arrhythmia, low K+)
- Repeat salbutamol nebs every 15mins if PEF<75%
- Add ipratropium 0.5mg/6hours to nebs if severe/life threatening
-
100mg IV hydrocortisone or 40-50mg PO prednisolone
- Continue prednisolone 50mg PO OD for 5-7 days after
- Monitor with ECG for arrhythmias
- Single dose 1.2-2g MgSo4 IV over 20mins if unresponsive to prev therapy
- If worse then refer to ICU!!!
- If better monitor peak flow and o2
- Continue discharge if PEF>75% within 1 hour of treatment
- Otherwise must be…
- stable on discharge meds for 24 hours
- Inhaler technique checked
- Peak flow>75% predicted or best
- Steroid and bronchodilator therapy
- Have a PEF meter and written management plan
- GP appointment in 2 days
- Resp clinic appointment in 4 weeks
10
Q
How would you manage a COPD exacerbation?
A
- 5mg/4h salbutamol neb + 500mcg/6h ipratropium neb
- O2 aim for 88-92%, adjust using abg
- 200mg IV hydrocortisone and 30mg PO prednisolone (continue OD for 7-14 days)
- Antibiotics if necessary eg. amoxi, clarithro, doxi
- Physiotherapy for sputum
- IV aminophylline if no response to nebs and steroids
- Non invasive positive pressure ventilation if RR>30 or PH<7.35
11
Q
How would you manage a tension pneumothorax?
A
- Large bore needle + syringe partially filled with 0.9% Nacl into 2nd ICS mid clavicular line
- Allow trapped air to bubble into syringe
- Place chest tube, Then request CXR
12
Q
How would you manage a Secondary Pneumothorax?
A
- SOB or rim of air>2cm on CXR = aspirate then do a chest drain if aspiration not successful
- If rim of air <2cm or no Sob = discharge and outpatient review in 2 weeks
Chest drain = 4-5th intercostal space midaxillary line
13
Q
How would you investigate and manage a PE?
A
Investigations
- U&Es, fbc, clotting
- Ecg (s1q3t3 or af or rbbb etc)
- Cxr
- Abg
- D dimer
- Ctpa or v/q scan
- Lower limb us doppler for dvt
- Wells score
Management
- 15L o2 if needed
- 10mg morphine IV + 10mg metoclopramide IV
- LMWH or fondaparinux
- If low bp, give 500ml NaCl IV over 15 mins
- Get ICU input
- Consider vasopressors like dobutamine or noradrenaline if still low bp (aim for sbp>90)
- If haemodynamically unstable give thrombolysis eg. 10mg alteplase IV bolus then 90mg/2hrs IVI
- If haemodynamically stable, commence long term anticoagulation eg. apixaban (doac)
14
Q
How would you manage an Upper GI Bleed?
A
- A-E
- 2 large bore cannula = fbc, u&es, lft, glucose, clotting, crossmatch
- Keep NBM
- IV fluids
- Transfuse blood if hb low
- adrenaline injection
- Varices = endoscopic banding, terlipressin and broad spec antibiotics
- Correct clotting problems = vitamin K, ffp, platelet concentrate
- Consider referral to ICU or HDU
- Catheterise and monitor urine output
15
Q
How would meningitis/ meningococcal septicaemia present?
A
- Meningitis = neck stiffness, photophobia but no shock
- Meningococcal septicaemia = symptoms + shock (long CRT, DIC, low bp) + non blanching rash
16
Q
How would you manage meningitis?
A
- Blood cultures
- Lp within an hour if no sign of shock, rash, high icp
- Give empirical antibiotics eg. ceftriaxone
- Give dexamethasone 10mg/6hrs IV for meningism
- If signs of high icp (papilloedema, seizures, etc)
- Airway support
- Fluid resus
- Keep at 30 degrees
- Give ciprofloxacin for prophylaxis
17
Q
How would you manage encephalitis?
A
- Blood cultures, serum for viral pcr (and throat swab and msu)
- Contrast ct
- Lp
- Eeg
- Management = aciclovir asap, phenytoin for seizures
18
Q
How would you manage status epilepticus?
A
- A-e and secure airway!
