Acute care

Question 1

Glasgow Coma Score (GCS)
eyes

Answer 1

E 4 Eyes open, spontaneous
E 3 Eyes open to voice/speech
E 2 Eyes open to pain
E 1 Eyes do not open

Question 2

Glasgow Coma Score (GCS) voice

Answer 2

V 5 Orientated
V 4 Confused
V 3 Inappropriate Words/speech
V 2 Incomprehensible sounds
V 1 No sound

Question 3

Glasgow Coma Score (GCS)
motor

Answer 3

M 6 Obeys commands
M 5 Localises to pain
M 4 withdrawal from pain
M 3 Abnormal flexion to pain (decorticate)
M 2 Extends to pain (decerebrate)
M 1 No response

Question 4

patient is unable to maintain their own airway adequately at GCS

Answer 4

8 or below

Question 5

Parkland formula can be used to calculate the amount of fluids required for an individual according to their weight.

Answer 5

4 x weight (kg) x %burn = ml fluid required in the first 24 hours from the time of the burn
Half of the total fluid calculated should be given in the first eight hours following the burn. The second half should be given in the subsequent 16 hours (depending on urine output) .

Question 6

Referral to a burns unit should be made if

Answer 6

All burns ≥ 2% TBSA in children or ≥ 3% TBSA in adults
All full-thickness burns
All circumferential burns
Any burn not healed in 2 weeks
Any burn with suspicion of non-accidental injury (should be referred to burn unit / centre for assessment within 24 hours)

Question 7

Red flags for sepsis

Answer 7

new deterioration in GCS/AVPU
Systolic BP <90, OR 40 mmHg below normal
Heart rate >130 p min
RR >25 p min
Need oxygen to keep SPO2 92%, 88% in COPD
Non blanching rash or mottled/ashen/cyanotic skin
Not passed urine in last 18h
Urine output less than 0.5 ml/kg/her if catheterised
recent chemo within last 6 weeks

Question 8

Sepsis six

Answer 8

Give oxygen
Take blood cultures
Give iv antibiotics
Give iv fluids
Take lactate
Take/ monitor hourly urine output

Question 9

Anaphylaxis adult adrenaline dose

Answer 9

Adult adrenaline dose: 500micrograms IM (0.5mL) 1:1000

Question 10

Children 6-12 years anaphylaxis adrenaline dose

Answer 10

300 microgramsIM (0.3mL) 1:1000

Question 11

Children less than 6 years anaphylaxis adrenaline dose

Answer 11

150 micrograms im (0.15 ml) 1:1000

Question 12

Canadian C-spine Rules

Answer 12

high risk (age >65, dangerous mechanism or paranesthesia),

Question 13

no c spine imobilisation if:

Answer 13

low risk (delayed neck pain, simple rear-end RTA, sitting position in ED, nil midline tenderness of C-spine, ambulatory at any time) and able to rotate neck (45degrees L and R)

Question 14

Cushing’s triad refers to a set of signs that are indicative of increased intracranial pressure (ICP)

Answer 14

bradycardia, hypertension, and irregular breathing.

Question 15

Cauda equina key features

Answer 15

lower motor neurone signs and symptoms
reduced lower limb sensation (often bilateral)
bladder or bowel dysfunction ( constipation/retention or incontinence)
lower limb motor weakness
severe back pain
impotence
saddle anaesthesia

Question 16

Cord compression key features

Answer 16

surgical emergency with a similar pathophysiology to CES, however is characterised by upper motor neurone signs

Question 17

Difference between metastatic spinal cord compression and cauda equina

Answer 17

MSCC is where a cancer or metastasis presses on and subsequently compresses the spinal cord.
Compression can also occur due to compromise of spinal stability due to vertebral metastases and compression from associated fractures.
Cauda equina syndrome is the same process but occurring at or below the level of the cauda equina (typically at the level of L1)
Both usually presents with pain and weakness and should be treated the same way

Question 18

Emergency initial treatment for STEMI/NSTEMI

Answer 18

MMONAC
Morphine
Metoclopramide
Oxygen (if sats <94%)
Nitrates (GTN spray)
Aspirin 300 mg
Clopidogrel 300 mg (Although, in practice, other similar drugs such as Ticagrelor are increasingly being used)

Question 19

Contraindications to thrombolysis in MI

Answer 19

Aortic Dissection
GI bleed
Allergic reaction
Iatrogenic: recent surgery
Neurological disease: recent stroke (within 3 months), malignancy
Severe HTN (>200/120)
Trauma, including recent CPR

