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LAZ FINAL YEAR COPY (MEDICINE AND SURGERY) > Emergencies > Flashcards

Emergencies Flashcards

1
Q

What NEWS score is considered significant?

A

5 or more in total or 3 or more in one domain

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2
Q

How do you assess the airway?

A

Protect cervical spine if an injury is possible
Look inside the mouth and remove objects/dentures
Assess for signs of obstruction
○ Use wide-bore suction under direct vision if secretions are present
If vocalising, can assume airway is patent
Listen for stridor, snoring or gurgling
Establish a patent airway using:
○ Manoeuvres (e.g. chin lift, jaw thrust)
○ Adjuncts (e.g. oropharyngeal airway (Guedel))
If airway still impaired –> CALL ARREST TEAM (2222)

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3
Q

How do you assess breathing?

A

Look for chest expansion (equal? Fogging of mask?)
Listen for air entry (equal?)
Feel for expansion and percussion (equal?)
Start 15 L oxygen via a non-rebreather
Use a bag valve mask if there is poor or absent respiratory effort
Monitor SaO2 and RR
Check for tracheal deviation and cyanosis
If NO respiratory effort –> CALL ARREST TEAM (2222)
○ Intubate and ventilate
If breathing is compromised, give 15 L oxygen through a non-rebreather mask

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4
Q

How do you assess circulation?

A

Look for pallor, cyanosis and distended neck veins (JVP)
Feel for central pulse (carotid/femoral) - rate and rhythm
Monitor defibrillator ECG and BP
Gain venous access and send bloods if time allows
12-lead ECG
Treat shock
If NO cardiac output –> CALL ARREST TEAM (2222)

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5
Q

How do you assess disability?

A

Consciousness (GCS/AVPU)
Pupils
Blood glucose

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6
Q

What are some common causes of peri-arrest?

A

Arrhythmia
MI
Hypovolaemia
Sepsis
Hypoglycaemia
Hypoxia
Pulmonary oedema
PE
Metabolic (hypo or hyperkalaemia)
Tension pneumothorax

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7
Q

What are the components of qSOFA?

A

RR > 22
GCS < 15
SBP < 100

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8
Q

What is the difference between severe sepsis and septic shock?

A

Severe sepsis: sepsis with evidence of organ hypoperfusion (e.g. hypoxaemia, oligaemia, confusion)
Septic shock: severe sepsis with hypotension despite adequate fluid resuscitation

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9
Q

What are the sepsis 6?

A

Give oxygen (15 L through non-rebreather)
Give IV fluids (bolus = 20 mL/kg)
Take blood cultures
Take lactate
Monitor urine output
Give broad-spectrum antibiotics

ALL WITHIN 1 HOUR

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10
Q

When should sepsis patients be escalated further?

A

SBP fails to reach > 90 mm Hg
Lactate remains > 4 mmol/L

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11
Q

How should haemorrhagic shock be managed?

A

2 L of crystalloid
If this fails to resuscitate –> X-match
Give FFP and packed red cells (1:1) aiming for platelets > 100 and fibrinogen > 1

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12
Q

Which medications are used in the management of anaphylaxis?

A

Adrenaline 0.5 mg IM (0.5 mL of 1:1000)
Repeat every 5 mins as necessary
Chlorphenamine 10 mg IV
Hydrocortisone 200 mg IV
IV fluid bolus if shocked

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13
Q

What should be done after the a patient with anaphylaxis has been stabilised?

A

Admit to ward
Monitor ECG
Continue chlorphenamine 4 mg per 6 hours PO if itching
Suggest MedicAlert bracelet
Prescribe autoejector
Consider skin-prick testing or specific IgE

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14
Q

Outline the management of aortic dissection.

A

Fast bleep cardiothoracic surgery
Transfer to ITU
Use hypotensives (e.g. labetalol) to maintain SBP 100-110
Document and debrief

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15
Q

Outline the management of a ruptured AAA.

