Emergencies Flashcards
Treatment for STEMI?
At The Museum My Parent Falls in 120 minutes
Aspirin
Ticagrelor
Morphine
Metaclopromide
PCI
Fibrinolysis if over 120 mins
NSTEMI treatment
At Night A Girl Fancies The New Boy
Analgesia
Nitrates
Aspirin
GRACE score
Fondaparinux
Ticagrelor
Nitrates
Beta blockers
Broad complex tachycardia
Always Eat At The Diner
Assess
electrolytes
amiodarone
three shocks 120j-150j, 160j-180j
dc
torsades
Supraventricular tachycardia
stable
Regular vagal manouvres
Adenosine 6,12, 12
Irregular treat as AF
unstable
DC three shocks
amiadarone
Bradycardia
Atropine
Transcutaneous pacing - heart block
Adrenaline
Isoprenaline
Pneumothorax
Primary spontaneous - discharge OR aspirate
Secondarary sponatenous <2cm - watch for 24 hours and 02 OR aspirate
Tension -decompression 2 ICS wide bore
Thyroid storm
Beta blockers or diltazem
carbizole after lugol’s
hydrocortisone, dexa
How to treat beta blocker toxicity?
Glucagon
How to treat benzo overdose?
Flumazenil
What potassium can be given if between 3.5-5.5
40, if lower ask for help
Hypothermia is associated with ?
J waves
How is severe COPD treated?
If 7.26 use NIV
How are haemorroids treated?
Fibre diet
Whata the transfusion reactions and how are they remedied?
What is the most common transfusion reaction?
Febrile reaction
What types of transfusion reaction do you slow?
TACO you slow and give diuretics
How do you treat a haemolytic reaction?
STOP and give fluids
What are some differentials for anaphylaxis?
What is the Jarisch herxheimer reaction?
Jarisch Herxheimer reaction (JHR) is a transient clinical phenomenon that occurs in patients infected by spirochetes who undergo antibiotic treatment. The reaction occurs within 24 hours of antibiotic treatment of spirochete infections, including syphilis, leptospirosis, Lyme disease, and relapsing fever.
What investigations are done for bowel obstruction?
Which would not be done?
CT scan
barium enema would require formal bowel preparation and this is contra indicated where large bowel obstruction is suspected. A flexible sigmoidoscopy is unlikely to be helpful and the air insufflated at the time of endoscopy may make the colonic distension worse. A cystogram would provide only very limited information.
What AAA should always be checked urgently
enlarging
Encephalitis with temporal lobe changes
Herpes simplex encephalitis (HSE) is the commonest cause of sporadic encephalitis and most commonly affects those <20 and >50. In contrast to other forms of encephalitis (e.g. CMV, cryptococcal), it often affects immunocompetent individuals (as well as the immunocompromised). HSE often has a prodrome of fever, headache and malaise followed by acute encephalopathy: focal neurological deficits, seizures, confusion and behavioural changes and potentially meningeal signs. Classically, HSE causes temporal lobe changes (hypodensities on CT, or hyperintensities on MRI) and bilateral temporal lobe changes are pathognomonic of HSE. (Note: although not required in this question, do be aware of the clinical features of temporal lobe changes e.g. aphasia, hemiparesis, memory loss etc since some questions may require you to infer temporal lobe involvement without imaging results).
Incubation periods of common GI infections?
1-6 hrs: Staphylococcus aureus, Bacillus cereus*
12-48 hrs: Salmonella, Escherichia coli
48-72 hrs: Shigella, Campylobacter
> 7 days: Giardiasis, Amoebiasis
What rash is shown here?
Rose spot rash in typhoid
Acute asthma
33-50% of expected
No full sentences
RR = >25
HR =>110
What is TLCO?
Transfer factor
What conditions reduce TLCO?
pulmonary fibrosis
pneumonia
pulmonary emboli
pulmonary oedema
emphysema
anaemia
low cardiac output
For what procedures would you do group and save?
Hysterectomy (simple), appendicectomy, thyroidectomy, elective lower segment caesarean section, laparoscopic cholecystectomy
For what procedures would you do 2 cross match?
Salpingectomy for ruptured ectopic pregnancy, total hip replacement
For what procedures would you do 4 cross match?
Total gastrectomy, oophorectomy, oesophagectomy
Elective AAA repair, cystectomy, hepatectomy
How should you initially treat an oesophageal cancer?
Stent
What fluids are used for DKA?
1l IV 1h
What type of heart block is normal in atheletes?
First degree heart block
How is COPD managed?
No asthmatic features/features suggesting steroid responsiveness
add a long-acting beta2-agonist (LABA) + long-acting muscarinic antagonist (LAMA)
if already taking a SAMA, discontinue and switch to a SABA
Asthmatic features/features suggesting steroid responsiveness
LABA + inhaled corticosteroid (ICS)
if patients remain breathless or have exacerbations offer triple therapy i.e. LAMA + LABA + ICS
if already taking a SAMA, discontinue and switch to a SABA
NICE recommend the use of combined inhalers where possible
What is a complication after bowel surgery?
