ED 2017 Release Flashcards
A 65 year old woman presents to the Emergency Department with central chest pain of one hour’s duration unrelieved by glycerine trinitrate. How would you assess and manage her?
ACS pathway
- Primary survey and resus
- Confirm diagnosis and rule out differentials
- Assess severity
- Treat - STEMI vs NSTEACS
- Long term: risk factor management, cardiac rehab, depression screen
A 26 year old man presents to the Emergency Department with acute onset of palpitations. His PR is 150/min and BP 105/90mmHg. An ECG shows supraventricular tachycardia with narrow QRS complex. How would you assess and manage him?
- Primary survey and resus, prepare for deterioration
- Assess ECG: sinus tachy vs SVT vs atrial flutter vs WPW
- Look for underlying cause: heart disease, electrolytes, thyroid, drugs
- Assess for end-organ damage/complications
- Treat cause
- Treat: SVT = vagal manoeuvres, adenosine; flutter = rate control or cardioversion if acute
- Treat end-organ issues
- Longterm: consider cardiologist referral for EPS
A 78 year old man is brought in by ambulance following a collapse at home. His PR is 42/min and BP 85/65 mmHg. How would you assess and manage him?
Shock: Primary survey and resus
A: ensure patent, consider I+V, C-spine collar if suggestive hx
B: assess RR, sats, WOB, auscultate, give O2 if sats < 94%
C: assess HR, BP, ECG, colour, cap refill, ausc
two IV large bore cannulae
IVF one side: 500mL bolus, consider inotropes if not improving
Bloods other side: VBG, blood cultures, coags, G&H, FBC, EUC, LFTs, trops, D-dimer, BSL
ABG
D: GCS, BSL, pupils, consider CTB, give dextrose if hypoglycaemic
E: temp, exposure, log roll, urinalysis, CXR
Short history if possible: AMPLE
treat suspected cause of shock
- complete heart block: stop any drugs, fix electrolytes, external pacing (also give analgesia) => insertion of pacemaker
- other cardiogenic: ACLS/reperfusion/surgery
- distributive: abx for sepsis, adrenaline if anaphylaxis
- restrictive: pericardiocentesis if tamponade
- hypovolaemic: fluids +/- blood
Long term
- GP F/U for risk factor modification
A young man is brought to the Emergency Department after having collapsed whilst self-administering an unknown drug by intravenous injection. He is unconscious, PR 72/min, BP 105/65 mmHg, RR 8/min. He is cyanosed and his pupils are small. How would you manage him?
Opioid toxicity: intervene if RR <12 or sats <90%
- Primary survey and resus esp B (bag-mask if apnoeic)
- Determine exact ingestion
- Rule out other causes and complications: BSL and then as per hx (eg LFTs, ECG, CK, CXR)
- Naloxone titrated to adequate ventilation
- Monitoring: esp because naloxone is short-acting
- Consider psych review
- Long-term: D&A referral, ?opioid substitution therapy
A 48 year old man presents to the Emergency Department requesting a prescription of Endone or Valium. He reports a back injury 30 years ago, which results in chronic back pain, with no new concerning features. He does not have a regular GP. The triage nurse informs you that he may be drug seeking and that he may be volatile. How would you assess and manage this situation?
Priorities
- not have any preconceptions
- stay safe: choose an environment where neither he nor I are trapped, where help is available
- elicit a thorough history and examination: pain, treatment, comorbidities (esp psych), ?addiction
- elicit concerns
- provide paracetamol +/- NSAID
- counsel as to pain options, referral to regular GP/psych
A 48 year old woman with type 2 diabetes presents with fever and loin pain. How would you assess and manage her?
Pyelo
- Primary survey and resus if necessary (urosepsis)
- Confirm PDx and rule out DDx (stones, cystitis, renal abscess) with hx, o/e, Ix
- Management: gent and amp, supportive care (fluids, analgesia, DVT prophylaxis)
A 19 year old woman with type 1 diabetes is brought into the Emergency Department in a stuporous condition. Her BSL is 26mmol/L and she has ketonuria. How would you assess her?
Diabetic ketoacidosis
Priorities
- primary survey and resus (incl ECG - ?hyperK)
- AMPLE, Ix to confirm DKA
- SPIG: initially infusion aiming to drop by 3-6/hr, then SC insulin once ketones < 0.3; and glucose once BSL<15
- search for and treat underlying cause: ?infection, ?cardiac event, ?recent stress eg surg, trauma
- D/C planning and education
A 38 year old man with alcoholic cirrhosis is brought into the Emergency Department by his friend who reports that he has became increasing confused and drowsy. He is drowsy, jaundiced and has obvious ascites. His temperature is 38.0°C. How would you assess and manage him?
