ABCDE

Question 1

A

Answer 1

call senior

protect c-spine, if ?injury

a: check patency - ?obstruction
m: establish patent airway

Question 2

B

Answer 2

a:
resp rate, chest expansion, percuss, auscultate

m:
no resp effort - treat as arrest, intubate + ventilate
breathing compromised - hi conc O2 + manage cause (eg relieve pneumothorax)

Question 3

C

Answer 3

a:
pulse, BP, CRT
peripheries shut down?
bleeding?

m:
if shocked - treat shock as
no cardiac output - treat as arrest

Question 4

D

Answer 4

AVPU
pupils - size, equality, reactions
GCS if time
glucose

Question 5

E

Answer 5

undress + cover to prevent hypothermia

Question 6

post-ABCDE - history from relative

Answer 6

events, intoxication, suicide, trauma?
PMH - esp diabetes, asthma + COPD, alcohol + drugs, epilepsy, recent head injury or travel
DH + allergies!

Question 7

acute: post ABCDE + history?

Answer 7

ensure ventilation + circulation are adequate
continue hx, exam, invs + mgmt

bloods - ABG, FBC, U+E, LFT, CRP, ESR, ± tox/drug screen
cultures
urinalysis
CXR, CT head

Question 8

GCS - components + total score for each

Answer 8

EVM - 456:
eye opening - 4
best verbal response - 5
best motor response - 6

record ‘not testable’ if a component not testable eg due to trachy, swollen eyes, paralysed by drugs

Question 9

GCS - best motor response

Answer 9

6 - obeying commands
5 - localising to pain - eg move hand to yours
4 - withdrawing to pain (normal flexion)
3 - flexor response to pain
2 - extensor response to pain
1 - no response to pain

command - stick out tongue / move hand

pain - don’t record until maximum stimulus given + 10s. try:
trapezius pinch
supraorbital
nailbed

normal flexion:
elbow bends + arm moves rapidly away from body/stimulus

abnormal pain responses (flexion + extension) help localise damage:

abnormal flexion:
decorticate posture:
elbows bend slowly + into chest, fist, legs extended
damage above red nucleus in midbrain

extension:
decerebrate posture:
extension of elbows, adduction + internal rotation of shoulder, forearm pronation / wrist flexion
midbrain damage below red nucleus

if diff in diff limbs, record best one. response of worse side may indicate focal brain damage or local injury

Question 10

GCS - best verbal response

Answer 10

5 - orientated to time, place person (ask)
4 - not orientated
3 - inappropriate speech
2 - incomprehensible sounds
1 - none

Question 11

GCS - eye opening

Answer 11

4 - spontaneous
3 - in response to speech
2 - in response to pain
1 - none

pain - start with pen side to finger bed + move centrally

Question 12

pupils - relevance of findings (for coma but maybe transferrable?)

Answer 12

normal direct + consensual - intact midbrain

mid position (3-5mm), nonreactive ± irregular - midbrain lesion

unilateral dilated + fixed - 3rd nerve compression

small + reactive - opiates or pontine lesion

Question 13

acute neuro exam

Answer 13

AVPU
resp pattern
pupils, visual fields, eye movements, fundus
spontaneous movements, tone, reflexes

Question 14

relevance of acute hyperventilation

Answer 14

hypoxia

acidosis

Question 15

sepsis - definitions (sepsis, severe sepsis, septic shock)

Answer 15

sepsis - systemic inflammatory response in the presence of infection with relevant signs

severe sepsis - sepsis with organ hypoperfusion (eg hypoxaemia, oliguria, lactic acidosis, altered cerebral function)

septic shock - severe sepsis with hypotension despite adequate fluid resus, or the need for vasopressors or inotropes to maintain BP

septicaemia - old term that meant multiplying bacteria in the blood. replaced with terms above.

Question 16

anaphylaxis - A-E

Answer 16

A + B:
secure airway
100% O2
intubate if resp obstruction imminent
remove cause + raise legs

C:
adrenaline (0.5mg IM (0.5ml 1:1000) ± repeat 5-minly)
IV access → chlorphenamine 10mg + hydrocortisone 200mg
saline - 500ml 0.9% bolus in 10 mins (may need 2L, titrate against BP)

D:
wheeze - treat for asthma
consider ventilation
still hypotensive - ICU ± IV adrenaline ± aminophylline + salbutamol nebs

Question 17

acute MI - A-E

Answer 17

call senior
immediate ECG + IV access + take cardiac + routine bloods
quick hx - PMH, RFs, CIs to pci
obs incl bilateral BP, glucose, gas
then A-E:

A + B:
low flow O2 if <94%
resp - auscultate, expansion, percussion

C:
radial pulses, JVP, scars, heart sounds, peripheral oedema

D + E:
aspirin + clopi 300
morphine 5mg IV
metoclopramide 10mg
PCI if available in 2h

