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