Suspect SBP +/- hepatic encephalopathy
Primary survey
A
B
C: BP support, take septic bloods, metabolic bloods, liver disease bloods (incl ammonia)
D: GCS, pupils
-SBP: paracentesis MCS and biochem to rule out secondary bacterial peritonitis => empirical abx (ceft)
- HE: MMSE, neuromuscular Ax => lactulose, supportive care
- rule out other causes with septic screen, metabolic screen, hx of constipation/sedation meds ?CT brain
E: t: rest of septic screen; exposure, log roll
Long term: prophylaxis
A 25 year old man presents with haematemesis after binge drinking. How would you assess and manage him?
Haematemesis = upper GI bleed
DDx: post-vomiting = ?Mallory Weiss tears, ulcers, gastritis, oesophagitis, angiodysplasia
Priorities
- Primary survey and resus as necessary: ETT if low GCS, O2 to sats, NBM and support BP (fluids, blood if necessary)
- Determine cause through history, exam and gastroscope (once haemodynamically stable)
- Check severity +/- complications: FBC, coags, UEC, LFTs, ECG +/- trops (not in 25yo)
- Treat bleed with PPI (and octreotide and abx if cirrhosis suspected) and then definitive endoscopically (thermal coagulation, haemoclips, band ligation for Mallory Weiss tears)
- Long term PPI
An 18 year old woman is brought to the Emergency Department after being rescued at the local beach. She got into difficulties swimming in the surf and recalls swallowing a lot of water. Lifesavers found her floating face-down on the surface of the water. She was quickly resuscitated on the beach and was able to breathe spontaneously. How would you manage her?
Drowning concerns
- lung injury -> chemical pneumonitis, ARDS, aspiration pneumonia
- laryngospasm -> hypoxia, LOC
- other injuries (trauma)
- cause for difficulty swimming eg intoxication, seizure
Approach
1) Primary survey and resus
A: ?head and neck injury, intubate if necessary
B: assess with ABG => O2, bipap, IV (protective lung ventilation and bronchodilators if ARDS); treat vomiting - antiemetics, NG to decompress stomach; abx only if contaminated water; treat any underlying resp condition eg asthma
C: judicious fluid therapy, CPR as necessary
D: assess for secondary brain injury
E: warm to 34 degrees - take off wet clothes and apply blankets
2) Simultaneous MISTAMPLE, including
- circumstances around difficulty swimming: immersion > 10 minutes, higher water temperature
- first aid done: delay to CPR, CPR > 25 minutes
- recovery, complications: >5 min to first breath, cardiac arrest, in a bad state on arrival (asystole, nonreactive pupils, pH < 7, GCS < 5, high lactate)
3) Secondary survey
incl bHCG!!!!!!!!!!!!!!!!!!!!
4) Transfer to ICU, supportive care - monitoring, breathing, fluids, electrolytes, acid-base
A 16 year girl is brought to the Emergency Department by her parents concerned that she has been bitten by a redback spider. They have brought the spider (now dead) in a jar. How would you manage this situation?
Redback bite concerns
- systemic envenomation (non-fatal): muscle rigidity, sweating, vomiting
- anaphylaxis to antivenom
- potential differentials
Priorities
1) Primary survey and resus
2) Assess bite and symptoms
- History: time since bite, situation at time, bite location, spider species, how sure it was this spider, systemic symptoms - pain, autonomic (SNS), non-specific (headache, n+v, dysphoria), screen for other bite sx - agitation, muscle fasciculation/spasm, oral paraesthesia, coma)
- Exam: site, local reaction, vitals, rigidity
- Investigations: UNNECESSARY
3) Call poisons
4) Supportive care: first aid - ice, analgesia
5) Antivenom if refractory pain and systemic features - prepared for anaphylaxis
6) Monitoring, education, discharge when asymptomatic
A 32 year old woman is brought in by ambulance having been bitten by a bee 20 minutes previously. She rapidly became short of breath and when the ambulance arrived she suffered a syncopal attack. How would you assess and manage her?
Anaphylaxis
1) Primary survey and resus
- call for help
- 0.5mg IM adrenaline
A: intubation if threatened
B: O2 as necessary
C: incl ECG; fluid resus if hypotensive
D: assess
E: assess
repeat adrenaline every 5 minutes until response achieved, if no response, infusion - titrate to response
2) Simultaneous MISTAMPLE - confirm diagnosis and rule out differentials (cardiac event, asthma)
history: anaphylaxis symptoms, MI sx, past history of allergy, meds
exam: vitals, hydration, anaphylaxis signs
3) Check for end-organ damage: EUC, LFTs
4) Supportive management: O2, fluids, analgesia and monitoring for at least 4 hours (biphasic)
consider antihistamine for pruritis
A 33 year old woman presents with a red, swollen left leg. She reports feeling sick for the past 24 hours and then noticing her left leg progressively getting red and hot. She does not recall, but her friend reports that she injected drugs into the left groin 18 hours previously. Her obs are: T 38.3°C,
PR 110/min, BP 98/47 mmHg, RR 16/min, and O2 sats 85% on room air.
