Day 3 A&E Flashcards
A 65-year old man presents to the A&E department with a 5 hour history of palpitations.
He has a past medical history of Ischaemic Heart Disease, and he had an MI 2 years ago. His basic observations are as follows:
HR 150, RR 25, BP 125/80, T 37.3, SO2 96%
On examination, JVP was not visible and there was no peripheral oedema. He has palpable peripheral pulses.
Auscultation of his heart and lungs were normal. A portion of his ECG is shown below:
What is the most appropriate management for this patient?
IV Amiodarone
This patient has developed a monomorphic broad complex tachycardia on his ECG.
This is also known as a ventricular tachycardia (VT).
The most appropriate management of VT in a haemodynamically stable patient is IV Amiodarone.
- NOT Vagal manoeuvres such as carotid sinus massage and Valsalva can be used as the first line management in stable patients with a narrow complex tachycardia, not broad complex tachycardia.
A 27-year-old male presents to A&E unconscious.
His basic observations; HR: 110, RR: 35, BP: 90/65 and Temp. 36.5
As part of his work up and ECG is taken.
What is the most likely explanation for the appearance of his ECG.
Acute pancreatitis
This patient’s ECG shows a polymorphic ventricular tachycardia, with QRS complexes ‘twisting’ along the baseline - this is an ECG of Torsades de Pointes. Torsades de Pointes is caused by lengthening of the QT interval (this refers to a QT interval >450ms).
There are many causes of Torsades de Pointes, one of which is hypocalcaemia, as hypocalcaemia causes prolongation of the QT interval.
Acute pancreatitis can cause hypocalcaemia and therefore, lead to Torsades de Pointes
What causes torsades de pointes? (3)
What is the treatment? (1)
hypocalcaemia, hypokalaemia, hypomagnesaemia,
IV magnesium sulfate
A 32 year old man is admitted to hospital following a road traffic accident. Initial assessment reveals extensive pelvic injury.
The patient is drowsy and speaking incoherently.
A set of observations are performed during initial resuscitation:
- Heart rate 128 bpm
- Blood pressure 83/68 mmHg
- Respiratory rate 36 /min
- Oxygen saturations 98% on room air
- Temperature 36.5 °C
What stage of hypovolaemic shock is the patient most likely to be in?
Stage 3
The patient has all the features of stage 3 shock, confusion, tachycardia, hypotension, tachypnoea and reduced pulse pressure.
A 50-year-old lady presents to the A&E Department with a 1 day history of pleuritic chest pain. She has a past medical history of COPD. Her observations are as follows:
HR 88, RR 20, BP 120/85, T 37.0, SO2 89%
On examination, she is comfortable at rest. On palpation, there is no tracheal deviation or crepitus over the chest. On auscultation, there is decreased air entry over her right lung.
A chest X-ray is ordered and this is shown below:
What is the best management option for this patient?
Chest drain insertion
This patient has features of a secondary spontaneous right-sided pneumothorax, most likely secondary to her underlying COPD.
Patients who have a secondary pneumothorax who are symptomatic or have a pneumothorax measuring >2 cm from the chest rim on radiographs should be offered a chest drain.
A 23 year old lady presents to the Emergency Department (ED) having taking a paracetamol overdose. She reports taking 12 tablets over a couple of hours earlier that morning, with the first tablet taken 3 hours ago.
On assessment she is asymptomatic and clinically stable. Her weight is approximately 60kg.
Which of the following is the next best step in management?
Start treatment with N-acetylcysteine (NAC) immediately
This patient has taken a staggered overdose which is defined as being an overdose taken over > 1 hour.
In these cases, measuring serum paracetamol levels and plotting on a nomogram is not a reliable method to determine if treatment is required.
Patients will usually be given three bags of NAC over a period of 21 hours.
An 89-year-old man presents to A&E with abdominal pain.
The pain has worsened over the past two days and is associated with nausea, vomiting and diarrhoea.
He also reports feeling weak and lethargic.
His past medical history includes hypertension and congestive heart failure The abdomen is soft and non-tender.
Observations are as follows: respiratory rate 11/min, SpO2 95% on room air, pulse rate 130/min, blood pressure 123/87, temperature 37.2.
Baseline blood tests show a hypokalaemia (3.2 mmol/L) but are otherwise normal.
A 12-lead ECG is performed, which shows prolonged PR interval and a down-sloping ST-segment depression most evident in lead V6 and II.
Which of the following is the most likely cause of this patient’s presentation?