A

Fast bleep vascular surgery and anaesthetics
Take the patient straight to theatre
Gain IV access
Administer O- if necessary
Keep SBP < 100 mm Hg

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16
Q

Outline the initial management of a STEMI.

A

Morphine 5-10 mg IV (repeat after 5 mins if necessary)
Metoclopramide 10 mg IV
Oxygen 15 L via non-rebreather
Nitrates
Aspiring 300 mg PO (with clopidogrel or ticagrelor)

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17
Q

What doses of second antiplatelet agents are used with aspirin in the prevention of atherothrombotic events in ACS?

A

Clopidogrel 300 mg followed by 75 mg
Ticagrelor 180 mg STAT followed by 90 mg BD

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18
Q

Which medications should patients who have had an MI take home?

A

Dual antiplatelet therapy (continue for 12 months)
GTN spray
Beta-blocker
ACE inhibitor
Statin

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19
Q

Outline the management of acute heart failure.

A

Diamorphine 1.25-5 mg IV (caution in liver failure or COPD)
Furosemide 40-80 mg IV
GTN spray 2 puffs sublingual (consider isosorbide mononitrate infusion 2-10 mg/hour)

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20
Q

What should be considered if a patient in acute heart failure deteriorates?

A

Further dose of 40-80 mg furosemide
Consider CPAP
Increase nitrate infusion
Refer to ITU

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21
Q

How should a patient with acute heart failure be managed once they have been stabilised?

A

Monitor daily weight and observations
Repeat CXR
Switch to oral furosemide or bumetanide
ACE inhibitor if LVEF < 40%
Consider beta-blocker and spironolactone
Consider biventricular pacing or transplantation
Consider digoxin and warfarin

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22
Q

Outline the management of broad complex tachycardia in a haemodynamically UNSTABLE patient.

A
  • DC cardioversion
  • Hypokalaemia and hypomagnesaemia
  • Amiodarone 300 mg IV over 10-20 mins through a central line
  • Procainamide and sotalol in refractory cases
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23
Q

Outline the management of broad complex tachycardia in haemodynamically STABLE patients.

A

Correct electrolyte abnormalities
Amiodarone 300 mg IV over 10-20 mins
If it fails –> DC cardioversion

NOTE: after correction of VT, patients should be given maintenance antiarrhythmic therapy (e.g. sotalol)

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24
Q

Outline the management of torsades des pointes.

A

Stop predisposing drugs (e.g. TCAs)
Correct hypokalaemia
Give magnesium sulphate 2 g over 10 mins

