A-->E Mx

Question 1

dosages & routes for Adrenaline
cardiac arrest
anaphylaxis
anaphylaxis in children

Answer 1

1mg–> 1:10,000–> IV

0. 5ml–> 1:1,000–> IM
1. 3 ml –> 1: 1,000–> IM

Question 2

Mx of Acute asthma attack?

Answer 2

1) NEBS salbutamol 5mg (back to back)
2) Hydrocortisone 100mg IV or PO prednisolone 40mg
3) ipratropium 500mcg NEBS

Question 3

Pre-partum Haemorrhage pregnant women?

Answer 3

1) Activate major obstetric haemorrhage protocol
2) Call for help! (midwife, obstetricians, neonatologists)
ALERT haematologist!
3) bloods –> G&S, cross match, FBC, U&E, LFT, CRP
4) ask for O- blood transfusion (its available in the emergency)

LEFT LATERAL LIE
Manual traction of uterus (push it to the left) (prevents naval compression during CPR)

EMERGENCY C-SECTION w/ in 5 minutes!

Question 4

how many weeks must the baby be to prepare for emergency C-section?
how quick?

Answer 4

if > 20 weeks, must be done w/in 5 minutes of cardiac arrest!!!

Question 5

Mx of STEMI

include routes of drugs and doses

Answer 5

CALL 2222, CRASH TEAM

Morphine if in severe pain–> 5-10mg IV in 10 mL slowly + antiemetic IV metaclopramide 10mg IV
Oxygen if sats less than 94%
Nitrates : sublingual 2 sprays
Aspirin: 300 mg PO

Refer for PCI w/in 2 hours
yes–> go for PCI
NOT available–> fibrinolysis–> TPA + antithrombin 3

Question 6

Hyperkalemia Mx

when do u commence treatment?

Answer 6

K+ > 6.5 mmol/L or ECG changes or Cardiac arrest or AKI

1) 30 mL, calcium gluconate 10% –> repeat in 5-10 mins if no improving in ECG
2) 10 U of regular insulin + 50 mL of dextrose 50% in water (- Given over 15-30 mins)
3) 5mg of nebs salbutamol (back to back 4x)
4) 15g calcium resonium

Question 7

Status Epilpeticus

Mx

Answer 7

lorazepam IV 4mg or 10mg PR diazepam
repeat after 10 mins
—-if after 20 mins not terminated

CALL SENIOR to give
20

Question 8

Acute heart failure

pulmonary edema

Answer 8

S-LMNOP
sit ptx upright
Loop dieuretics- furesomide 40-80mg IV slowly
Nitrates- 2 puffs
Oxygen
CPAP

Question 9

PE

Answer 9

Ix: ABG, XRAY, d-dimer
Wells score
1st line: DOAC Apixaban or
rivaroxaban 15 mg 2x daily for 21 days

If not suitable……

LMWH for 5 days followed by dabigatran or edoxaban OR
LMWH + vit K antag for 5 days

Question 10

Massive PE

Answer 10

Thrombolysis

Question 11

COPD exacerbation

Answer 11

Ix: ABG, XRAY

Salbutamol 5mg/4h & ipratropium 500mcg/6h

Mx:

1) Prednisolone 30 mg for 5 days OR IV hydrocortisone 200mg
2) Amoxicillin 500mg/8h PO
3) Physiotherapy to aid sputum expectoration

if respiratory acidosis or rising PCo2—> NIV (BiPAP) if PH <7.35,

Question 12

Tension Pneumothorax

Answer 12

1) Large wide bore cannula 2nd intercostal space mid clav above each rib
2) chest drain–> followed by xray to check position
5th intercostal space (or the inferior nipple line)
The mid axillary line (or the lateral edge of the latissimus dorsi)
The anterior axillary line (or the lateral edge of the pectoris major)

Question 13

Subarachnoid hemmorhage

Answer 13

Ix: Urgent CT head
LP after 12 hours

1) mainstain cerebral perfusion FLUIDS
2) Nimodipine (60mg/4h PO for 3wks, or 1mg/h IVI) for 21 days!
3) Sx: endovascular coiling vs surgical clipping

Question 14

Acute upper GI BLEED

Answer 14

1) activate major haemorrhage protocol
2) Ix: basic bloods, clotting, G&S, CXMATCH, CXRAY, ABG, ECG
3) Transfusion–> Hb <70
4) Correct clotting abnormalities (vitamin K (p274), FFP, platelets).