Digoxin toxicity
This patient most likely takes Digoxin for congestive heart failure. The abdominal pain, nausea and vomiting may be explained by gastroenteritis, or due to the effects of Digoxin toxicity itself.
Hypokalaemia (which can result from vomiting and diarrhoea) worsens Digoxin toxicity - allowing it to occur in therapeutic concentrations.
The downsloping ST segment is the characteristic ‘Salvador Dali’s moustache’ or reverse tick sign - this does not necessarily indicate toxicity, but is seen with Digoxin use.
Note, yellow discolouration of vision (xanthopsia) is a classic but rare sign of Digoxin toxicity.
A 75 year old man with a history of IVDU (now on methadone for the last 20 years) comes into the A&E after suspected food poisoning.
He feels sick and has vomited four times.
His family have all had similar symptoms earlier today after eating a salad at the local takeaway.
An admission ECG shows a QTc of 490ms.
He is given something for his nausea when he arrived at triage.
He suddenly collapses and is found to be pulseless.
What medication did he receive?
A serotonin 5HT3 antagonist, it is often used as an adjunct with chemotherapy to reduce nausea.
Importantly, it can be given PO/IM/IV making it useful when a patient is unable to keep oral foods down.
One should note that ondansetron can increase QT interval and put a patient at risk of torsades de pointes which is what happened in this case.
This patient is already on another drug notorious for prolonging QT interval – methadone.
A 57 year old farmer presents with difficulty breathing, diarrhoea, urinary frequency and muscle spasms.
On examination his eyes are watering and he appears sweaty.
He is also bradycardic.
What is the most likely cause of his presentation?
Organophosphates
Organophosphates (found in pesticides) cause over-activity of the cholinergic system giving the symptoms described in this scenario.
A 72-year-old woman presents to the emergency department with chest pain and palpitations.
On examination, she has a rapid, regular pulse and bibasal inspiratory crackles.
Her observations are below:
- HR 200
- BP 92/55
- RR 25
- SaO2 95%
- Afebrile
ECG shows a regular QRS rate of 150bpm and QRS duration > 120ms (>3 small squares).
Having completed an ABCDE assessment and established IV access, what is the single best next step?
Synchronised DC cardioversion
This patient has monomorphic VT and is displaying adverse signs (chest pain, indicating myocardial ischaemia, haemodynamic instability and pulmonary oedema).
Therefore, she is clinically unstable and requires immediate electrical cardioversion.
What is a normal QRS width?
what can causes an elongated QRS?
Normal QRS width is 70-100 ms
hypokalaemia
Treatments for
VT (2)
SVT (2)
VT
- Amiodarone 300mg IV when the patient is clinically stable
- synchronised dc cardioversion
SVT
- vasovagal maneouvres when the patient is clinically stable
- adenosine 6mg iv
An 83 year old man with a past medical history of heart failure presents with shortness of breath, raised JVP, and peripheral oedema.
Auscultation of the lungs reveals bibasal crackles.
Observations are O2 saturation of 94%, respiratory rate of 22, HR 106, BP 82/54, and temperature of 37.1 degrees Celsius.
An echocardiogram performed 3 weeks ago identified an ejection fraction of 20%.
Multiple doses of IV furosemide are given but no improvement is seen.
What is the which of the following is the best next step in management?
IV dobutamine
Intravenous inotropes (e.g. dobutamine, milrinone) may sometimes be necessary in managing patients with a severely reduced LV systolic function.
Inotropes increase the contractility of the heart.
These measures are done to maintain systemic perfusion to the end-organs.
A 22 year old man is brought into the Emergency Department (ED) following an asthma attack.
He is given nebulised salbutamol and ipratropium inhalers, IV hydrocortisone and IV magnesium sulphate.
Despite this, he remains short of breath and auscultation of the chest reveals a wide-spread expiratory wheeze.
An arterial blood gas (ABG) is performed on 15L of oxygen and shows:
- pH: 7.32 (7.35-7.45)
- PaO2: 7.6 kPa (11-15 kPa)
- PaCO2: 6.3 kPa (4.5-6 kPa)
- Bicarbonate: 27 mmol/L (22-28 mmol/L)
Which of the following is the next best step in management?
- Bilevel positive pressure ventilation (BiPAP)
- IV salbutamol
- Mechanical ventilation
- IV aminophylline
- Continuous positive pressure ventilation (CPAP)
Mechanical ventilation
This patient has near-fatal asthma which is characterised by raised PaCO2 levels.