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25
Outline the management of narrow complex tachycardia.
Vagal manoeuvres Adenosine 6 mg IV bolus (followed by 0.9% saline flush) If unsuccessful --> after 2 mins give 12 mg bolus If unsuccessful --> after 2 mins give 12 mg bolus Alternative: verapamil 2.5-5 mg over 2 mins
26
How should AF in an unstable patient be treated?
Emergency cardioversion If unavailable --> IV amiodarone Control ventricular rate: verapamil 40-120 mg/8 hrs PO or bisoprolol 2.5-5 mg/day PO Start anticoagulation with LMWH NOTE: cardioversion is only recommended if it can be done within 48 hours of the onset of symptoms
27
Which medications should patients with AF be given to take away?
Use CHADS-Vasc to calculate need for anticoagulation (1 or more requires warfarin) Rate control (beta-blocker or CCB) Rhythm control (flecainide if no structural heart disease, otherwise amiodarone)
28
Outline the investigations that you would request for a suspected acute asthma attack.
Bedside: PEFR, ECG, ABG, SaO2 Bloods: FBC, U&E Imaging: CXR?
29
Outline the management of severe acute asthma.
Nebulised salbutamol 5 mg with oxygen IV hydrocortisone 100 mg (or PO prednisolone 40-50 mg) If it worsens - add ipratropium bromide nebuliser 0.5 mg - stat dose of magnesium sulphate 1.2-2 g IV over 20 mins
30
If a patient with a severe asthma is showing signs of improvement, how should they be cared for?
Nebulised salbutamol every 4 hours Prednisolone 40-50 mg OD for 5-7 days Monitor PEFR and oxygen saturations
31
How should a patient with life-threatening acute asthma be escalated if initial treatment fails to cause an improvement?
Refer to ICU May need ventilatory support (e.g. intubation) May need intensified treatment (e.g. IV aminophylline, IV salbutamol)
32
Outline the management of an infective exacerbation of COPD.
BRONCHODILATOR: nebulised salbutamol 5 mg/4 hr + nebulised ipratropium 0.5 mg/6 hr OXYGEN: at 24-28% via venturi mask aiming for 88-92% STEROIDS: IV hydrocortisone 200 mg (or oral prednisolone) ANTIBIOTICS: trust guidelines (e.g. amoxicillin or doxycycline)
33
How should the treatment of a patient with an infective exacerbation of COPD be escalated if they fail to respond to initial treatment?
Consider IV aminophylline Consider NIV Consider intubation and ventilation Consider respiratory stimulant (e.g. doxapram)
34
Which investigations may be useful in patients with acute pancreatitis?
Bedside: glucose Bloods: amylase, lipase, FBC, U&E (calcium), LFTs, ABG, glucose Imaging: USS, erect CXR, AXR (rule out other causes of acute abdomen), ERCP
35
Outline the management of acute pancreatitis.
Assess severity using Modified Glasgow Criteria NBM IV fluids to achieve normal vital signs (3rd spacing) Insert catheter to monitor urine output Analgesia (IM pethidine 75-100 mg/4 hr or morphine) If worsening --> ITU (may need ERCP)
36
Outline the management of a primary pneumothorax.
No SOB + < 2 cm rim of air on CXR --> consider discharge and repeat CXR in a few weeks SOB + > 2 cm rim of air on CXR --> aspiration - if unsuccessful --> repeat aspiration - if unsuccessful --> insert chest drain
37
Outline the management of a secondary pneumothorax.
No SOB, age < 50 yrs + < 2 cm rim of air --> aspiration - if successful --> admit for 24 hours - if unsuccessful --> insert chest drain SOB, age > 50 yrs and > 2 cm rim of air --> insert chest drain
38
Outline the management of tension pneumothorax.
Insert a large-bore needle that is partially filled with saline into the 2nd intercostal space in the MCL on the side of the suspected pneumothorax - remove plunger to allow air to bubble through the syringe OR: into the safe triangle
39
Outline the management of PE in a stable patient.
Oxygen Morphine 5-10 mg IV with 10 mg metaclopramide SC tinzaparin 175 U/kg/24 hrs (or UFH 10,000 IV bolus)
40
How does the systolic BP affect the management of PE?
SBP > 90 mm Hg --> warfarin loading regimen (e.g. 5-10 mg warfarin PO) SBP < 90 mm Hg --> IV colloid infusion + contact ICU --> dobutamine 2.5-10 µg/kg/min IV --> IV noradrenaline infusion --> consider thrombolysis