Post-operative ileus is a common complication in colorectal surgery due to intra-operative bowel handling. Management is conservative with nasogastric tube insertion for stomach decompression for symptom control and placing the patient nil by mouth to allow bowel rest. The recommencement of fluids/light diet should be in stages and guided by the clinical state of the patient.
What is a complication post-surgery?
What should be done post fibrinolysis?
If fibrinolysis is given for an ACS, an ECG should be repeated after 60-90 minutes
What are rules for epilepsy?
Patients cannot drive for 6 months following a first unprovoked or isolated seizure if brain imaging and EEG normal
If syncope and first 1 month
Alcohol intoxication
CIWA score
Onset of symptoms is usually 24-72hours after alcohol cessation of reduced intake, symptoms include: Severe tremor, delusions, tachycardia, pyrexia, visual and auditory hallucinations, confusion and disorientation, clouding of consciousness If agitation is severe, please refer to
A long-acting benzodiazepine, such as chlordiazepoxide hydrochloride or diazepam, is recommended to attenuate alcohol withdrawal symptoms; local clinical protocols should be followed.
Pabrinxes and thiamine
Legislation for pituitary tumour
It is recommended that all patients with a pituitary incidentaloma, including those without symptoms, undergo clinical and laboratory evaluations for hormone hypersecretion and hypopituitarism.
Surgery is only needed if:
A visual field deficit due to the lesion.
Other visual abnormalities, such as ophthalmoplegia or neurological compromise due to compression by the lesion.
Lesion abutting or compressing the optic nerves or chiasm on MRI.
Pituitary apoplexy with visual disturbance.
Hypersecreting tumours other than prolactinomas
What is the CURB-65?
Confusion = 1
Urea > 7 = 1
Respiratory rate > 30 breaths per minute= 1
Systolic blood pressure < 90 mmHg / Diastolic < 60 mmHg = 1
Age > 65 = 1
A 37-year-old attends surgery due to a one day history of severe central abdominal pain radiating through to the back. He has vomited several times and is guarding on examination. Parotitis and spider naevi are also noted. What could be the cause?
Acute pancreatitis because parotitis and spider nevi are associated with alcoholism
What is a FAST scan?
FAST scans (focused assessment with sonography for trauma), are used in trauma to quickly assess the extent of free fluid in the chest, peritoneal or pericardial cavities. This non-invasive test can be used within emergency care in the primary or secondary survey to quickly investigate the extent of free fluid or pneumothorax.
New onset syncope after return from India?
This patient has likely been infected with hookworm, explaining the anaemia, eosinophilia and the rash he described. Hookworms (nematodes) are acquired from skin contact with contaminated soil, commonly from walking barefoot in an affected area and are endemic in much of Asia, Africa and South America. The worm migrates from the skin into the intestine and from there causes chronic blood loss, hence causing anaemia. Diagnosis can be made from stool culture with identification of the ova in the patient’s faeces.
What are sick day rules for diabetics?
Diabetes sick day rules: when unwell, If a patient is on insulin, they must not stop it due to the risk of diabetic ketoacidosis. They should continue their normal insulin regime but ensure that they are checking their blood sugars frequently
What is the signs of life threatening asthma?
PEFR < 33% best or predicted
Oxygen sats < 92%
‘Normal’ pC02 (4.6-6.0 kPa)
Silent chest, cyanosis or feeble respiratory effort
Bradycardia, dysrhythmia or hypotension
Exhaustion, confusion or coma
What are some strange signs of life threatening asthma?
Normal CO2
and 92% saturation
Best investigation for acute pancreatitis?
Serum lipase has a longer half-life than amylase when investigating suspected acute pancreatitis and may be useful for late presentations > 24 hours
What causes a loud S2 sound?
Pulmonary hypertension
Chest drain placement for pneumothorax
It is advised that chest drains are placed in the ‘safe triangle’. The triangle is located in the mid axillary line of the 5th intercostal space. It is bordered by:
Anterior edge latissimus dorsi, the lateral border of pectoralis major, a line superior to the horizontal level of the nipple, and the apex below the axilla.
Chest drain swinging: Rises in inspiration, falls in expiration
DVLA, multiple seizures and driving
The person with epilepsy may qualify for a driving licence if they have been free from any seizure for 1 year. This needs to include being free of minor seizures and epilepsy signs such as limb jerking, auras and absences. Episodes not involving a loss of consciousness are included.
How is LEMS different to MG?
Lambert Eaton syndrome involves weakness in the muscles of the proximal arms and legs, and one of the ways it can be differentiated from myasthenia gravis is that the legs are normally worse affected
How is salicylate overdose managed?
Both pulmonary oedema and metabolic acidosis are indications for haemodialysis in salicylate overdose.
How is paracetemol overdose treated
activated charcoal if ingested < 1 hour ago
N-acetylcysteine (NAC)
liver transplantation
What are complications of Measles?