Clinically the patient is likely to be exhausted and unable to sustain ventilatory effort thereby leading to Type 2 respiratory failure as shown on the ABG.
The most effective method of managing this would be to intubate the patient and start mechanical ventilation.
A 58-year old man presents to the Emergency Department with nausea and vomiting for the past two hours.
He is known to the alcohol liaison service and his past medical history includes severe depression.
His wife states he has ingested a bottle of anti-freeze.
Examination is unremarkable and observations are stable.
An arterial blood gas (ABG) demonstrates a metabolic acidosis.
What is the most appropriate management in this case?
Fomepizole
Fomepizole inhibits alcohol dehydrogenase.
At a sufficiently high concentration, ethanol saturates alcohol dehydrogenase, preventing it from acting on ethylene glycol, thus allowing the latter to be excreted unchanged by the kidneys.
Historically, this has been done with intoxicating doses of ethanol. However, ethanol therapy is complicated by its own toxicity.
Fomepizole inhibits alcohol dehydrogenase without producing serious adverse effects.
A 20-year-old gentleman is brought into the Emergency Department.
He is a known epileptic and is taking valproate regularly.
He started seizing about 5 minutes ago and is still currently jerking uncontrollably.
His basic observations are as follows: HR 100, RR 12, BP 140/90, T 35.8, SO2 92% RA.
He is immediately put in the recovery position, started on high flow oxygen and an oropharyngeal airway adjunct is inserted.
His blood glucose level is 6.2 mmol/L. After about 15 minutes, he is still seizing.
2 doses of IV Lorazepam 4mg had been administered but it did not seem to help.
His SO2 has improved to 98% on room air.
What is next most appropriate treatment option for this patient?
IV infusion of Phenytoin
This patient is in status epilepticus that has persisted for 15 minutes and failed to improve on 2 doses of IV Lorazepam.
A second, more longer-acting anticonvulsant is needed at this stage, and guidelines recommend an infusion of Phenytoin.
The surgical foundation doctor is called to assess a 32 year old male on a surgical ward.
On arrival the patient is comatose and appears to be making a poor respiratory effort; there is no apparent sign of airway compromise.
The patient’s oxygen saturations are 78%, the respiratory rate is 7 breaths per minute, and heart rate is 121 beats per minute.
What is the next most appropriate action?
Commence manual ventilation with a bag-valve mask
This patient has signs of significant respiratory compromise with low oxygen saturations and a low respiratory rate.
Given the respiratory rate of <10 and associated hypoxia, this patient needs manual ventilation, connecting the bag-valve mask to 15L/min oxygen.
Given a nurse is present, they can assist in calling for help or pulling the emergency buzzer, while the clinician starts ventilation.
A 60-year old man presents to the Emergency department with palpitations and dizziness.
His past medical history includes ischaemic heart disease.
On examination he is sweating and has bibasal lung crepitations.
His blood pressure is 78/52mmHg, respiratory rate 18, Sp02 98% (room air) and temperature 37.4.
His ECG shows a ventricular tachycardia.
What is the most appropriate management in this case?
Cardioversion
As this patient has a ventricular tachycardia (VT) as well as signs of haemodynamic compromise (hypotension) the first-line management is cardioversion.
VT is a broad complex tachycardia originating from a ventricular ectopic focus.
If treated rapidly, VT generally has a favourable short-term outcome.
VF or pulseless VT is treated by unsynchronised defibrillation; whereas other VTs can be treated with synchronised cardioversion.
Amiodarone is used in patients with VT; however, it is not first-line in haemodynamically unstable VT.
When should Implantable cardioverter defibrillators (ICDs) be used?
(2)
ICDs should be considered in patients who have sustained VT causing syncope, sustained VT with an ejection fraction less than 35% or a previous cardiac arrest due to VT or ventricular fibrillation (VF).
ICDs can also be used in myocardial infarctions which are complicated by non-sustained VT.
A 58-year old man is rushed into the Emergency Department via ambulance. He was found unresponsive by a passer-by. There is nobody available to provide any further information.
The ambulance crew provide the following ECG
What is the most likely diagnosis?
How can he be manged?
Ventricular Fibrillation
Ventricular fibrillation (VF) is an important shockable cardiac arrest rhythm.
This rapid and irregular electrical activity means the ventricles are unable to contract in a synchronised manner, which results in an immediate loss of cardiac output.
Management of VF and pulseless VT
Defibrillation and CPR are the mainstays of treatment. However if persistent, Amiodarone 300mg IV (same dose used to treat monomorphic VT) and Adrenaline 1mg IV (1:10,000) can be given after the third shock has been delivered.