Question 18

acute HF - A-E

Answer 18

brief hx
alert ICU + sit pt up
get obs, glucose, ECG

A+B:

a: resp - auscultate, expansion, percussion
m: 100% oxygen if no lung dx

C:

a: cardio - pulses, JVP, HS, oedema
m: IVa - gas, routines, troponins, BNP

D:
a: CXR ± echo
m:
treat cause eg AF, sepsis
IV furosemide 40-80mg
IV GTN if sBP > 90
IV opiate

E:
?CPAP + ITU

Question 19

acute asthma - A-E

Answer 19

call senior ± ICU
IV access, obs + ECG monitor

A:
assess severity - PEF, speech, RR, HR, sats
auscultate, expansion, percuss
ABG + glucose

B:
salbutamol 5mg nebd with O2
hydrocortisone 100mg IV ± pred 50mg po
O2 if <92

C:
heart sounds
monitor for arrhythmias

D - if life-threatening:
salbutamol nebs every 15m
ipratropium 0.5mg: add to nebs
MgSO4 1.2-2g IV over 20m

reassess PEF + ABG

E - improving:
salbutamol nebs every 4h
monitor PEF + sats
± O2 - sats 94-98
oral pred - 40mg, 5-7d

not improving:
ICU - ?ventilatation, aminophylline, IV salbutamol

Question 20

acute asthma: concerning signs that indicate ICU referral

Answer 20

deteriorating PEF
hypoxia persistent, hypercapnia, acidosis
exhaustion, altered LOC

Question 21

acute COPD: A-E

Answer 21

call senior ± ICU
obs + glucose

A:
auscultate, expansion, percuss
pulses, heart sounds, JVP, oedema

B:
salbutamol 5mg/4h neb
ipratropium 500mcg/6h
ABG + CXR

C:
IV access + ECG monitor

D:
if <88 - 28% oxygen (aim 88-92 / 94-98 if no hypercapnia on abg. adjust re abg + aim for PaO2 > 8)

E:
hydrocortisone 200mg IV
pred 30mg po (continue 1-2wk)
abx - amoxicillin/clarithro/doxy APLGs
physio to aid sputum expectoration

no improvement:
?IV aminophylline
?NIV

don’t forget sepsis!

Question 22

PE - A-E

Answer 22

call senior
ask nurse to set up obs + ECG

A + B:
a: resp exam + ABG
m:
oxygen if hypoxic - 10-15L/m
morphine 5mg IV
antiemetic if pain/distress

C:
a: CRT, pulses, HS, JVP, oedema, calves
m:
IVa - routines, clotting, lipids, glucose

D:
CXR
well’s score ± d-dimer/CTPA/VQ (CKD)

E - PE confirmed:
start LMWH
sBP<90 - ring ICU
sBP>90 - start warfarin loading regimen eg 5mg po

Question 23

shock from upper GI bleed - A-E

Answer 23

call senior/surgical reg + keep NBM
ask nurse to set up obs, BM + ECG

brief hx

A + B:
protect airway
brief resp
oxygen?

C:
brief cardio + assess for shock (pulses, CRT, JVP, HS)
2 large bore cannulae ACF (14-16G) - urgent routines, glucose, clotting, crossmatch 6 units
fluids eg saline challenge or rapid crystalloid IV infusion - up to 1L

D:
brief abdo
use rockall scoring system to determine next steps eg transfusion or just crystalloid
correct clotting abnormalities eg PCC

E:
?ICU + surgeons
catheterise + monitor UO
urgent endoscopy in 4h if variceal bleed or 12-24h if unstable

avoid saline in decompensated liver disease (ascites, peripheral oedema) - worsens ascites

Question 24

bacterial meningitis - A-E

Answer 24

call senior + ICU
get obs + ECG
?sepsis - sepsis six

A:
brief resp

B:
100% oxygen
ABG

C:
brief cardio + get IVa
in - ceftriaxone + vanc, dex, fluids (cautiously if ICP)
out - cultures + PCRm, lactate, clotting, routines, glucose, serology

D:
brief abdo
catheterise
throat + rectal swabs (v + b)

E:
brief neuro + CNs + fundus
CXR when stable
consult senior re LP - ci if icp, rash, septicaemic sx eg hypoperfusion

inform PHE
cipro for contacts
change abx as per cultures

Question 25

status epilepticus - A-E

Answer 25

senior, ICU, obs, ECG

A:
open + maintain airway + lay in recovery position
remove false teeth
insert oral/nasal airway
intubate if necessary

B:
100% oxygen ± suction
ausc chest

C:
IVa - lorazepam 2-4mg slow IV bolus OR buccal midazolam
routine, glucose, calcium, anticonvulsant levels ± tox screen
ABG
ausc HS

D:
check pupils

no response in 10min - repeat

E: