Clinical Emergencies

Question 1

Asthma A to E findings.

Answer 1

A. Tongue swelling, cough, cyanosis, unable to complete sentences

B. Wheeze, reduced chest expansion, tachypnoea, increased respiratory effort, silent chest

C. Tachycardia

D. Drowsiness (carbon dioxide retention)

E. Rashes

Question 2

Asthma investigations.

Answer 2

• Bedside: PEFR, ECG, ABG, SaO2
• Bloods: FBC, U&E
• Imaging: CXR

Question 3

Asthma Management.

Answer 3

• Warn ICU is severe or life-threatening asthma attack
• Bronchodilataion: nebulised slabutamol 5mg with high flow oxygen
• Steroids: IV hydrocortisone 100 mg or PO prednisolone 40-50 mg
• Oxygen: 15 L/min oxygen through a non-rebreathe mask if saturations < 92%
• If life-threatening:
  
  • ​Add nebulised ipratropium bromide 500 mcrg
  • Administer IV magnesium sulphate 1.2-2 g over 20 mins
• If responding to treatment:
  
  • 4-hrly salbutamol nebulisers
  • Prednisolone 40-50 mg OD for 5-7 days
  • Monitor PEFR and SaO2
• If NOT responding to treatment:
  
  • ​Refer to ICU for intensified therapy (e.g. intubation, IV aminophylline)

Question 4

Acute exacerbation of COPD A to E findings.

Answer 4

A. Cough (productive?)

B. Wheeze, crepitations (infection?), bronchail breathing, increased respiratory effort

C. Tachycardia, raised JVP (right heart strain)

D.

E. Fever

Question 5

Acute exacerbation of COPD investigations.

Answer 5

• Bedside: ECG, ABG
• Bloods: FBC, U&E, CRP, sputum culture
• Imaging: CXR

Question 6

Acute exacerbation of COPD management.

Answer 6

• Bronchodilator: nebulised salbutamol 5 mg/4hr + nebulised ipratropium bromide 500 mcrg/6hr
• Oxygen: if SaO2 < 88% start 24-28% oxygen via venturi mask aiming for 88-92%
• Steroids: IV hydrocortisone 200 mg (or oral prednisolone)
• Antibiotics: following trust guidelines (e.g. amoxicillin, doxycycline)
• If no response to treatment → Refer to ICU
  
  • ​Consider IV aminophylline
  • Consider NIV
  • Consider intubation and ventilation
  • Consider respiratory stimulant (e.g. doxapram)

Question 7

Acute coronary syndrome A to E findings.

Answer 7

A.

B. Shortness of breath

C. Tachycardia, arrhythmia, cardiogenic shock

D.

E. Sweating, anxiety

Question 8

Acute coronary syndrome investigations.

Answer 8

• Bedside: ECG, capillary glucose
• Bloods: troponin, FBC, U&E, blood glucose, cholesterol
• Imaging: CXR

Question 9

Acute coronary syndrome management.

Answer 9

• Immediate
  
  • ​IV morphine 5-10 mg (repeat after 5 mins if necessary)
  • IV metoclopramide 10 mg
  • 15 L/min oxygen via non-rebreathe mask if hypoxic
  • PO aspirin 300mg AND PO clopidogrel 300 mg OR PO ticagrelor 180 mg
• STEMI
  
  • ​Percutaneous coronary intervention if able to reach PCI centre within 120 mins of first medical contact
  • Fibrinolysis (alteplase) within 30 mins of admission if PCI unavailable
• NSTEMI
  
  • ​SC Fondaparinux 2.5 mg OD
  • Assess risk and need for angiography (e.g. GRACE score)
• Drugs and take away on discharge
  
  • ​Dual antiplatelet therapy (aspirin 75 mg OD for life AND clopidogrel 75 mg OD for 1 year OR ticagrelor 90 mg for 1 year)
  • ACE inhibitors (e.g. ramipril 1.25-2.5 mg OD - increasing up to 10 mg)
  • Statin (e.g. atorvastatin 80 mg OD)
  • Beta-blocker (e.g. bisoprolol 2.5 mg OD - increasing up to 10 mg)

Question 10

Acute heart failure A to E findings.

Answer 10

A. Cough, pink frothy sputum

B. Cardiac wheeze, tachypnoea, bibasal crepitations

C. Tachycardia, raised JVP, S3 gallop rhythm, displaced apex

D. Anxious, sweaty

E. Pale, sitting up, ankle swelling

Question 11

Acute heart failure investigations.

Answer 11

• Bedside: ECG, ABG
• Bloods: troponin, U&E, BNP
• Imaging: CXR, echocardiogram

Question 12

Acute heart failure management.

