Acute medicine

Question 1

Management of sepsis

Answer 1

A-E management
Venous blood sample- blood cultures, FBC, U&Es, CRP, venous blood gas (lactate and glucose), creatinine, clotting screen
Broad spectrum anti-microbial according to protocols without delay
Discuss with consultant
IV fluid bolus without delay
Refer to critical care for review of management including vasopressors, inotropes and central venous management

Question 2

High risk of sepsis

Answer 2

Objective assessment of new or altered mental state
Tachypnoea of >25 or new requirement of oxygen to maintain sats >92
Systolic BP <90 or 40 below normal
Oliguria (<0.5ml/kg/hour) or not passed urine in 18 hours
Mottled/ashen cyanosis of lips
Non-blanching rash

Question 3

Management of a patient in anaphylaxis

Answer 3

A-E
Comfortable position
1 in 1000 IM adrenaline 500mcg (0.5ml) for an adult
Repeat after 5 mins if no improvement
Remove trigger if possible
Give oxygen at the highest rate possible- 100% 15L non-rebreathe mask
Obtain IV access and give fluid challenge- 500ml of 0.9% saline over 15 minutes
Slow IM or IV chlorphenamine and hydrocortisone

Question 4

Clinical features of anaphylaxis

Answer 4

Sudden onset and rapid progression of
Looking and feeling unwell
Airway swelling, hoarse voice, stridor, stertor
Breathing difficulties- SOB, wheezing, cyanosis, confusion
Circulatory signs of shock- hypotension, tachycardia, shock, syncope, LOC, cardiac arrest

Question 5

Status epilepticus management

Answer 5

Make sure the patient is helped to the floor and in a comfortable position
Ensure nothing is in their mouth
When seizure stops ensure patent airway and put into recovery position
Buccal midazolam or rectal diazepam in the community
Continue normal medications
Ambulance if seizure lasts more than 5 minutes
Secure airway, high flow oxygen, respiratory and cardiac function, check BM, secure IV access
IV lorazepam X2
Phenytoin infusion

Question 6

Burn assessment

Answer 6

Timing, type and cause (flame, scald, chemical, electrical, contact burn)
Extent of the burn 
Risk of inhalation injury
Possibility of NAI
Assess and document depth of burn 
Cap refill
Tetany

Question 7

Burn initial management

Answer 7

Do not try and remove tar but remove clothing
Irrigate burn within 20 minutes with cool-tepid water
Wrap patient in blanket to avoid hypothermia
Layer cling film onto the burn or a clean cotton sheet if not available
Elevate area if possible
Analgesia
Transfer

Question 8

Attempt defibrillation if which rhythms are identified

Answer 8

Ventricular tachycardia or ventricular fibrillation

Question 9

Do not attempt defibrillation if which rhythms are identified

Answer 9

Asystole or pulseless electrical activity

Reversible cause must be found and corrected

Question 10

Management of a patient with a shockable rhythm

Answer 10

Defibrillate as soon as possible
Everyone should stand clear and oxygen masks be removed
Immediately resume CPR at a rate of 30:2
2 minutes and then stop for no more than 5 seconds to check the monitor
Up to 3 shocks like this with 2 minutes in between
Then IV 1mg of 1 in 10000 adrenaline and 300mg amiodarone and resume CPR
Shock
Give further IV adrenaline after alternating shocks

Question 11

Mild hyperkalaemia values

Answer 11

5.5-5.9mmol/L

Question 12

Aetiology of hyperkalaemia

Answer 12

AKI,CKD, hyperkalaemic renal tubular acidosis
Iatrogenic- medications
Trauma- burns
DKA
Addison's disease- lack of aldosterone

Question 13

Clinical features of hyperkalaemia

Answer 13

General weakness and fatigue
Palpitations, chest pain, SOB
In most cases no signs

Question 14

Hyperkalaemia management

Answer 14

URGENT if >7.0mmol/L or ECG changes (particularly widening of QRS)
Suspension of potassium containing fluids or medications that may raise
10mls of 10% calcium gluconate solution if ECG changes present to stabilise the cardiac membrane
Insulin glucose infusion and nebulised salbutamol to shift the potassium intracellularly
Calcium resonium to excrete the potassium, correction of the underlying cause
Haemodialysis if refractory and resistant