Amiodarone is given as a one-off dose. However Adrenaline may be repeated every other cycle following a shock (i.e. cycles 3, 5, 7 etc.)
The medical foundation doctor has been called urgently to a general medical ward to assess a 45 year old gentleman who has become unresponsive.
The student nurse at the bedside does not know any background or history about the patient.
On A to E assessment, the patient is maintaining his airway, and no abnormality is noted on breathing or circulation assessment.
On assessing disability, the GCS is 4/15, pupils are equal and reactive to light, and bedside blood glucose is 2.3mmol/L.
There is an IV cannula in situ.
What is the single best initial treatment?
100ml 20% glucose IV over 10 minutes
This patient has severe hypoglycaemia causing his unresponsiveness.
He needs to be given 15 - 20g of rapid-acting carbohydrate.
Given this patient is unconscious, IV treatment is indicated. 100ml of 20% glucose corresponds to 20g of glucose, and guidance suggests this is given over 10 mins (although practically it may be given as a slow IV push via a syringe).
A 20-year-old man with no significant past medical history is brought into A&E by ambulance after a collapse.
He was playing football, suddenly fell to the floor, and was unconscious for around 5 minutes.
He reports palpitations prior to the collapse, but no shortness of breath, dizziness, chest pain, or visual symptoms.
There was no abnormal limb jerking while he was on the floor, and no post-ictal state. Neurological examination is unremarkable.
A 12-lead ECG shows a regular, narrow complex tachycardia, with short PR interval and slurred upstrokes on the QRS complexes.
What is the most likely diagnosis?
Wolff-Parkinson-White syndrome
Wolff-Parkinson-White syndrome is a type of supraventricular tachycardia caused by a congenital accessory conduction pathway in the heart.
The classical sign on ECG are short PR intervals and delta waves (slurred upstroke in the QRS complex).
Treatment is by ablation of the accessory pathway.
Features on ECG in WPW
(4)
Delta waves (slurred upstroke in the QRS)
Short PR interval (<120ms)
Broad QRS
If a re-entrant circuit has developed the ECG will show a narrow complex tachycardia
A 35-year-old East Asian lady presents to the Emergency Department complaining of a headache, which came on quite suddenly last evening.
She also feels very nauseous and noticed her left eye becoming quite red.
Apart from having migraines as a teenager, she is otherwise fit and healthy with no significant past medical history.
She recently started taking amitriptyline as she had trouble sleeping.
She has no drug allergies.
Her basic observations are as follows:
HR 100, RR 20, T 37.0, BP 130/80, SO2 98% RA.
Give her underlying diagnosis
Which of the following is the best initial treatment for her?
Acetazolamide and Timolol
This lady has acute angle closure glaucoma.
Risk factors include being female, Asian and the use of certain medications including those with antimuscarinic properties, such as amitriptyline.
Patients with acute angle closure glaucoma complain of a sudden headache, nausea and loss of vision.
Symptoms may worsen at night.
The initial management includes administering IV Acetazolamide and a topical beta-blocker such as Timolol.
An urgent Ophthalmology referral should be made.
A 28-year-old man with a history of Type 1 Diabetes is found collapsed on the floor at a bus stop.
A witness reports that preceding the blackout, the man appeared agitated and confused.
On initial assessment, the patient has a GCS of 7 and his blood glucose level is 1.7 mmol/L (4-7 mmol/L).
IV access is obtained.
Which of the following is the next best step in management?
100ml of 20% glucose IV
This patient is displaying neuroglycopaenic symptoms of hypoglycaemia which typically develops when the blood glucose level is
- less than 2.8 mmol/L.
These symptoms include confusion, drowsiness, seizures, slurred speech and loss of consciousness.
As this patient has a severely reduced level of consciousness, it is important not to put any glucose replacement in his mouth as this carries the risk of choking and aspiration.
Instead, glucose should be given IV at a concentration of either 20% or 10%.
A 45-year-old man is brought to the emergency department by his partner as she is concerned by his ‘overnight’ behaviour change. She states that he has been unwell with the ‘flu’ for several days, with fever, muscles aches and a sore throat. However last night, he became verbally abusive and agitated which is out of character for him. He does not have any ongoing health issues to her knowledge.
On examination, the patient appears confused and drowsy, and is disoriented to place and time. He is not compliant with neurological examination, but appears to shy away from the light, clutching his head. There is an erythematous rash with overlying scale over the forehead, nose and nasolabial folds, and a white coating over the tongue extending to the oropharynx. His partner states that the scaly rash appears everytime he gets the ‘flu’.