Answer 12

• Sit upright
• 15 L/min oxygen via non-rebreather mask
• Gain IV access
• Diamorphine 1.25-5mg IV (caution in liver failure and COPD)
• Furosemide 40-80 mg IV STAT
• GTN spray 2 puffs sublingual
• If NO response to treatment
  
  • ​Repeat furosemide dose
  • Consider CPAP
  • Consider nitrate infusion
  • Consider ITU admission
• If stable following response to treatment
  
  • ​Monitor daily weight
  • Repeat CXR
  • Switch to oral diuretics (furosemide or bumetanide)
  • To take away on discharge
    
    • ​ACE inhibitor
    • Beta-blocker
    • Consider spironolactone

Question 13

Pulmonary embolism A to E findings.

Answer 13

A.

B. SOB, haemoptysis, normal breath sounds, cyanosis

C. Hypotension, tachycardia, raised JVP (right heart strain)

D.

E. Swollen, tender calf

Question 14

Pulmonary embolism investigations.

Answer 14

• Bedside: ECG, ABG
• Bloods: FBC, U&E, clotting, D-dimer
• Imaging: CXR, CTPA

Question 15

Pulmonary embolism management.

Answer 15

• 15 L/min oxygen via non-rebreathe mask if hypoxic
• Morphine 5-10 mg IV (with metoclopramide 10 mg IV)
• Treatment with DOAC (apixaban or rivaroxaban)
• If critically ill (haemodynamically unstable) with massive PE → immediate thrombolysis
• Ongoing management
  
  • ​Compression stockings
  • Continue DOAC

Question 16

Sepsis A to E findings.

Answer 16

A.

B. Tachypnoea, cough

C. Hypotension, slow capillary refill, tachycardia

D. Low GCS

E. Rash, cellulitis (? source infection)

Question 17

Sepsis investigations.

Answer 17

• Bedside: ECG
• Bloods: FBC, U&E, lactate, glucose, blood culture
• Imaging: depending on cause (e.g. CXR)

Question 18

Sepsis management.

Answer 18

Sepsis 6

• High flow oxygen
• IV fluids (e.g. bolus 0.9% NaCl 500 mL over 10-15 mins)
• Take blood cultures
• Give broad-spectrum antibiotics according to trust guidelines
• Monitor urine output (consider inserting catheter)
• Take lactate (ABG)

Question 19

Anaphylaxis A to E findings.

Answer 19

A. Stridor, angioedema

B. Cyanosis, wheeze, reduced breath sounds due to airway obstruction

C. Hypotension

D. Low GCS

E. Rash (urticaria), allergy bracelet

Question 20

Anaphylaxis management.

Answer 20

• If airway copromised: secure airway and give high flow oxygen
• Administer 0.5 mcrg adrenaline IM (i.e. 0.5 mL of 1:1000)
  
  • Repeat every 5 mins if needed
• Secure IV acccess
• Administer 10 mg chlorphenamine IV and 200 mg hydrocortisone IV
• Administer IV fluid bolus if in shock
• Ongoing management
  
  • ​Allergy clinic to identify allergen (skin prick testing + specific IgE)
  • Discharge with two adrenaline auto-ejectors
  • Teach to self-infect adrenaline

Question 21

Stroke A to E findings.

Answer 21

A.

B. Laboured, abnormal (e.g. depressed, Cheyne-Stokes)

C. Irregularly irregular (AF)

D. Unequal pupils (space-occupying lesion?), low GCS, low BM (hypoglycaemia), unilaterally increased or decreased tone, weakness

E.

Question 22

Stroke investigations.

Answer 22

• Bedside: ECG, capillary glucose
• Bloods: FBC, U&E, lipids, clotting, cardiac enzymes, G&S
• Imaging: CT head, carotid doppler

Question 23

Stroke management.

Answer 23

• Oxygen if SpO2 < 94%
• Nil by mouth
• Treat arrhythmia and low glucose if present
• Request urgent CT head scan
• Once haemorrhagic stroke has been RULE OUT:
  
  • Aspirin 300 mg PO STAT (administer PR if concerns about swallow)
  • Consider thrombolysis with tPA if:
    
    • Age < 80 yrs and < 4.5 hours from start of symptoms
    • Age > 80 yrs and < 3 hours from start of symptoms
• Will need physiotherapy and SALT input
• To take away
  
  • ​After 2 weeks, switch from 300 mg Aspirin to 75 mg Clopidogreal OD PO
  • Statin (e.g. atorvastatin 80 mg)
  • Blood pressure medication
  • Anticoagulants (e.g. apixaban or warfarin) if co-existing AF

Question 24

Acute upper GI bleed A to E findings.