- O2 and suction as required
- Bloods = u&es, lfts, fbc, glucose, ca2+, toxicology screen, anticonvulsant levels
-
IV bolus of 4mg Lorazepam
- Give 2nd dose of Lorazepam in 10mins
- Can also use buccal midazolam or rectal diazepam
-
IVI of phenytoin in a different line to lorazepam
- Monitor ecg and bp
- 250mg IV thiamine if alcohol or malnourishment suspected
- 50mls 50% glucose IV if needed
- Fluids for hypotension
- ICU help!!! (may need propofol infusion and ventilation with continuous EEG monitoring)
19
Q
What are some signs of a raised ICP?
A
- Papilloedema
- Pupil changes
- Decreased visual acuity
- Altered gcs eg. drowsy, coma, irritable
- Headache worse on coughing and leaning forward
- Vomiting
- Low hr, high bp (cushings response)
- Cheyne-stokes respiration
20
Q
How would you manage high ICP?
A
- A-e, treat seizures etc
- Elevate head to 30 degrees
- Hyperventilate cause cerebral vasoconstriction
- Mannitol
- Dexamethasone for high icp due to oedema surrounding tumours
- Monitor
21
Q
How would you diagnose DKA?
A
- Acidaemia (ph<7.3)
- Hyperglycaemia (glucose>11)
- Ketonaeima >3 or ketonuria >2+ on dipstick
22
Q
How would you manage DKA?
A
- A-e
- 1L 0.9% nacl over 1 hour (if sbp<90 then give resus 500ml over 15mins etc)
- VBG, glucose, ketones, u&es, fbc, crp, cxr, ecg
- add 50 units insulin to 50ml 0.9% nacl and infuse at 0.1 units/kg/hr
- check cap blood glucose and ketones hourly
- check vbg every 2 hours
- continue fluids, assess need for K+
- monitor urine output, consider catheter or ng tube
- start on LMWH
- when glucose <14mmol/L start 10% glucose at 125ml/hr too to prevent hypoglycaemia
23
Q
How would you manage a thyrotoxic storm?
A
- a-e
- bloods t3,t4, cultures incase infection
- iv access for fluids, ng if vomiting
- propranolol 60mg/4hours PO
- high dose digoxin can help slow heart but makes sure they have been started on BB already. Cardiac monitoring
- carbimazole PO
- after 4 hours give Lugols solution (aqueous iodine oral solution)
- Hydrocortisone IV or dexamethasone PO to prevent conversion of T4 to T3
- Treat suspected infection with coamoxi
24
Q
How would you manage an addisonian crisis?
A
- A-e
- Bloods for cortisol and ACTH, u&es (may have high K+, low Na+)
- Fix high K+ with calcium gluconate and do ecg
- Fix low Na+ with rehydration and steroids
- Hydrocortisone 100mg IV stat
- Fludrocortisone potentially needed if underlying adrenal disease (ask senior)
- Search for underlying cause eg. infection, trauma, surgery, missed meds - if so educate!
25
Q
What is basic management for poisoning?
A
- A-E
- Bloods and specific for levels of poison
- Empty stomach if appropriate
- Specific antidote or activated charcoal
- Search on toxbase!!!
- Continue to monitor eg. catheter, icu if necessary, cardiac monitor, etc
- Proper hx and psychiatric assessment. Risk assess!!!
26
Q
How would benzo poisoning present and be managed?
A
- Agitation, euphoria, slate grey cyanosis, slurred speech, blurred vision
- Flumazenil 200mcg over 15s then 100mcg at 60s intervals if needed
27
Q
How would opiate poisoning present and be managed?
A
- Constricted pupils, resp depression, etc
-
Naloxone eg. 2mg IV
- Can result in opiate withdrawal symptoms eg diarrhoea and cramps
- Give diphenoxylate and atropine
- High dose opiate misusers may need methadone to combat withdrawal
28
Q
How does neuroleptic malignant syndrome present and is managed?
(neuroleptic malignant syndrome occurs with drugs that cause dopamine receptor blockade eg haloperidol and other antispychotics)
A
- Hyperthermia, rigidity, extrapyramidal signs, autonomic dysfunction, confusion, coma, etc.
- Manage with dantrolene IV or bromocriptine and amantadine
29
Q
How would anticholinergics poisoning present?