His observations are below:
- HR 105
- RR 21
- BP 95/55
- SaO2 99% RA
- T 38.3
Give the likely causes of his symptoms?
What is the single best empirical treatment?
Aciclovir and Cefotaxime
This man is very ill with signs of an intracranial infection and a worrying drop in GCS.
The signs of meningeal irritation with fever and behaviour change are highly suggestive of meningoencephalitis.
Given the history of repeated seborrheic dermatitis during intercurrent illness and current oropharyngeal candidiasis, it is likely an opportunistic infection secondary to HIV.
Aciclovir covers for HSV-1 and HSV-2.
Cefotaxime is a 3rd generation cephalosporin and covers for most causes of bacterial meningitis.
A 24-year-old woman is brought into A&E by her friends with agitation and confusion.
On examination, she is shivering and tremulous, with hyperreflexia of her lower limbs.
Neurological examination is otherwise normal, and pupils are equal and reactive to light.
Observations are as follows: respiratory rate 12/min, SpO2 95% on room air, pulse rate 129/min, blood pressure 134/89, temperature 38.1.
She suffers from depression for which she is receiving treatment from her GP.
Which is the most likely diagnosis?
Serotonin syndrome
This patient has presented with features of serotonin syndrome, which can occur in patients taking therapeutic doses of serotonin reuptake inhibitors (SSRIs).
This syndrome is often confused with neuroleptic malignant syndrome, but the clinical features are distinct.
Clinical features of serotonin syndrome can be split into neurological and autonomic.
Neurological features are of altered mental state, tremor, ataxia and hyperreflexia.
Autonomic features include
- tachycardia
- hypertension
- diarrhoea
- hyperthermia
What is Neuroleptic malignant syndrome?
What is the predominant symptom?
This is often confused with serotonin syndrome.
It is caused by antipsychotic medications or sudden reduction in dopaminergic drugs (e.g. for Parkinson’s disease).
It can present with similar autonomic features, but the predominant neuromuscular feature is of rigidity (compared to tremor and hyperreflexia in serotonin syndrome).
A 75 year old man is reviewed by the cardiology registrar in resus.
He has a past medical history of atrial fibrillation and has been taking bisoprolol and amiodarone.
His heart rate fluctuates with a maximum rate of 150bpm.
The rest of the observations are within normal limits and electrolytes within normal range.
His ECG is reproduced below:
What is the next best initial step in management? (3)
IV Magnesium Sulphate and stop any causative medication
The patient’s ECG is consistent with Torsades de pointes a polymorphic ventricular tachycardia associated with prolonged QT.
It must be treated urgently due to the risk of unstable VT or VF leading to sudden cardiac death.
If the patient is haemodynamically unstable, then cardioversion is indicated
A 75-year-old gentleman presents to the Emergency Department with a 2-hour history of severe crushing central chest pain.
He has a past medical history of HTN, DM and IHD. His basic observations are as follows:
HR 100, RR 25, BP 150/95, T 37.3, SO2 97% RA.
An ECG is performed and it is shown below:
What is the most appropriate definitive treatment for this patient?
PCI
The ECG shows ST elevation in leads aVL, V2 to V5 with reciprocal changes in II, III, aVF.
This is diagnostic of a STEMI.
The definitive treatment for this is a PCI, involving inserting a stent to reperfuse the affected myocardium.
A 78 year old woman presents to A&E with haematemesis.
She has been having epigastric pain intermittently over the last 3 weeks, especially a few hours after eating.
She has a past medical history of osteoarthritis and hypertension.
She takes amlodipine and over-the-counter ibuprofen.
Which of the following is the definitive treatment for this patient?
Endoscopic clipping
The history of an upper GI bleed in a patient who has NSAID exposure, especially without concurrent protection with acid suppression, is highly suggestive of a bleeding peptic ulcer.
Endoscopy is the method of choice for managing bleeding from a peptic ulcer. Therapeutic measures include clipping, thermal coagulation, fibrin, or thrombin.
A 38-year-old woman presents to A&E with a two-day history of abdominal pain.
The pain is severe and most prominent in the epigastric region, with radiation to the back.
She reports nausea and several episodes of vomiting.
She has no significant past medical history but admits to regularly drinking at least 30 units of alcohol a week.