MEDS
5) if variceal suspicion–> IV terlipressin (1-2mg/6hr/ <3days) & broad-spectrum IV
(piperacillin/tazobactam IV 4.5g/8h).

ALL ptx should have endoscopy within 24 hours

Question 15

PEPTIC ULCER

Answer 15

ABC approach as with any upper gastrointestinal haemorrhage
IV proton pump inhibitor

1st-line treatment is –> endoscopic intervention
adrenaline and diathermy

if this fails (approximately 10% of patients) then either:

URGENT interventional angiography with transarterial embolization or
surgery

Question 16

GCA

Answer 16

1) refer rheumatolgoist

Question 17

raised ICP

Answer 17

investigate and treat the underlying cause

1) head elevation to 30º
2) IV mannitol may be used as an osmotic diuretic
3) controlled hyperventilation**
4) Restrict fluid to <1.5L/d

**aim is to reduce pCO2 → vasoconstriction of the cerebral arteries → reduced ICP
leads to rapid, temporary lowering of ICP. However, caution needed as may reduce blood flow to already ischaemic parts of the brain

5) Removal of CSF, different techniques include:
- drain from intraventricular monitor (see above)
- repeated lumbar puncture (e.g. idiopathic intracranial hypertension)
- ventriculoperitoneal shunt (for hydrocephalus)

IF ITS BRAIN METSS only
DEXAMETHASONE 10mg IV and follow with 4mg/6h IV/PO

Question 18

Ascites

what if SBP

Answer 18

1) reduce dietary dietary Na
2) fluid restriction is sometimes recommended if the sodium is < 125 mmol/L
3) Spironolactone
4) drainage if tense ascites (therapeutic abdominal paracentesis)
large-volume paracentesis for the treatment of ascites requires albumin ‘cover’. Evidence suggests this reduces paracentesis-induced circulatory dysfunction and mortality
5 ) Offer prophylactic oral ciprofloxacin or norfloxacin for people with cirrhosis and ascites with an ascitic protein of 15 g/litre or less, until the ascites has resolved’

If SBP confirmed you give–> cefotaxime

Question 19

hypoglycaemia

Answer 19

LESS THAN 4 mmol/L

conscious can swallow–> 5-7 oral dextrose tablet or fruit juice 150 ml
conscious cannot swallow–> 1.5- 2 glucogel or 1mg IM glucagon
unconscious–> IV 75ml 20% glucose over 10-15 mins

test blood glucose after 10-15 mins, if still less than 4mmol/L repeat cycle to Max of 3x

Question 20

DKA

Answer 20

TRIAD of
Glucose more than 11
PH less than 7.3
Ketones more than 3

Features: abdo pain, kussmuls breathing, sweating, palpitations, SOB, dizzy, pear drop smell breath

INSULIN
an IV should be started at 0.1 unit/kg/hou

Mx:

0. 9% of 1L of normal saline in 1 hr
1. 9% of 1L of normal saline 2hr
2. 9% of 1L of normal saline 2hr
3. 9% of 1L of normal saline 4h
4. 9% of 1L of normal saline 4h
5. 9% of 1L of normal saline 6 h

Add potassium Chloride in the SECOND BAG
if K+ is 3.5 - 5.5—> 20mmol per 500 ml
(10mmol per hr)

DKA is resolved when
pH MORE than 7.3
blood ketones LESS than 0.6 mmol/L
HCO3- MORE than 15.0mmol/L

Question 21

Addisonion Crisis

Answer 21

CF:  Weakness
• Lethargy
• Weight loss
• Dizziness
• LowBP
• Nausea & vomiting

IV or IM Hydrocortisone 100mg stat

• IV Hydrocortisone 50mg QDS or 200 mg/24 hours

maintenance or 200mg/24 hr infusion
• IV fluids

Question 22

Thyrotoxic Crisis

Answer 22

DPPL(mnemonic)

IV Propanolol 2mg
dexamethasone - e.g. 4mg IV qds - blocks the conversion of T4 to T3
Propylthiouracil

After 4hrs, give Lugol’s solution (aqueous iodine oral solution). Iodine should typically be administered after thionamide therapy has been started to prevent stimulation of new hormone synthesis

sedate with chlorpromazine.

Question 23

pheochromocytoma

Answer 23

Sweating, palpitations, headache

SEND ICU
Start with short-acting, IV A- blocker, exL phentolamine 2–5mg IV. Repeat to main-tain safe BP.