How would you manage it?
A
- Sludge BBB=
- Salivation
- Lacrimation
- Urination
- Diaphoresis (excess sweating)
- GI upset
- Emesis
- Bradycardia
- Bronchospasm
- Bronchorroea
- Give atropine
30
Q
How would carbon monoxide poisoning present? How would you manage it?
A
- Reduced reflexes, tachycardia, pulmonary oedema, shock, met acidosis, flushed cherry pink skin
- Give hyperbaric oxygen
31
Q
How would you manage sympathomimetics (cocaine, amphetamines) overdose?
How would they present?
A
- Tachycardia, dilated pupils, insects crawling, agitation, arrhythmias, tremor
- Give activated charcoal
- Monitor bp, ecg, temp for 12 hours
- Monitor urine output and U&Es for aki, lfts, ck, fbc, coagulation for dic
- IV lorazepam for anxiety
- Metoprolol IV for narrow complex tachycardias
- Nifedipine PO for HTN
- Try to cool for hyperthermia
32
Q
How would paracetamol overdose present? How would you manage it?
A
- Nausea, vomiting
- Hepatic necrosis= jaundice, RUQ pain, encephalopathy, hypoglycaemia
- Metabolic acidosis, oliguria, renal failure
- 150mg/kg in adults can be fatal
- Give activated charcoal 1g/kg
- glucose, U&Es, lfts, inr, abg, fbc, hco3-, abg for met acidsis
- blood paracetamol level at 4 hours post ingestion (plot on graph)
- If <8hours after ingestion
- Activated charcoal if <2hours after ingestion
- Acetylcysteine
- If >8hours after ingestion
- Acetylcysteine + 5% dextrose
- 5% patients will have an allergic rash
- Toxbase!
- next day do inr, u&es, lft
- refer to liver specialist if deterioration
33
Q
How would aspirin (salicylate) poisoning present and be managed?
A
- mild symptoms = tinnitus, lethargy, dizziness, vomiting
- Severe symptoms = sweating, bounding pulse, deafness, breathless, hypo/hyperglycaemia, confusion (pulmonary oedema and met acidosis in fatal)
- Do salicylate conc, U&Es, glucose, K+ (usually hypoK), ABG, urine and blood pH, ECG
- Management
- Activated charcoal if >125mg/kg ingested <1hr ago
- Gastric lavage if >500mg/kg ingested <1hr ago
- Aggressive rehydration!!!
- Glucose if necessary
-
Sodium Bicarbonate if >500mg/kg ingested
- Monitor urine pH (should be 7.5-8.5)
Haemodialysis for severe eg. plasma salicylate >700mg/kg
34
Q
How would serotonin syndrome present?
How would you manage it?
A
(SSRIs, TCAs, ecstacy, tramadol, etc)
Presentation = altered mental state, hyperthermia, autonomic dysfunction, rhabdomyolysis, tremor, clonus, hyperreflexia, sweating, mydriasis
Management
- IV fluids
- benzodiazepines
- severe cases = serotonin antagonists like cyrpoheptadine or chlorpromazine
35
Q
How would you manage burns?
A
- Lund and Browder charts to assess size
- Burn depth ie partial thickness (painfull/red/blistered) or full thickness (painless/grey/white)
- A-E
- Flexi bronchoscopy/laryngoscopy useful to investigate eg. if hot gases inhaled or hx of fire or smoke inhalation etc.
- Involve anaesthetists early incase of intubation
- Parkland formula to decide fluid replacement
- Simple saline gauze or paraffin gauze
- Titrate morphine IV for analgesia
- Ensure tetanus immunity
- Skin grafts for major full thickness burns etc
36
Q
How would you investigate hypothermia?
Rectal Temp <35C
A
- Shivering = mild. Not shivering = severe
- U&es, plasma glucose, amylase, tfts, fbc, blood cultures
- Abg
- Ecg may show j waves
37
Q
How would you manage hypothermia?
A
- A-e
- Warm humidified o2
- Remove wet clothing and slowly rewarm using blankets or active external warming (aim for 0.5C/hour)
- Warm IVI
- Cardiac monitoring
- Antibiotics to prevent pneumonia
- Monitor renal function (consider catheter)