41
Describe the ongoing management of PE after the immediate situation has been dealt with.
Reduce risk of recurrence (e.g. compression stockings) LMWH should be continued with warfarin until INR > 2 for 24 hours or 5 days after starting warfarin (whichever is longest) If obvious cause of VTE --> 3 months warfarin If no obvious cause of VTE --> continue for 3-6 months
42
How is a massive PE in a haemodynamically compromised patient treated?
10 mg alteplase followed by 90 mg infusion over 2 hours
43
What crucial blood tests should be requested in patients with an acute upper GI haemorrhage?
FBC Group and save X-match 6 units of blood Clotting screen LFT
44
Outline the immediate management of shocked patients with an acute upper GI bleed.
Protect airway and keep NBM Insert two large-bore cannulae Rapid IV crystalloid infusion up to 1 L If grade III-IV shock, give O- blood until X-match is complete Correct clotting anomalies (e.g. PCC, vitamin K) Consider ICU referral for central venous line Catheterise to monitor urine output (aim > 30 mL/hour) Monitor vital signs Notify surgeons Endoscopy within 4 hours for variceal bleed and within 12-24 hours if unstable on admission
45
Outline the medical management of acute upper GI bleeds.
Major ulcer bleeding --> omeprazole 80 mg IV stat over 40-60 mins followed by 8 mg/hour for 72 hours Variceal bleeding --> resuscitate then urgent endoscopy for banding or sclerotherapy + terlipressin 2 mg SC QDS NOTE: if large bleed, Sengstaken-Blakemore tube may be used to tamponade the bleed and lactulose may be given to reduce absorption of nitrogenous products
46
Outline the management of bacterial meningitis.
Sepsis 6 Cefotaxime 2 g IV (add ampicillin 2 g/6 hrs IV if immunocompromised or > 55 years) Call critical care team If meningitis only: consider adding dexamethasone 4-10 mg/6 hrs IV
47
Outline the ongoing management of a patient with bacterial meningitis who has been stabilised.
Discuss antibiotic treatment with microbiology Isolate in side-room for 24 hours Treat contacts with ciprofloxacin 500 mg PO
48
Which drug treatment is used for suspected encephalitis?
IV aciclovir (10 mg/kg/8 hrs IV)
49
How much insulin should be given to patients with DKA?
50 u actrapid in 50 mL of 0.9% saline Infused continuously at 0.1 u/kg/hour Aim for a 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 NOTE: check VBG at 1 hour, 2 hours and 2 hourly thereafter
50
When should glucose be added to the infusion in DKA?
10% glucose at 125 mL/hour alongside saline when glucose < 14 mmol//L
51
Outline the management of acute abdomen.
Gain IV access Catheterise and place on fluid balance chart if hypotensive Analgesia: 100 mg diclofenac PR for renal pathology, or 5-10 mg morphine IV for intra-abdominal pathology Send blood sample for FBC, U&E, amylase, LFT, CRP and G&S IV antibiotics if indicated NBM
52
Outline the management of stroke.
15 L/min oxygen if low saturations or SOB NBM 100 mL/hour 0.9% saline Treat arrhythmias Get exact timescale of symptom onset Request urgent CT scan Once haemorrhagic stroke ruled out: aspirin 300 mg STAT and thrombolyse with tPA of < 80 yrs and < 4.5 hours or > 80 yrs and < 3 hours
53
Outline the treatment of hyperkalaemia.
10 mL 10% calcium gluconate IV over 2 mins (repeat every 15 mins up to 5 doses) 10 IU Actrapid with 50 mL 50% dextrose IV over 10 mins Consider 5 mg salbutamol nebuliser Monitor ECG and have access to crash trolley Check ABG for acidosis
54
How are pre-renal and post-renal causes of AKI treated?
Pre-renal: fluid resuscitation with 0.9% saline (250-500 mL bolus) followed by infusion of 20 mL + last hour's urine output Post-renal: catheterise NOTE: pulmonary oedema should be treated with furosemide IV
55
List the indications for dialysis in AKI.
Hyperkalaemia unreponsive to medical treatment in an oliguric patient Pulmonary oedema unresponsive to medical treatment Uraemia (e.g. encephalopathy) Severe metabolic acidosis (pH < 7.2)
56
Outline the management of hypokalaemia.