Answer 24

A. Blood in mouth

B. Coughing (aspirated blood)

C. Hypotension, tachycardia, peripherally shut down, prolonged capillary refill

D. Dizziness

E. Abdominal pain, chronic liver disease (jaundice, spider naevi et.c)

Question 25

Acute upper GI bleed investigations.

Answer 25

* **Bedside:** BP * **Bloods:** group and save, X-match 6-10 units of blood, clotting screen, LFT, FBC, U&E * **Imaging:** endosopy * Scoring system: Rockall

Question 26

Acute upper GI bleed management.

Answer 26

* **Immediate** * ​Protect airway and keep NBM * Insert two large-bore cannulae * Rapid IV crystalloid infusion up to 1 L * Use O-ve blood until X-match is complete if grade 3-4 shock * Correct clotting abnormalities (e.g. vitamin K, FFP, PCC) * Consider referral to ICU for central venous lins * Insert catheter to monitor urine output * **Urgent endoscopy** * **If MASSIVE BLEED:** may require tamponade with Sengstaken-Blakemore tube * **Medical manageent** * **​**Major ulcer bleeding → omeprazole 80 mg IV STAT over 40-60 mins * Variceal bleeding → terlipressin 2 mg SC QDS

Question 27

Diabetic ketoacidosis A to E findings.

Answer 27

**A.** Vomit, ketotic breath **B.** Laboured breathing (Kussmaul) **C.** Tachycardia, dehydrated **D.** Drowsy, confused **E.** Insulin injection sites, insulin pump

Question 28

Diabetic ketoacidosis investigations.

Answer 28

* **Bedside:** capillary glucose and ketones, urine dipstick, ECG * **Bloods:** lab glucose and ketones, U&E, ABG/VBG, FBC, blood culture, amylas * **Imaging:**

Question 29

Diabetic ketoacidosis management.

Answer 29

* **Insulin** * ​Add 50 U Actrapid to 50 mL 0.9% NaCl * Infuse continuously at 0.1 U/kg/hour * Aim for fall in ketones of 0.5 mmol/L/hour OR rise in venous bicarbonate of 3 mmol/L/hour with a fall in glucose of 3 mmol/L/hour * If not achieving these targets, increase insulin infusion by 1 U/hour until targets are achieved * Check VBG at 1 hour, 2 hours and 2 hourly thereafter * Focus on pH, bicarbonate, glucose and potassium * Consider LMWH * Once **glucose \< 14 mmol/L,** start the patietn on **10% glucose at 125 mL/hour** alongside saline * Continue fixed-rate insulin until ketones \< 0.3 mmol/L, venous pH \> 7.3 and venous bicarbonate \> 18 mmol/L * Treat any precipitatns of DKA (e.g. infection) * **Fluid replacement** * ​ Use 0.9% NaCl * Usual fluid deficit: 100 mL/kg * Replace fluid deficit over 48 hours * **Potassium replacement** * ​ Usual deficit: 3-5 mmol/kg * Do NOT add K+ to the first bag * Monitor urine output and only add K+ once urine output \> 30 mL/hour * Check U&E hourly and replace as necessary * If serum K+ is 3.5-5.5 mmol/L → add 40 mmol of K+ to 1 L of fluid

Question 30

Acute kidney injury A to E findings.

Answer 30

**A.** Vomiting **B.** Tachypnoea, cough (pulmonary oedema), bibasal crackles **C.** Tachycardia, fluid overload **D.** Confusion (uraemia), oliguria **E.** Abdominal pain (retention)

Question 31

Acute kidney injury investigations.

Answer 31

* **Bedside:** ECG (hyperkalaemia), urine dipstick, urine sample (MC&S, ACR), ABG (acidosis) * **Bloods:** U&E, calcium, phosphate, FBC, CRP/ESR, LFTs, CK, renal screen * **Imaging:** USS, CXR

Question 32

Acute kidney injury management.

Answer 32

* Treat **HYPERKALAEMIA** * ​10-30 mL 10% Calcium Gluconate IV over 2-10 mins (can repeat every 15 mins up to 5 doses until K+ corrected) * N.B. IV calcium gluconate must be administered by a doctor (i.e. not a nurse) due to risk of arrhytmia * 10 U Actrapid with 100 mL 20% glucose IV over 10 mins * Consider 5 mg Salbutamol nebuliser * Monitor ECG and ensure quick access to defibrillator * Repeat U&E * ABG to check for acidosis * Treat the **CAUSE** * ​Hypovolaemia → IV fluids * Retention → catheterise * Pulmonary oedema → cautious use of furosemide * **Indications for urgent dialysis** * ​Refractory hyperkalaemia * Refractory pulmonary oedema * Uraemic complications (e.g. pericarditis, encephalopathy) * Severe metabolic acidosis (pH \< 7.2)