She has multiple track marks on her upper limbs. She refuses a blood test or cannula as she wants to save her veins. How would you manage this situation?
PDx: Cellulitis sepsis on background of IDU (?opioid intoxication)
DDx: DVT/PE, ?IE
Priorities:
Primary survey and resus
A and B: intubate, O2 if resp depression
C: assess and aim to septic screen (plus other septic bloods) and provide BP support and abx (fluclox 2g Q6hrly IV) via 2 large bore IV cannulae ->
counsel patient on importance/ease of IV access, assess capacity (with assistance of senior doctor), consider alternatives depending on condition (CVC)
D: GCS, pupils, BSL => analgesia
E: evaluate sources of infection
Counselling
- progression of disease -> sepsis (multiorgan failure and death), endocarditis, osteomyelitis
- minimise as much as possible
A 22 year old man is brought to the Emergency Department following a collapse shortly after injecting cocaine. His friends report that he started shivering within approximately 15 minutes and then passed out. On examination, his GCS is now 10. His temperature is 38.8°C, PR 124/min and BP 90/70mmHg. How would you assess and manage him?
Cocaine intoxication -> shock (likely cardiogenic)
- supportive care
- BENZO and COOL (ICE)
- look for complications: CT brain, CXR, trops (hypertension, shock)
Priorities:
Primary survey and resus
- A: monitor closely, manoeuvres to improve
- B: O2 if sats < 94%
- C: ECG, UO, trops, bloods – fluid resus, consider inotropes if no response after 2-3L, BENZO, consider CXR
- D: GCS, pupils, quick neuro exam, consider CT brain
- E: COOL to below 38.8 - ice water
Simultaneously AMPLE hx
A 16 year old boy has been unwell for two days with fever and headaches. He has now become drowsy and is brought to the Emergency Department. He is febrile (T 39°C), drowsy with neck stiffness but no focal neurological signs and no papilloedema. There is a fine petechial rash over his body and legs. How would you assess and manage him?
Meningitis/encephalitis
Priorities
- Primary survey and resus if necessary (don’t forget sepsis bloods, neuro exam ?raised ICP)
- Confirm provisional diagnosis: hx, exam, LP MCS, biochem, viral PCR
- Assess severity: ABG, ECG
- Empirical antibiotics: ceftriaxone + acyclovir (enceph) + dexamethasone
- Supportive care: fluids, electrolytes
A 22 year old woman is brought to the Emergency Department after having her first generalised seizure. She is slightly confused. How would you assess and manage her?
Priorities
- Primary survey and resus if necessary
- Confirm seizure (not syncope) and characterise: hx and exam, EEG, serum prolactin
- Look for underlying cause of seizure: hx and exam (toxins, trauma, infections, fhx of epilepsy); FBC, CRP, UEC, CMP, BSL, CT brain, as per history (eg tox screen, LP)
- Treat underlying cause if found
- Counselling: no driving for 6 months, no swimming/operating heavy machinery, lifestyle changes
A 54 year old man with hypertension presents with the sudden onset of severe right sided headache, nausea, vomiting and left sided weakness. He is drowsy but orientated and coherent when roused. He has no neck stiffness or papilloedema but has a dense left hemiplegia and extensor plantar response. He is in sinus rhythm with a BP of 230/130 mmHg. How would you manage him?
Priorities
- Confirm ICH, rule out ischaemic stroke, SAH
- Assess baseline
- Provide supportive care (incl ICP reduction as necessary)
- Reduce BP with GTN infusion
- Surgical evacuation indicated if >3cm and deteriorating or brainstem compression +/- hydrocephalus from ventricular obstruction
A 68 year old woman presents feeling dizzy and vomiting. She reports intermittent episodes of “the world spinning” over the last 4 days made worse by movement. She is currently vomiting profusely and unable to stand or walk. How you would assess and manage her?
Vertigo
- worried about potential central causes, impact on life
Priorities
- Primary resus
- Determine cause of vertigo: peripheral vs central (timing, associated symptoms, audiometry +/- CT brain)
- Determine severity of vomiting-related derangement: EUC-CMP-BSL
- Supportive care: prochlorperazine, fluids, vestibular rehab
- Treat underlying cause: BPPV -> Epley manoeuvre; vestibular neuritis -> pred; triptans for migraine maybe
- Long term prophylaxis: Cawthorne-Cooksey home exercises for BPPV; HCT (and salt restriction) for Meniere’s; amitriptylline (or other) for migraine
A 20 year old man presents with the sudden onset of a severe occipital headache and transient loss of consciousness an hour ago while at work. He complains now of persistent headache, nausea and photophobia. He has neck stiffness but no focal neurological signs. How would you assess and manage him?
SAH Priorities - primary survey and resus - confirm SAH: hx, o/e, CT brain and LP if CT negative - rule out DDx: meningitis, ICH - determine source of bleeding: DSA - ICU: monitoring and supportive care - neurosurg: clipping/coiling
