A&E / Emergencies notes

Question 1

what anti-epileptics should you use in status epilepticus?

2 main ones - why is one used preferentially..?

but what do you need to beware of with it..

then where do you go after this…?

Answer 1

iv acces - IV loraz
no iv access - buccal midaz

lorazepam better because:

• fewer CVRS SEs
• longer duration of anti-epileptic effects
• similar time to action

watch out for respiratory depression…
(main side effect of ALL the benzos especially if you’re IV / infusing them….)

then phenytoin IVI (if already on phenytoin - go for diazepam IV infusion ?longer acting…?)

then it’s probably RSI-o-clock

Question 2

NB - good to run through A&E ila notes

Answer 2

ys yes yes

Question 3

what are some side effects of and CIs to phenytoin?

bearing these in mind, what would you monitor whilst giving this infusion….

Answer 3

SEs: hypotension…
CIs: bradycardia / heart block

BP+ECG monitoring….

Question 4

when do you call anaes / ITU in s epilepticus?

what will they likely do

Answer 4

refractory status - (unresponsive to 2 drugs..)

induce GA

thiopental / propofol

adequate dose to maintain burst suppresssion (titrate

Question 5

what are the components of the DVT Wells score

Answer 5

C3P0 R2D2

cancer (malignancy ongoing / in last 6 months)
collateral superficial veins
calf swollen >3cm more than the affected side…
Pitting oedema
oedema of the whole leg (swollen)

Recent immoblisation
recent surgery
DDx more likely than DVT…

Question 6

what are the components of the PE wells score

Answer 6

don’t die, tell the team to calculate criteria…
DVT clinically suspected (signs and symptoms of)
DDx’s less likely than PE
Tachycardia
Three days surgery / surgery in past 4 weeks
Thromboembolism previously (prev DVT or PE)
Coughing up blood
Cancer currently??

Question 7

management of DTs?

Answer 7

1. chlordiazepoxide - large doses QDS

2. pabrinex - 2 pairs of 2 vials…(A+B)

Question 8

are sensitive or specific tests good for ruling things in or out?

Answer 8

specificity - in (SP-IN)

sensitivity - out (SN-OUT)

Question 9

how does a tension PT cause shock?

Answer 9

mediastinial shift
kinks the IVC and other vessels
decreases cardiac return
subsequent traumatic arrest with PEA

Question 10

findings OE for a tension PT

Answer 10

tracheal deviation
decreased breath sounds over the affected area
hyperresonance over the collapse

Question 11

how to correct a tension pneumothorax

Answer 11

needle thoracocentesis
14-16IV cannula in the 2nd IC space in the mid clav line
corrects the tension element - releives pressure and creates a simple pneumothorax

Question 12

what are some chest injuries that you need to be worried about…..?

Answer 12

lethal 6 - these need to be detected and treatedin your primary survey!!

• airwy obstruction
• tension / open PT
• cardiac tamponade
• massive haemothorax
• flail chest

hidden 6

• thoracic aortic dissection
• tracheobronchial
• traumatic diaphragmatic tear…
• myocardial contusion
• pulmonary contusion
• esoph disruption….

Question 13

what is the difference between an anaphylactic and an anaphylactoid reaction?

Answer 13

anaphylactic - IgE mediated type 1 hypersensitivity reaction
(tends to be in response to external stimulants….)

anaphylactoid - DIRECT RELEASE OF MEDIATORS FROM THE INFLAMMATORY CELLS
no antibodies involved
usually in response to drugs - esp acetylcysteine

Question 14

what drugs might you give in anaphylaxis and in what doses

Answer 14

1. chlorpenamine (antihistamine) - 10mg IV
2. hydrocortisone 200mg IV
3. Adrenaline 1/1000 0.5 ml IM every 10 minutes (?max 6?)
4. IVI 500ml saline - squeeze the bag in over 15 minutes..
5. • if wheeze ./ susp bronchospasm - Nebulised salbutamol

keep giving IM adrenaline every 10 minutes - IV adrenaline only if no pulse or seriously ILL - needs experienced clinician and you’d stop as soon as there’s a response