• -> When BP controlled, give long-acting a-blocker,
• • phenoxybenzamine ** 10mg/24h PO

Question 24

Hypothermia

Answer 24

Diagnosis : Check oral or axillary T°.
If ordinary thermometer shows <36.5°C

Tests: Urgent U&E, plasma glucose, and amylase. Thyroid function tests; FBC; blood cultures. Consider blood gases. The ECG may show J-wave

All should receive WARM, humidified O2; ventilate if comatose or respira-
tory insufficiency.

Remove wet clothing, slowly rewarm, aiming for rise of 1⁄2°C/h (check temp, BP, HR, and RR every 30min) using blankets or active external warm- ing (hot air duvets).
If T° rising too quickly stop & allow to cool slightly. Rapid rewarming causes peripheral vasodilation and shock. A falling BP can be a sign of too rapid warming.

• Warm IVI.
• Cardiac monitor is essential (AF, VF, and VT can occur at any time during rewarming or on stimulation).
• Consider antibiotics for the prevention of pneumonia, Give these routinely in ptx over 65yrs with T° <32°C.
• Consider urinary catheter (to monitor renal function).

Question 25

Delerium Tremens

Answer 25

alcohol withdrawal peaked in 72 hrs
Tactile hallucinations, Tremor, Tachycardia, confusion, seizures

Mx:
Benzodiazepine:
10 mg TDS chlordiazepoxide, slowly decreasing doses over 10 days Lorazepam may be preferable in patients with hepatic failure

Question 26

Alcohol Dependence

Answer 26

DAN
Disulfurim
Acomprosate
Naltrexone

Question 27

Alcohol withdrawal

Answer 27

1) CIWA assessment to aid
2) chlordiazepoxide reducing doses over 10 days
3) IV pabrinex or oral thiamine (b1)

treat seizures w/ lorazepam
treat sedate haloperidol

Question 28

NMS

Answer 28

10 days after starting antipsychotics

Fever, vital signs shit, alternating BP, raised CK or myoglobin, reduced reflexes, sweating, lead pipe rigidity

Mx: 
Stop medication
IV fluids, monitor vital signs
Dantrolene (muscle relaxant) 
Bromocryptine

Question 29

Seretonin Syndrome

Answer 29

hyperreflexes, autonomic symptoms
Cx: TCA, ecstacy, MAOI, SSRI

w/ in minutes of starting meds

supportive including IV fluids
Benzodiazepines

more severe cases are managed using serotonin antagonists such as

Mx: cyproheptadine and chlorpromazine

Question 30

Wernickes Korskoff

Answer 30

Wernickes
Confusion, Ataxia, ophthalmoplegia,

Korskoff
retrograde amnesia
anterograde amnesia
confabulation

oral pabrinex or IV thiamine

Question 31

GCA

Answer 31

temporal headache, Amarusis fugax, blurry vision, jaw claudication.

Blood: ESR, CRP
Ix: USS , temporal artery biopsy, skipped beaded appearance

Mx
no jaw claudication or visual symptoms– > Prednisolone 40mg od & aspirin 75mg od

YES Jaw claudication or visual symptoms–> Prednisolone 60mg & aspirin 75mg

Question 32

Septic Arthritis

Answer 32

unilateral red swollen hot joint

joint aspiration–> synovial fluid sampling –> gram stain
Bloods & BC, ESR, ANA
Sepsis 6

Mx:
Flucloxacillin 2g QDS IV
if allergic Vancomycin IV

Washout, debridement, irrigation

Question 33

Acute limb ischemia

Answer 33

CF: the 6 P’s

Ix:
Bedside: doppler USS—> pulses
ECG: AF Labs: FBC, U&E, LFT, Coag, serum LACTATE, G&S, urinalysis (myoglob)
gold standard: CT angio

** EMERGENCY—> w/ in 6hrs**
Urgent referral to the on-call vascular team
A—> E
IV opioids
IV unfractionated heparin

Endovascular therapies:
—Thrombolysis – catheter through artery to apply thrombolysis directly into the clot
—Thrombectomy – catheter through artery & remove thrombus
—Percut. mechanical thrombectomy –> cut open vessel & remove thrombus

Question 34

Compartment syndrome

Answer 34

cx: tight cast

Ix: intracompartmental pressure

Mx: 
Do not elevate leg
cutt cast open
HIGH flow oxygen
fluids improve oxygen delivery
analgesia

Definitive:
Emergency fasciotomy open
leave wound open for 2 days, debridement

MONITOR FOR RHABDOMYOLOSIS–> U&E
MONITOR for reperfusion injury

Question 35

myxoedemic coma

Answer 35

thyrosxione and hydrocortisone