Question 15

Haemodialysis acute indications

Answer 15

A- acidosis
E- electrolytes- refractory hyperkalaemia
I- intoxicants- salicylates, lithium 
O- overload- congestive heart failure
U- uraemic pericarditis or encephalitis

Question 16

Hs and Ts of reversible cardiac arrest

Answer 16

Hypoxia
Hypovolaemia
Hypothermia
Hyperkalaemia/ hypokalaemia/ other electrolyte abnormalities

Tamponade
Tension pneumothorax
Thrombus
Toxins

Question 17

Signs of hypercalaemia

Answer 17

Bones- deformity and pain
Groans- n+v, constipation, abdo pain
Stones- renal colic from calculi
Psychic moans- drowsiness, confusion, psychosis
Cardiac- hypertension, shortening QT interval, arrhythmias

Question 18

Maximum safe dose of paracetamol for an adult in 24 hours

Answer 18

4g
Serious toxicity greater than 150mg/kg in any 24 hour period (21 tablets for a 70kg man)
Therapeutic is usually 75mg/kg in 24 hour

Question 19

1st investigations for paracetamol overdose

Answer 19

Serum paracetamol concentration
LFTs
Prothrombin time and INR
BM

Question 20

Management of paracetamol overdose

Answer 20

Plot need for NAC on a measured plasma paracetamol curve 4 hours
If timing is unreliable then consider NAC- nomogram also becomes more unreliable after 15 hours
Staggered overdose then NAC
Activated charcoal in the first hour
Consider liver transplant

Question 21

Signs and symptoms of an opioid overdose

Answer 21

Drowsiness
N+V
Confusion
Decreased levels of consciousness
Hypoventilation 
Pin-point pupils

Question 22

Management of an acute opioid overdose

Answer 22

A- remove obstruction, jaw thrust, oropharyngeal airway insertion
B- 100% oxygen 15L via non-rebreath mask
Naloxone- 400mcgs IV if no response then up to another 2 doses
C- BP, cap refill, fluid balance chart, wide bore cannula insertion- 14G or 16G, bloods- FBC, LFTs, U&Es, CRP, serum lactate, coag screen, toxicology screen, IV fluids, CPR
D- GCS, pupillary response, BM, ketones, medication chart review, imaging- CT head
E- inspection, temperature, catheterisation,
REASSESS- senior help

Question 23

Management of salicylate overdose

Answer 23

Consider activated charcoal if presenting within an hour and second dose if levels continue to rise
Gastric lavage if levels >500mg/kg in an hour
Aggressive rehydration
Low threshold to give glucose
Alkalisation of the urine increases excretion
Haemodialysis
Mechanical ventilation if reducing conscious level

Question 24

Management of hypercalcaemia

Answer 24

IV rehydration and bisphosphonates

Investigation for underlying cause- malignancy or hyperparathyroidism

Question 25

Investigations for cellulitis

Answer 25

Wound swab FBC, U&Es, LFTs, ESR, CRP USS Skin biopsy

Question 26

Differentials for cellulitis

Answer 26

Cutaneous abscess, septic arthritis, acute gout, DVT, malignancy, pre-malignant eg. Bowen's disease, erysipelas

Question 27

Management of cellulitis

Answer 27

High dose oral antibiotics- flucloxacillin or if allergic then oral macrolide IV rehydration Elevation of the leg Analgesia Identification and management of co-morbidities

Question 28

Management of life-threatening asthma

Answer 28

Admission Oxygen- 100% 15L via a non-rebreathe mask Bronchodilation with SABA Oral corticosteroid (and continued for 5 days or until recovery) SAMA if not improved- ipratropium bromide IV magnesium sulphate IV aminophylline following senior review

Question 29

What is hypoglycaemia

Answer 29

Blood glucose <4mmol/L

Question 30

Treatment of suspected hypoglycaemia

Answer 30

If patient is conscious and can swallow then 15-20g of fast-acting carbohydrate (roughly 3-4 teaspoons of sugar) If patient has had hypoglycaemic episode before then they may have a glucose 40% gel to hand Repeat after 10-15mins up to 3 times in total Long acting carbohydrate once blood glucose is above 4mmo/L If not responding to above or emergency then: IM glucagon or glucose 10% IV infusion If insulin injection is due then it should not be omitted but may need reviewing

