EM + CC

Question 1

What are the indications for a tracheostomy?

Answer 1

• weaning from prolonged mechanical ventilation (reduced dead space and the work of breathing compared to ET tube)
• emergency airway compromise
• in preparation for major head and neck surgery
• neuromuscular disorders (to manage excess trachea-bronchial secretions)

Question 2

A-E management in a patient with a tracheostomy in urgent resp distress

Answer 2

• call for help (anaesthetist, ENT surgeon) plus have difficult airway trolley nearby
• A-E
• apply humidified oxygen 15L/min via a non-rebreathe mask and over the tracheostomy site.
• remove speaking valve and suction any secretions
  remove cuff so patient can breathe around it
• change inner cannula
• monitor

Question 3

What are the 2 different types of nutrition and their key subtypes?

Answer 3

Enteral
- oral
- NG tube
- NJ tube
- PEG
- PEJ

Parenteral (intravenous)

Question 4

What does PEG/PEJ stand for?

Answer 4

percutaneous endoscopic gastrostomy / jejunostomy

Question 5

reasons to use an NJ tube rather than NG and vice versa?

Answer 5

NJ: in acute pancreatitis as they bypass the duodenum and pancreatic duct and therefore reduce pancreatic enzyme release that would have exacerbated pancreatic inflammation; good if pt is at risk of lung aspiration as they bypass the stomach.

NG: larger diameter and less likely to block

Question 6

Considerations when starting parenteral nutrition

Answer 6

• build up gradually
• slow down feed if experiencing diarrhoea or distension
• daily bloods to check for re-feeding syndrome (low K+, phosphate and Mg)

Question 7

indications for total parenteral nutrition (TPN)

Answer 7

• insufficient intestinal absorption e.g. short bowel syndrome
• bowel rest (e.g. bowel obstruction, intestinal fistula)

Question 8

complications of TPN

Answer 8

contributes to gut atrophy if prolonged
exacerbates acute phase response
IV line infection
re-feeding syndrome
acalculous cholecystitis
fatty liver
electrolyte and glucose imbalance

Question 9

What is the electrolyte disturbance that you get in re-feeding syndrome?

Answer 9

hypokalaemia
hypophosphateamia
hypomagnesaemia

Question 10

Where on the chest do you perform CPR to get maximal output?

Answer 10

• middle of the sternum
• 1/3 depth or 4-5 cm (check tidal volume and pulses)

Question 11

VF on ECG

Answer 11

• broad
• irregular

Question 12

VF on ECG next step

Answer 12

1) continue CPR as defibrillator is charging
2) defibrillate
3) restart CPR for 2 minutes
4) second shock
5) CPR for 3 minutes
6)

Question 13

what type of defibrillation in cardiac arrest / VF?

Answer 13

unsynchronised

Question 14

VT features

Answer 14

• broad complex
• fast rate
• constant QRS morphology

can be monomorphic or polymorphic (torsades de pointes)

Question 15

summarise cycle of CPR

Answer 15

1st shock -> CPR

2nd shock -> CPR

3 shock -> adrenaline 1mg IV (1 in ????), amiodarone (300mg) -> continue CPR

Question 16

Mx of asystole on ECG (pulseless)

Answer 16

• CPR
• adrenaline

(make sure that the pads are on, especially if completely flat)

Question 17

6Hs and 4 Ts

Answer 17

Hypothermia
Hypovolaemia
H
H
Hypoglycaemia
Heroin OD

Thrombosis

Question 18

loin to groin pain in elderely

Answer 18

AAA - do not miss

be careful of diagnosing renal colic

can often be a ruptured AAA!!

Question 19

causes of commonly missed life threatening causes of epigastric pain?

Answer 19

• ruptured AAA
• inferior MI

(peptic ulcer, pancreatitis, gallstones - commonly considered)

Question 20

causes of life threatening abdo pain with soft abdomen

Answer 20

• mesenteric ischaemia (pain out of proportion to examination findings)

Question 21

Pain out of proportion - diagnoses

Answer 21

-> usually vascular

PE
mesenteric ischaemia
necrotising fasciitis

Question 22

What to consider if a pt with asthma is not responding to treatment

Answer 22

In pts with acute asthma make sure that you did not miss a pneumothorax (CXR)

call anaesthetist

Question 23

IVDU + back pain

dx?

Answer 23

discitis until proven otherwise

-> MRI

Question 24

define shock

Answer 24

inadequate tissue perfusion and oxygenation

Question 25

Where might the blood be in a trauma patient?

Answer 25

intra abdominal
chest
pelvis
long bones

+ at the scene (ask the paramedics)

Question 26

are adults hypotensive from head injury?

Answer 26

no

(children are more likely to be, but also rare)

Question 27

can you get neurogenic shock from head trauma?

Answer 27

yes

can get it from head and high C-spine injuries

Question 28

Spinal shock vs neurogenic shock

Question 29

What % of rib fractures are missed on CXR

Answer 29

50%

Question 30

What MAP is needed to sustain good organ perfusion?

Answer 30

60 mmHg

Question 31

What is Prehn’s sign?
When is it +ve and -ve?
What doe +ve and -ve mean here?

Answer 31

• useful in acute testicular pain

Positive = pain improves upon elevating testicle -> suggests orchitis/epidydimorchitis

Negative = pain still present when elevating testicle -> Testicular torsion

Question 32

What are the indications to start NAC in paracetamol OD?

Answer 32

• staggered OD
• above treatment line on nomogram
• pts who present 8-24h after ingestion of an acute overdose of more than 150 mg/kg of paracetamol even if the plasma-paracetamol concentration is not yet available
• present > 24h if they are clearly jaundiced or have hepatic tenderness, their ALT is >ULN

Question 33

What does “staggered” OD mean?

Answer 33

drug taken in >1h