Observations are as follows:
- respiratory rate 10/min,
- SpO2 95% on room air,
- pulse rate 130/min,
- blood pressure 108/68,
- temperature 37.9
A 12-lead ECG is performed which shows sinus tachycardia.
What is the most likely diagnosis?
Acute pancreatitis
Epigastric pain radiating to the back is characteristic of acute pancreatitis.
Patients may also describe that the pain is relieved by leaning forwards.
Gallstones and alcohol are the two biggest causes of pancreatitis, accounting for over 70% of cases.
Serum amylase and lipase will aid diagnosis.
An 82-year-old gentleman is brought into the Accident and Emergency department by ambulance acutely distressed with difficulty breathing and coughing up frothy pink sputum.
He has had two previous myocardial infarctions.
His observations are taken (see below).
On examination, he looks unwell.
He is sweaty and there are fine inspiratory crepitations throughout the lung fields.
- Temperature: 37.2
- Oxygen saturations: 97% on room air
- Heart Rate: 87
- Respiratory rate: 24
- Blood pressure: 168/98
What is the next most immediate appropriate action to take?
Sit the patient upright
The underlying diagnosis is pulmonary oedema. This patient will likely need multiple investigations including ECG, chest X-ray and blood tests.
However, the most immediate action that can be performed is to sit the patient upright and improve oxygenation.
This patient may well end up receiving furosemide for management of pulmonary oedema.
However, in the first instance sitting the patient up may provide immediate symptomatic benefit.
A 72-year old is admitted to the Emergency Department with a 4-day history of lethargy and palpitations.
His past medical history includes hypertension but he is otherwise well and relatively active.
On examination his pulse is irregularly irregular.
His pulse rate is 118 bpm, respiratory rate 16 and blood pressure 132/76mmHg.
His ECG confirms Atrial Fibrillation (AF).
What is the most appropriate medication for first-line management?
Bisoprolol
As the patient is over the age of 65 and it is more than 48 hours after onset of symptoms, rate control is preferred over rhythm control.
Rate control options include beta-blocker (e.g. bisoprolol), a non-dihydropyridine calcium channel block (e.g. diltiazem or verapamil) or digoxin.
It is important to check for a history of asthma, as brittle asthma is a contraindication for beta-blockers due to the potential for bronchospasm.
A 28-year old gentleman presents to the A&E Department with a 4 hour history of diffuse abdominal pain, vomiting and lethargy.
His past medical history includes Type 1 DM, asthma and eczema.
He takes regular insulin, inhaled corticosteroids and PRN salbutamol.
He has no drug allergies.
On examination, he appears very lethargic.
His capillary refill time is 4 seconds.
His observations are as follows:
T: 37.3, HR: 105, RR: 25, O2: 98%, BP: 105/70
You quickly do an ABG and it shows the following:
- pH: 7.22 (7.35 - 7.45)
- PO2: 11.5 kPa (10 - 15)
- PCO2: 4.3 kPa (4.5 - 6)
- HCO3: 15 mmol/l (22 - 26)
- Na: 148 mmol/l (135 - 145)
- K: 5.0 mmol/l (4.5 - 5.0)
- Lac: 1.0 mmol/l (0.5 - 1.0)
- Glucose: 25 mmol/l
A urine dip shows the following:
- Leucocytes NIL
- Nitrites NIL
- Protein +
- Blood NIL
- Ketones 3+
Which of the following is the best option for the initial management of this patient?
1L of 0.9% NaCl IV STAT
This patient appears severely dehydrated.
He has
- vomiting
- appears lethargic
- has a capillary refill time of 4 seconds
- a dropping BP
- raised sodium level
He would need intravenous fluids as soon as possible, hence this is the right answer.
Clinical signs of dehydration
(5)
vomiting
appears lethargic
has a capillary refill time of 4 seconds
a dropping BP
raised sodium level
You are crash-bleeped to attend to a patient on AMU.
Other members of the team have arrived and CPR has already been commenced.
The defibrillator pads have just been attached and the ECG shows that the patient is in sinus rhythm with a ventricular rate of 65 bpm.
The carotid pulse is not palpable at the rhythm check.
What is the single next best step?
Recommence CPR
This patient has pulseless electrical activity (PEA).
This falls under the ‘non-shockable rhythm’ branch of the adult advanced life support algorithm.
It is important to minimise interruptions to CPR, which provides vital organ perfusion.
A 4 year old girl has severe difficulty breathing. She is drooling and appears unwell and in respiratory distress.
She has no relevant past medical history, although her mother is against vaccinations.
Her temperature measures 39.
