Chapter 4 - Acute

Question 1

Acute management: STEMI

Answer 1

1. ABCDE and 15L O2 via non-rebreathe
2. Aspirin 300mg PO
3. Morphine 5mg IV + metoclopramide 10mg IV
4. GTN spray
5. PCI or thrombolysis
6. Beta blocker
7. Transfer to CCU

Question 2

Acute management: NSTEMI

Answer 2

1. ABCDE and 15L O2 via non-rebreathe
2. Aspirin 300mg PO
3. Morphine 5mg IV + metoclopramide 10mg IV
4. GTN spray
5. Clopidogrel 300mg PO + LMWH (enoxaparin)
6. Beta blocker
7. Transfer to CCU

Question 3

Acute management: Acute LVF

Answer 3

1. ABCDE and 15L O2 via non-rebreathe
2. Sit patient up
3. Morphine 5mg IV + metoclopramide 10mg IV
4. GTN spray
5. Furosemide 40mg IV
6. Isosorbide dinitrate IV +/- CPAP
7. Transfer to CCU

Question 4

Acute management: Unstable tachycardia (shock, syncope, heart failure)

Answer 4

1. Synchronised cardioversion
2. Amioderone 300mg IV over 10-20 minutes and repeat shock
3. Amioderone 900mg over 24 hours

Question 5

Acute management: SVT (narrow, regular)

Answer 5

1. Vagal manoevres
2. Adenosine 6mg IV rapid bolus
3. 12mg more
4. 12mg more

Question 6

Acute management: AF (narrow, irregular)

Answer 6

Beta blocker or
Diltiazem or
Digoxin

to control rate

Question 7

Acute management: VT (broad, regular)

Answer 7

1. Amioderone 300mg IV over 20-60 minutes

2. Amioderone 900mg over 24 hours

Question 8

Acute management: polymorphic VT e.g. torsades de pointes

Answer 8

1. Seek help

2. Magnesium sulphate IV 2g over 10 minutes

Question 9

Acute management: Anaphylaxis

Answer 9

1. ABCDE + 15L O2 via non-rebreathe
2. Remove trigger
3. 0.5mg 1:1000 Adrenaline IM - repeat every 5 minutes until better
4. Chlorphenamine 10mg IV
5. Hydrocortisone 200mg IV
6. If wheeze, treat for asthma

Question 10

Acute management: Acute asthma exacerbation

Answer 10

1. ABCDE + 15L O2 via non-rebreathe
2. Salbutamol 5mg NEB
3. Hydrocortisone 100mg IV
4. Ipratropium bromide 500mcg NEB
5. Magnesium sulphate 2g IV - if life threatening
6. Theophylline - if life threatening

Question 11

Acute management: Tension pneumothorax

Answer 11

Emergency aspiration, then chest drain quickly

Question 12

Acute management: Secondary pneumothorax, >2cm rim

Answer 12

Chest drain

Question 13

Acute management: Secondary pneumothorax, no complication

Answer 13

Aspirate

Question 14

Acute management: Secondary pneumothorax, >50y/o

Answer 14

Chest drain

Question 15

Acute management: Secondary pneumothorax, SOB

Answer 15

Chest drain

Question 16

Acute management: Primary pneumothorax, SOB or >2cm rim

Answer 16

Aspirate,
Aspirate again
Chest drain if unsuccessful

Question 17

Acute management: Primary pneumothorax, <2cm rim and not SOB

Answer 17

Discharge with outpatient appointment

Question 18

Acute management: Pneumonia

Answer 18

1. ABCDE + 15L O2 via non-rebreathe
2. Antibiotics (Co-amox/amoxicillin)
3. Paracetamol
4. IV fluids

Question 19

CURB65 and what it means

Answer 19

Confusion (<8/10 on AMTS)
Urea >7
Resp rate >30
BP <90 systolic
>65

0-1 home treatment
2 - admission
>3 - ITU

Question 20

Acute management: PE

Answer 20

1. ABCDE + 15L O2 via non-rebreathe
2. Morphine 5g IV and metoclopramide 10mg IV
3. LMWH (e.g. tinzaparin)
4. IV fluids
5. Thrombolysis

Question 21

What would you be treating with this thrombolysis regimen? What drug would you use?

10mg IV over 1 minute
90mg IV over 2 hours

Answer 21

PE

Alteplase

Question 22

What would you be treating with this thrombolysis regimen? What drug would you use?

0.9mg/kg IV over 1 hour

Answer 22

Stroke

Alteplase

Question 23

Acute management: GI Bleed

Answer 23

8 Cs

1. ABCDE + 15L O2 via non-rebreathe
2. Cannulae (2 large bore)
3. Catheter + monitor fluid balance
4. Crystalloid (if BP ok) or colloid (low BP)
5. Cross match 6 units blood
6. Correct clotting problems - give FFP or prothrombin complex or platelet infusion
7. Camera
8. Culprits - NSAID, aspirin, warfarin, heparin
9. Call the surgeon if severe

Question 24

Acute management: Bacterial meningitis

Answer 24

1. ABCDE + 15L O2 via non-rebreathe
2. IV fluid
3. IV Dexamethasone
4. LP +/- CT head
5. 2g cefotaxime IV
6. ITU

Question 25

Acute management: Seizures

Answer 25

1. ABC - may need artificial airway
2. Recovery position + O2
3. IV 4mg lorazepam after 5 minutes
4. Repeat after another 5 minutes
5. Inform anaesthetist + intubate
6. Phenytoin infusion
7. May need propofol

Question 26

Acute management: Stroke (ischaemic)

Answer 26

1. ABCDE
2. If <80y/o and <4.5hours since onset, thrombolyse
3. Aspirin 300mg PO
4. Stroke unit

Question 27

Acute management: Hyperglycaemia

Answer 27

1. ABCDE + 15L O2 via non-rebreathe
2. IV fluids - 1L stat then over 1 hour, 2 hours, 4 hours, 8 hours
3. Sliding insulin scale - IVII 0.1units/kg/hour
4. Assess for K+ need

Question 28

By what should these things fall in DKA/HHS?
Glucose
Ketones

Answer 28

3mmol/L/hour

0.5mmol/L/hour

Question 29

Acute management: Hypoglycaemia

Answer 29

1. Oral glucose
2. 100ml 20% glucose IV OR 1mg IM glucagon if no IV access
3. Recheck BM every 15 mins until BM4 then check hourly

Question 30

For which drugs would you use bowel irrigation if taken in overdose?

Answer 30

Lithium

Iron

Question 31

3 options of ways to reduce absorption of overdosed drugs

Answer 31

Gastric lavage
Bowel irrigation
Activated charcoal

Question 32

What are the 2 indications for naloxone in opiate overdose?

Answer 32

Low GCS

Slow breathing

Question 33

What is the antidote for benzodiazepine overdose?

Answer 33

Flumazenil

Question 34

What is flumazenil the antidote for?

Answer 34

Benzodiazepines