Monitor U&E and ECG 40 mmol/L KCl in 1 L of 0.9% saline (unless oliguric --> insert catheter to ensure accurate assessment of urine output) Admit to ICU for insertion of a central line if > 10 mmol/hr needed If MILD: oral K+ supplementation (SandoK)
57
Which investigations would be useful in a patient with hyponatraemia?
Hypovolaemic --> low urine sodium Euvolaemic --> TFT, SST, plasma and urine osmolality Hypervolaemic --> low urine sodium
58
Outline the management of hyponatraemia.
Do NOT correct faster than 8-10 mmol/L/24 hrs Hypovolaemic --> 0.9% saline Euvolaemic --> fluid restriction
59
Outline the management of hypocalcaemia.
Mild and asymptomatic: monitor, consider vitamin D supplements and calcichew Severe tetany: 10 mL 10% calcium gluconate IV over 10 mins
60
Outline the management of hypercalcaemia.
Correct dehydration with 0.9% saline (3-6 L in 24 hours with the first 1 L going in over 1 hour) Furosemide may be needed in elderly patients who are prone to pulmonary oedema Insert catheter to monitor urine output IV bisphosphonate for bone pain (takes 1 week to work)
61
Which investigations are important to order in patients with status epilepticus?
U&E FBC LFT Glucose Calcium Toxicology AED levels CT/MRI head
62
Outline the management of status epilepticus.
Secure the airway (may need adjuncts) STEP 1: Slow IV bolus of IV lorazepam 2-4 mg Second dose if no response within 10 mins Thiamine if alcoholism is suspected Glucose 50 mL 50% IV if hypoglycaemia is suspected STEP 2: IV phenytoin infusion 15-20 mg/kg at < 50 mg/min STEP 3: rapid sequence induction with thiopental and EEG monitoring
63
Outline the management of pneumonia.
Treat hypoxia and hypotension if necessary Antibiotics following local guidelines (e.g. CAP = coamoxiclav and clarithromycin; HAP = tazocin) Analgesia if pleuritic chest pain CPAP if no improvement
64
Which investigations should be requested in suspected pneumonia?
Bedside: oxygen saturation, ABG, sputum sample, urine sample (Legionella) Bloods: FBC, U&E, CRP, atypical serology Imaging: CXR
65
Which investigations would you request in a patient with delirium?
Bedside: glucose, ABG, ECG, urine dipstick Bloods: FBC, U&E, LFTs, blood glucose, blood cultures Imaging: CXR, CT/MRI
66
Outline the management of bradycardia.
Sit the patient up (unless dizzy) 15 L/min oxygen if hypoxic Give 0.5 mg atropine IV every 2-3 mins (up to max 6 doses) If unsuccessful --> isoprenaline 5 µg/min If unsuccessful --> adrenaline 2-10 µg/min If unsuccessful --> transcutaneous pacing
67
Outline the management of hyperosmolar hyperglycaemic state (HHS/HONK).
Rehydrate slowly with 0.9% saline over 48 hours (deficit is typically 110-220 mL/kg) Equated to 8-15 L for 70 kg adult First 1 L may be given quickly over 30 mins Replace K+ when urine starts to flow Use insulin sliding scale if glucose is NOT falling by 5 mmol/L/hr with rehydration Keep glucose at 10-15 mmol/L for first 24 hours (avoid cerebral oedema)
68
If a nurse contacts you regarding a patient who has become unconscious, what should you tell them to do?
Check for respiratory effort/pulse and begin CPR if absent
69
How should an Addisonian crisis be treated?
100 mg hydrocortisone STAT Followed by 100 mg/8 hrs hydrocortisone NOTE: they may need fludrocortisone, glucose and fluids
70
What are the components of a SOFA score?
Respiratory rate Bloodpressure GCS Liver (bilirubin) Coagulation (platelets) Renal (creatinine and urine output) Sepsis = infection + increase of 2 or more on SOFA
71
Outline the management of NSTEMI.
Give oxygen if breathless or SaO2 < 90% Morphine 5-10 mg IV + antiemetic Nitrates (GTN spray or sublingual) Aspirin 300 mg PO + second antiplatelet agent (clopidogrel, ticagrelor, prasugrel) Oral beta-blocker (e.g. metaprolol) if hypertensive/tachycardic/low LV function Fondaparinux 2.5 mg OD SC or LMWH 1 mg/kg/12 hours SC IV nitrate if pain continues HIGH RISK PATIENT - Features: rise in troponin, dynamic ST or T wave changes, risk factors - Begin infusion of tirofiban and refer for inpatient angiography (within 72 hours) - Angiography may need to be within 24 hours if GRACE score > 140