What is the most likely microbiological cause of this patient’s condition?
Haemophilus influenzae B
This patient has acute epiglottitis, which is most frequently caused by bacterial infection of the soft tissue structures that are anatomically superior to the glottis.
Haemophilus influenzae B (Hib) is the most common cause of epiglottitis in non-vaccinated children.
A 19-year-old lady is brought into the Emergency Department (ED).
She reports worsening abdominal pain and vomiting over the last 3 days.
Additionally, she notes feeling more weak and drowsy over the last 24 hours.
Investigations reveal a random blood glucose level of 24 mmol/L (4-11 mmol/L) and a serum ketone level of 3 mmol/L (<0.1 mmol/L).
Which of the following arterial blood gas (ABG) patterns is most commonly seen in patients presenting with diabetic ketoacidosis?
Raised anion gap metabolic acidosis
The anion gap is the difference between measured cations and measured anions in the serum.
It is calculated by the following equation:
- ([Na+] + [K+]) – ([Cl-] + [HCO3])
The normal range is approximately between 10-20 mmol/L.
In a raised anion gap metabolic acidosis, there is either endogenous or exogenous acid that leads to a decrease in the bicarbonate (in order to buffer the acid) thereby increasing the anion gap.
In DKA, the ketones are the source of the acidosis.
Other important causes of a raised anion gap metabolic acidosis include uraemia (in renal failure), lactic acidosis (e.g in sepsis) and ingestion of drugs such as aspirin, methanol and ethylene glycol.
A 45 year old male patient presents to the emergency department with palpitations and severe malaise.
He has a past medical history of unipolar depression, for which he is takes amitriptyline.
He has recently been treated for a lower respiratory tract infection.
Electrocardiogram reveals polymorphic wide complex tachycardia.
The patient is haemodynamically stable.
Give the likely diagnosis
Which of the management options is most appropriate?
Intravenous magnesium sulfate
The patient presents with torsades de pointes (TdP), a polymorphic ventricular tachycardia that has occurs due to QT prolongation (in this case most likely secondary to co-prescription of a tricyclic antidepressant with a macrolide).
Treatment is with intravenous magnesium sulphate, withdrawal of offending drugs, and correction of electrolyte abnormalities.
A 74-year-old woman presents to the Emergency Department by ambulance.
She was found at home alone by her neighbour with an empty bottle of medication next to her.
She appears to be confused and is complaining of dizziness and nausea.
She also complains of blurred vision with a yellow discolouration.
Her past medical history includes anxiety, depression, hypertension and atrial fibrillation.
Her observations include a heart rate of 30bpm, blood pressure 74/52mmHg and Sp02 95% (on room air).
The ECG reveals reverse tick ST depression with first degree heart block.
What is the diagnosis?
What is the first-line treatment?
What is the next most effective treatment for this patient?
Digoxin overdose
First line is atropine
Intravenous digoxin-specific antibody (Digibind)
The ECG reveals reserve tick ST depression with first degree heart block which is the classic effect seen in digoxin overdose.
This patient is experiencing severe digoxin toxicity (the presence of arrhythmia and xanthopsia - yellow vision, haemodynamically unstable) following an overdose of digoxin tablets with suicidal intention.
Digoxin-specific antibody (Digibind) is reserved for the reversal of life-threatening overdoses.
Digibind binds to molecules of digoxin, making them unavailable for binding at their site of action on cells in the body.
The fragment-digoxin complex accumulates in the blood, from which it is excreted by the kidney.
A 60-year old woman presents to the Emergency Department with shortness of breath.
Her past medical history includes angina.
On examination she is clammy.
Her blood pressure is 94/54mmHg.
Her ECG shows a sinus bradycardia of 38bpm.
What is the first initial step in management?
IV Atropine
The Resuscitation Council (UK) guidelines emphasise that the management of bradycardia depends on haemodynamic compromise and identifying the potential risk of asystole.
The factors indicating haemodynamic compromise (and therefore the need for treatment) are shock, syncope, myocardial ischaemia and heart failure.
IV Atropine 500 micrograms is given, and can be repeated every 3–5 min to a total of 3 mg.
How does IV Atropine work?
(2)
The most important therapeutic action of atropine is the inhibition of smooth muscle and glands innervated by postganglionic cholinergic nerves
It also dilates the pupils
A 35-year old man presents to the A&E Department with a history of increasing confusion over the past 2 hours.
He also complains of a bad headache and is feeling nauseous.
He had just returned from a ski holiday yesterday.