Question 31

Diabetic ketoacidosis management

Answer 31

Replacement of fluid and electrolytes and administration of insulin is the basics 500ml of sodium chloride 0.9% over 10-15 minutes When BP is over 90mmHg then NaCl at a rate that replaces deficit and maintains pressure Include KCl and adjust according to plasma-potassium concentration Start insulin infusion, mixed with sodium chloride at a fixed rate of 0.1units/kg/hour Monitor blood glucose and ketones hourly and adjust rates accordingly Once blood-glucose falls below 14mmol/L, 10% glucose should be given IV

Question 32

What is shock?

Answer 32

Circulatory failure (either pump or peripheral) resulting in inadequate organ/ tissue perfusion

Question 33

Management of heart failure acutely

Answer 33

``` Position upright Oxygen 100% 15L non-rebreathe Diuretics- IV furosemide Morphine slowly IV Anti-emetics Nitrates ```

Question 34

Signs of heart failure on a CXR

Answer 34

Alveolar oedema- bat winging Kerley B lines Cardiomegaly Effusions (pleural), loss of costophrenic angles

Question 35

Management of heart failure once stable from acute

Answer 35

Monitoring and repeat CXR Switch IV furosemide to oral ACE-i, beta-blocker (consider hydralazine and nitrate if ACE-i contraindicated) Spironolactone Optimise management of AF if this is present Consider biventricular pacing/ cardiac transplantation

Question 36

Investigations for heart failure

Answer 36

``` ECG U&Es, troponins ABG CXR, Echo Consider BNP- good negative predictive value ```

Question 37

Status epilepticus management

Answer 37

Ensure airway is patent and patient is in a comfortable position where they will not be hurt A-E approach Airway and oxygen 100% Suction where required In community buccal midazolam IV access Take bloods- FBC, U&Es, LFTs, toxicology, glucose, calcium Lorazepam IV- and repeat after 10-20 minutes Thiamine infusion if suspected alcoholism or malnourishment, glucose 50% 50ml if hypoglycaemic Phenytoin IV After 60-90 minutes seek ICU help, with anaesthetic help-propofol infusion Anaesthetics after 20 minutes into status epilepticus

Question 38

When to perform a CT head in <1hr

Answer 38

GCS <13 on initial inspection or decreasing Focal neurological deficit Suspected open or closed depressed skull fracture or signs of basal skull fracture Post-traumatic seizure Vomiting more than once

Question 39

Signs of a basal skull fracture

Answer 39

Battle's sign- post-auricular ecchymosis Panda eyes- periorbital ecchymosis CSF leak through ears or nose Haemotympanum

Question 40

Management of raised intracranial pressure of unknown cause

Answer 40

``` A-E assessment Position the patient at 30-45 degrees Correct hypotension and treat seziures If intubated then hyperventilate to reduce the partial pressure of CO2 as this will cause cerebral vasoconstriction Osmotic agents such as Mannitol Fluid restriction Monitor patient closely Aim to make a diagnosis and treat the cause or exacerbating factors ```

Question 41

Upper GI bleed management

Answer 41

A-E assessment Protect the airway and keep NBM Insertion of 2 wide bore cannulae Bloods- FBC, U&Es, LFTs, glucose, cross-match 4-6 units of blood If haemodynamically unstable and cross-match not complete then use O neg blood Correct clotting abnormalities- platelets, FFP, vitamin K Fluid challenge of 1L crystalloid- 0.9% saline Urgent endoscopy as soon as adequately resuscitated- for diagnosis and management- cauterisation, adrenaline or banding to stop the bleeding If suspected variceal bleeding then broad spectrum antibiotics and terlipressin IV ICU referral considered and use of a central line for fluid resuscitation Sengstaken-Blakemore tube for uncontrollable variceal bleeding

Question 42

Management of acute epiglottitis

Answer 42

Secure airway IV antibiotics Supplemental oxygen Corticosteroids

Question 43

Management of severe hypocalcaemia

Answer 43

Monitor ECG and bloods Calcium gluconate Supplementary calcichew going forward