Question 20

Hypovolaemic shock

Answer 20

Inadequate circulating volume secondary to fluid loss
Causes:
Haemorrhagic ( eg trauma, GI bleeding, obstetric haemorrhage, ruptured AAA)
D & V
DKA
Burns

Question 21

Distributive shock

Answer 21

Inadequate perfusion secondary to maldistribution
Causes:
Sepsis
Neurogenic shock
Anaphylactic

Question 22

Obstructive shock

Answer 22

Inadequate cardiac output as a result of mechanical obstruction
Causes:
PE
Tension pneumothorax
Cardiac tamponade (prevents heart from filling adequately)
Acute IVC or SVC obstruction

Question 23

Cardiogenic shock

Answer 23

Inadequate cardiac output as a result of cardiac failure
Causes:
MI
Myocardial contusion
Myocarditis
Late sepsis
Overdose ( beta blockers)
Complete heart block

Question 24

Clinical signs hypovolaemic shock

Answer 24

peripheral vasoconstriction an increase in diastolic pressure, increased capillary refill time,
Hypotension and tachycardia
Weak thready pulse with cool pale moist skin

Question 25

Clinical signs Distributive shock

Answer 25

warm peripheries
and dry
euvolemic
bounding pulse

Question 26

Clinical signs Neurogenic shock

Answer 26

leads to vasodilation and absence of sweating
warm dry skin

Question 27

Clinical signs cardiogenic shock

Answer 27

Hypotension and tachycardia, may be bradycardic ( eg bradyarrhythmia)
Weak thready pulse with cool pale moist skin

Question 28

septic shock =

Answer 28

Sepsis with hypotension unresponsive to fluid resuscitation

Question 29

amber flags sepsis

Answer 29

Concerns about mental status
Acute deterioration in functional ability
Immunosuppressed
Trauma/surgery/procedure in the last 8 weeks
Respiratory rate 21-24 bpm
Systolic BP 91-100 mmHg
Heart rate 91-130 bpm or new dysrhythmia
Tympanic Temperature <36.0oC
Clinical signs of wound infection

Question 30

red flags sepsis

Answer 30

Evidence of new or altered mental state
Systolic BP <90mmHg (or drop of >40 from normal)
Heart rate >130 per minute
Respiratory Rate >25 per minute
Requires oxygen to keep SpO2 >92% ( >88% in COPD)
Non-blanching rash / mottled/ashen/cyanotic
Lactate >2 mmol/l
Recent Chemotherapy
Not passed urine in the last 18 hours (<0.5ml/hr if catheterised)

Question 31

sepsis management

Answer 31

Give oxygen
Take blood cultures
Give iv antibiotics
Give iv fluids- 500ml bolus Hartmann’s solution or 0.9% sodium chloride over 15m, up to 4x
Take lactate
Take/ monitor hourly urine output

Question 32

CT scan within 1 hour for cervical spine

Answer 32

GCS less than 13 on initial assessment
patient has been intubated
plain X-rays are technically inadequate/suspicious
a definitive diagnosis of cervical spine injury is needed urgently (for example, before surgery)
patient is having other body areas scanned for head injury/multi-region trauma

the patient is alert and stable, there is clinical suspicion of cervical spine injury and any of the following apply:
- age 65 years or older
- dangerous mechanism of injury (fall from a height of greater than 1 metre or 5 stairs; axial load to the head, for example, diving; high-speed motor vehicle collision; rollover motor accident; ejection from a motor vehicle; accident involving motorised recreational vehicles; bicycle collision)
- focal peripheral neurological deficit
- paraesthesia in the upper or lower limbs

Question 33

Life threatening asthma features

Answer 33

33,92 CHEST.

PEF <33%
SO2 <92% or PO2 <8
Cyanosis
Hypotension
Exhaustion, altered consciousness
Silent chest
Tachyarrhythmias

Question 34

Severe asthma is characterised by any one of:

Answer 34

PEF 33-50%
RR more than equals to 25
HR more than equals to 110
Inability to complete sentence in one breath

Question 35

Moderate asthma is characterised by the following:

Answer 35

Increasing symptoms
PEF >50-75%
No features of severe asthma

Question 36

Dystonic reactions are rapidly abolished by injection of drugs such as

Answer 36

procyclidine hydrochloride or diazepam

Question 37

When to give adrenaline in cardiac arrest

Answer 37

Img IV as soon as poss for a non shockable rhythm
After 3 attempts for a shockable rhythm
Repeat adrenaline every 3-5 minutes while ALS continues

Question 38

When to give amiodarone in cardiac arrest

Answer 38

300mgIV given for shockable rhythm after 3 shocks
further 150mg IV given after 5 shocks
Lidocaine may be used as an alternative 100mg IV