While skiing, his family recalls an incident where he fell over and hit his head against some rocks.
However, he appeared fine and walked away from that accident without any problems.
Currently, his basic observations are as follows:
HR 67, RR 30, T 36.7, SO2 94%, BP 150/95
What is the most likely cause of his current presentation?
Damage to middle meningeal vessels
Damage to the middle meningeal vessels would result in an Extradural haemorrhage (EDH).
Patients with an EDH usually experience a lucid interval after a recent traumatic incident.
This refers to a period where there is temporary improvement in a patient’s condition following injury, after which the condition deteriorates.
This patient has a history of a lucid interval following his ski accident. A few days later, he has started to deteriorate, showing signs of raised intracranial pressure (ICP), probably resulting from an extension and worsening of the bleed in his brain.
A 75-year old gentleman presents to the A&E department with a 2 hour history of severe crushing central chest pain.
He has a past medical history of HTN, DM and IHD. His basic observations are as follows:
HR 100, RR 25, BP 150/95, T 37.3, SO2 97%
An ECG is performed and is shown below:
What is the most appropriate initial treatment for this patient?
What is the diagnosis?
Morphine, Metoclopramide, Aspirin 300mg, Clopidogrel 300mg, GTN spray, PCI
The ECG shows ST elevation in leads aVL, V2 to V5 with reciprocal changes in II, III, aVF.
This is diagnostic of a STEMI. As this patient is saturating at 97%, she does not require oxygen.
The 2008 BTS guidelines recommend that oxygen therapy should only be administered in patients who are saturating less than 94% as there is an increased mortality risk.
These are the most appropriate options for managing a STEMI in the initial setting.
The mnemonic MMONAC can be used to remember this. It stands for Morphine, Metoclopramide, (Oxygen if sats <94%), Nitrates (GTN spray), Aspirin 300 and Clopidogrel 300.
A 70-year-old man presents to the emergency department with retrosternal pain.
He describes it as burning and 10/10 in severity.
It came on as he was walking to the shops.
He has had several episodes of this in the last month, but they typically resolved after he stopped and rested for five minutes or so.
In the last week, he has been getting such pains daily.
He has a past medical history of hypertension and hypercholesterolaemia, and is an ex-smoker with a 25 pack-year history.
On examination, he is pale and sweaty, but cardiac, respiratory and abdominal examination are otherwise normal.
Initial ECG is normal. Blood tests have been sent but have not yet returned.
His observations are below:
- HR 95
- BP 144/80
- RR 25
- SaO2 95%
- T 36.9
Given the most likely diagnosis, what is the single best management plan?
Give aspirin 300mg PO
This patient has acute coronary syndrome.
The history of increasing frequency of chest pain brought on by activity and alleviated by rest is strongly suggestive of crescendo angina.
Without troponin results, it is not yet possible to determine whether this is unstable angina or an NSTEMI.
ECG can initially be normal in both unstable angina and NSTEMI, and serial ECGs should be performed to look for dynamic changes.
A 20-year-old male is brought in by ambulance to the Emergency Department.
He was a restrained front-seat passenger in a road traffic accident.
He is complaining of left sided pleuritic chest pain and shortness of breath.
His vital signs are stable and he is given analgesia and sent for a chest x-ray.
While he is in the x-ray department he becomes more short of breath.
His heart rate begins to rise and his blood pressure begins to fall.
You are called to review him in the x-ray room as he is quickly becoming unstable.
You review the x-ray that has just been taken.
What is the next immediate step that should be taken?
What exact treatment is needed?
Urgent needle decompression followed by chest drain insertion
This patient has a left sided apical pneumothorax, but worryingly the mediastinum is shifted towards the right.
This is highly concerning for a tension pneumothorax and needs to be urgently decompressed using a wide bore needle/cannula in the 2nd intercostal space, midclavicular line and followed up with a chest drain.
55-year old man presents to the A&E department with a 1 day history of palpitations.
He has a past medical history of childhood asthma and schizophrenia. He was started on a new antipsychotic yesterday. His basic observations are as follows:
HR 100, RR 25, BP 125/80, T 37.3, SO2 96%
On examination, JVP is not visible and there was no peripheral oedema. Auscultation of his heart and lungs were normal.
A portion of his ECG is shown below:
What is the most appropriate management for this patient?
IV Magnesium Sulphate
IV Magnesium Sulphate is the most appropriate treatment for TDPs, which is what this patient has on ECG. Anti-psychotics can cause a prolonged QT interval, which can develop into TDP.