Complications :
transient immunosuppression
otitis media (7 - 9%)
pneumonia (1 - 6%)
acute postinfectious encephalitis (~1 per 1000)
subacute sclerosing panencephalitis (SSPE) (1 per 100 000)
death (1 - 3 per 1000)
SSPE
Fatal degenerative central nervous system disease caused by persistent infection with a mutated measles virus.
Onset is several years after measles (average seven years).
What are features of measles?
Viral illness, paramyxovirus - ssRNA
Highly contagious and airborne, infectivity is close to 100% in susceptible individuals.
A key diagnostic feature is the presence of prodromal illness for 2 -4 days before the rash
fever
conjunctivitis
rhinorrhea
sore throat
dry cough
Koplik’s spots on the oral mucosa
→ coalescing erythematous macules and papules
begins behind ears / in hairline
→ spreads to rest of body
What are the features of mumps?
RNA virus, aerosol spread
causes painful parotid swelling (lifting the earlobe)
Usually a prodrome of malaise, fever, headache, myalgia and arthralgia for 3 - 5 days before swelling observable
Complications include :
Meningitis
Swelling of testicles in 25 - 50% of males. If orchitis is bilateral (~30%) this may lead to oligospermia, subfertility and decreased testosterone production (but only rarely sterility).
Encephalitis - rare but serious, 0.02 - 0.3%
Pancreatitis
What are the features of rubella? Why vaccinate for rubella if mild?
Viral infection, RNA virus.
Droplet spread, highly contagious
Rubella causes a mild childhood illness - the rationale for vaccination is to prevent congenital rubella syndrome, which has high incidence of serious birth defects if susceptible pregnant women are exposed in the first trimester.
Features of rubella :
Red pink rash
Lymphadenopathy
Fever
Coryza
Arthralgia
Congenital rubella syndrome
Cataracts
Deafness
Congenital heart defects
Brain damage
Fetal loss
What are the features of whooping cough?
Bacterial –Bordetella pertussis
Highly contagious, droplet spread
Initial coryzal symptoms with a cough, which is initally mild. becoming more severe after ~ 2 weeks
The cough s characterised by episodes of numerous rapid coughs, followed by a crowing or high-pitched whoop. These episodes frequently end with the expulsion of a thick, clear mucous, often followed by vomiting
Cough may last up to 2 months
Most dangerous in infants as it is associated with apnoea (stopping breathing) which can be fatal
To protect neonates, pregnant women should be vaccinated at 28-38 weeks
What are the features of h. influenzae?
Bacteria, coccobacillus
Can cause respiratory infections, ocular infection, sepsis and meningitis.
In countries without vaccination programs, it is the commonest cause of meningitis in children <5 years, with a mortality of ~ 10%
Can also cause epiglottis
short history of high fever, tachypnoea, inspiratory stridor and excessive drooling
intubation or emergency tracheotomy may be required to prevent airway obstruction and death
peak incidence 5–10 years
What precaution is given with menigiococcal vaccine?
Paracetemol
Hep B in children?
Acute infection may present with
fatigue
myalgia
pyrexia
loss of appetite
nausea
diarrhoea
abdominal pain
jaundice
dark urine and pale faeces
but may be asymptomatic
Development of chronic infection varies with age. Up to 90% of infants who are infected with the virus develop chronic infections but <5% of adults.
Chronic HBV complications include liver cirrhosis (25%) and cancer (5%).
What is rotavirus?
dsRNA virus, most common cause of significant diarrhoeal illness in children worldwide
Mostly faeco-oral spread
Rarely fatal in developed world but higher mortality in developing countries
Live attenuated vaccine (oral) developed in 2006
Symptoms :
Fever
Vomiting
Diarrhoea
Extensive nausea and vomiting in some children result in difficulties in providing oral fluids -> dehydration
What are menigioccal B and c?
Bacterial disease, Neisseria meningitidis - gram negative diplococcus
Commonly asymptomatically carried in the nasopharynx, occasionally causes invasive disease with 8–15% mortality.
Two peaks of incidence, young children and adolescents, overall 0.6 per 100 000.
Serogroups B and C are most common types isolated in Europe
Can cause meningitis
headache
neck stiffness
photophobia
fever
and septicaemia
shock
fever
non-blanching rash (extravasation due to DIC)
multiple organ failure
Septicaemia has a 40% mortality
If suspected give immediate antibiotics IV or benzylpenicillin intramuscularly
if no IV access
What is Lights criteria?
What is cushing triad
As the brain and ventricles are enclosed by a rigid skull, they have a limited ability to accommodate additional volume. Additional volume (e.g. haematoma, tumour, excessive CSF) will therefore lead to a rise in intracranial pressure (ICP).
Pathophysiology
the normal ICP is 7-15 mmHg in adults in the supine position
cerebral perfusion pressure (CPP) is the net pressure gradient causing cerebral blood flow to the brain
CPP = mean arterial pressure - ICP
How is malignant hyperthermia treated?
Malignant hyperthermia is a recognised serious side effect of suxamethonium among those who are susceptible and requires IV dantrolene therapy