72
Which additional measures may be used during the A to E approach of a trauma patient?
Check for blood on the floor Arrange FAST scan/pelvic X-ray For unstable pelvic fractures use a pelvic band to reduce blood loss
73
Outline the algorithm for the major haemorrhage protocol.
Take baseline blood samples (FBC, G&S, X-match, Clotting, fibrinogen) If trauma < 3 hrs: give tranexamic acid (1 g over 10 mins, then 1 g/8 hrs infusion) Limit use of O-negative blood and use group-specific blood as soon as possible
74
What is the definition of major haemorrhage?
Loss of more than one blood volume in 24 hrs Loss of 50% blood volume in 3 hours Bleeding in excess of 150 mL/minute
75
Which extra parts of an A to E would you do in a patient with suspected spinal cord compression?
D - palpate for spinal tenderness and perform a lower limb neurological examination to assess tone, power, reflexes and sensation E - percuss the bladder (urinary retention), perform a rectal examination (tone and saddle anaesthesia) - important to consider cauda equina as a differential
76
Outline the management of cord compression.
Ix: urgent MRI whole spine within 24 hours Rx: dexamethasone 16 mg PO Discuss with neurosurgery Definitive: RADIOTHERAPY or decompressive surgery
77
What must be done before a CTPA is performed in a patient with suspected PE?
Check renal function and ask about allergy to contrast
78
What must always be done before thrombolysing a patient?
Discuss with a senior
79
What is Cushing's reflex?
Irregular breathing (Cheyne-Stokes) Hypertension Bradycardia
80
Who could angry patients be directed towards?
PALS NOTE: always gain consent from the patient before discussing their care with a family member
81
What is the first step in managing a patient with VT?
Put out a peri-arrest call
82
What are the 4 Hs and 4 Ts of cardiac arrest?
Hypoxia Hypovolaemia Hypokalaemia/hyperkalaemia Hypothermia Toxic Thromboembolic Tamponade Tension pneumothorax
83
Which medications should be continued after correction of VT?
Establish and treat the cause Maintenance: amiodarone infusion for 12-24 hours followed by oral sotalol or amiodarone
84
How can recurrence of VT be prevented?
Ablation of arrhythmogenic area OR ICD
85
Outline the management of hypothermia.
Prepare crash trolley Confirm temperature with low-reading thermometer (PR) and check every 30 mins Set up ECG (bradycardia and J waves) Remove wet clothing Give warmed humidified oxygen Slowly rewarm at 0.5 degrees per hour CARDIAC MONITORING IS ESSENTIAL
86
What is the difference between the Glasgow Blatchford and Rockall scores?
Blatchford - used at first presentation Rockall - used after intervention to determine risk of re-bleed/death
87
Which investigations are important to request in someone who has taken a paracetamol overdose?
Paracetamol levels (4 hrs post-dose) LFTs Clotting studies U&E FBC Bone profile ABG (acidosis and lactate)
88
Outline the management of bowel obstruction.
IV 0.9% saline 5-10 mg morphine IV NBM NG tube aspiration Correct electrolyte imbalance Consider giving antibiotics if septic/perforated (co-amoxiclav and gentamicin)
89
Outline the management of acute limb ischaemia.
URGENT open surgery and angioplasty ALERT the vascular surgeons If embolic: surgical embolectomy or thrombolysis (tPA) Anticoagulate with LMWH after either procedure and look for source of emboli (e.g. AF, aneurysms) WARNING: post-op reperfusion injury can lead to compartment syndrome Compartment syndrome is treated with fasciotomy It is very painful so patients should be given morphine
90
Who is part of the cardiac arrest team?
Medical team on call (Med reg, SHO, FY1) Anaesthetist Nurse Porters CCOT
91
What are some contraindications for NIV?
Pneumothorax Drowsiness
92
For the treatment of hyperkalaemia, what do you mix the insulin in?
10 U Actrapid in 100 mL of 20% dextrose given over 30 mins

LAZ FINAL YEAR COPY (MEDICINE AND SURGERY) (4 decks)

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