ABCDE

Question 1

General ABCDE plan

Answer 1

A: Observe for use of the accessory muscles of respiration. Central cyanosis. Speak to patient to check if their airway is compromised. Treat airway obstruction by either head tilt/ chin lift or jaw thrust or remove visible foreign bodies using suction or forceps

B: Count the respiratory rate. Assess the depth and rhythm of each breath. Listen to breath sounds a short distance from their face

C: Colour of hands and fingers. Temperature. Capillary refill time. Pulse rate. BP

D: Pupil size. ACVPU (sternal rub). Glucose

E: Remove clothes - minimise heat loss with a blanket after. Observe chest, medical bracelet

Question 2

Airway compromise

Answer 2

Genereal ABCDE

Question 3

Central abdominal pain

Answer 3

Early appendicitis (FBC, CXR, CT or USS of RIF.
Prophylactic antibiotics +/- full septic 6 if appropriate. Appendectomy)

Acute pancreatitis (FBC, imaging to find cause. Fluids, analgesia, anti-emetics, Ca if hypoglycaemic, insulin if hyperglycaemia)

Question 4

Choking

Answer 4

If conscious: Encourage the patient to cough
5 back blows with the heal of hand between shoulder blades. 5 abdominal thrusts performed from behind the patient, with a fist placed between the umbilicus and xiphisternum, grasping it with the other hand and pulling upwards and inwards sharply

If unconscious: Call or help and start ABC. Airway: Open the mouth and observe if the obstruction is visible and removable. Only attempt to remove an object under direct vision. Open the airway with a jaw thrust or head tilt/chin lift

Breathing: If the patient is not breathing, begin cardiopulmonary resuscitation

Question 5

Asthma exacerbation

Answer 5

OH SHIT ME
Oxygen
Hydrocortison
Salbutamol
Ipratropium
Theophylline
Magnesium
Entubation and ventilation

Question 6

COPD exacerbation

Answer 6

iSOAP
Sit-up
Ipratropium
Salbutamol
Oxygen 24% via Venturi mask: SpO2 88-92%,
Amoxycillin
Prednisolone

Question 7

Acute coronary syndrome

Answer 7

STEMI:
Morphine
Oxygen (if sats <94%)
Nitrates (GTN spray)
Aspirin 300 mg
Clopidogrel 300 mg
PCI if patients present within 12 hours of symptom onset (must be haemodynamically stable)
Thrombolysis if present within 12 hours of symptom onset but after 2 hours of medical contact

NSTEMI:
Morphine
Metoclopramide
Oxygen if sats <94%
Nitrates (GTN spray)
Aspirin
Clopidogrel

Question 8

Acute angle closure glaucoma

Answer 8

Pilocarpine eye drops and a topical Timolol. An urgent Ophthalmology referral should be made

Definitive management: Peripheral iridotomy to relieve intra-ocular pressure

Question 9

Anaphylaxis (5)

Answer 9

Remove trigger if possible
Oxygen and lie patient flat and raise legs
Arenaline
Chlorphenamine and hydrocortisone
IV fluid challenge if hypotensive

Question 10

A-Fib

Answer 10

Adverse signs (shock, syncope, PO, etc): DC conversion

Absence of adverse signs: AF with a duration of <48h can be safely cardioverted, whilst those with an unknown duration or duration >48h require anticoagulation for a minimum of 3 weeks before and 4 weeks after cardioversion

Question 11

DKA

Answer 11

If patient is alert, not significantly dehydrated and able to tolerate oral intake without vomiting –> Encourage oral intake and give subcutaneous insulin injection

If patient is vomiting, confused, or significantly dehydrated –> give IV fluids and insulin infusion at 0.1 units/kg/hour 1hr after starting IV fluids. If there is evidence of shock, the initial bolus should be 20ml/kg

Question 12

HHS

Answer 12

Fluid resuscitation of 0.9% saline:
1L over 1-2 hours
1L (+KCl) over 2-4 hours
1L (+KCl) over 4-6 hours
1L (+KCl) over 6-8 hours
1L (+KCl) over 8-10 hours

Insulin at 0.05 units/kg/hour if ketones >1mmol/L or glucose fails to fall

Question 13

Tension PTX

Answer 13

High flow oxygen
Needle decompression using a 16-gauge cannula inserted at the second intercostal space, mid-clavicular line, on the affected side

Question 14

SVT

Answer 14

Adverse features (HISS): Synchronised DC shock

Stable with regular rhythm: Carotid sinus massage or the Valsalva manoeuvre. IV Adenosie if no improvement, followed by a 20 ml IV Normal Saline bolus

Question 15

Myxoedema coma

Answer 15

ITU/HDU care
IV T3/T4 + hydrocortisone
Mechanical ventilation and oxygen - if hypoventilation
IV fluids to correct hypovolaemia
Correct hypothermia and hypoglycaemia

Question 16

AKI

Answer 16

Find and treat causes using bloods, urine dip, bladder scan, USS renal tract and ECG for hyperkalaemia
Stop renotoxic drugs
IV fluids
Dialysis if hyperkalaemic, acidotic, PO etc

Question 17

Addisonian crises

Answer 17

Fluid resuscitation if hypotensive
IV hydrocortisone
IV glucose if hypoglycaemic
Swap back to their oral steroids after 3 days
Consider fludrocortisone if there is adrenal disease

Question 18

Hypoglycaemia

Answer 18

Mild: Eat/drink 15-20g fast acting carbohydrate such as glucose tablets, a small can of Coca-Cola, sweets or fruit juice)

Severe: dextrose IV or glucagon IM if no IV access

Question 19

Thyrotoxic storm

Answer 19

IV propanolol
IV digoxin if propanolol fails or is contraindicated (e.g. asthma, low BP)
Propylthiouracil
IV hydrocortisone

Question 20

Sepsis

Answer 20

BUFALO
Bloods
Urine output
IV fluids
IV ABX
Lactate
O2

Imaging e.g chest xray, echocardiogram, abdominal ultrasound
Viral PCR for e.g. influenza

Question 21

Bradycardia

Answer 21

IV atropine, epinephrine (adrenaline), and dopamine.

Question 22

Primary PTX

Answer 22

If the patient is NOT short of breath AND the pneumothorax is <2 cm on a chest x-ray conservative management is sufficient

If the patient IS short of breath OR the pneumothorax is >2 cm the pneumothorax should be aspirated with a 16-18G cannula under local anaesthetic

Question 23

Secondary PTX

Answer 23

If the patient is NOT short of breath and the pneumothorax is 1-2 cm on the chest x-ray aspiration is required

If the patient IS short of breath OR the pneumothorax is >2 cm on the chest x-ray an intercostal drain is necessary