Emergencies

Question 1

NEWS2 Score 3 points

Answer 1

RR 8≤ or ≥25
SpO2 ≤91%
Temp ≤35.0 C
SBP ≤90 or ≥220
HR ≤40 or ≥131
Consc V, P, and, U

7 pts = Continous monitoring (specialist registrar level, consider ICU)

5pts or 3 in any = Vitals minimun once every hour.

Question 2

NEWS2 Score 2 points

Answer 2

RR 21-24
SpO2 92-93%
Any O2 suplemental
Temp ≥39.1 C
SBP 91-100
HR 111-130

7 pts = Continous monitoring (specialist registrar level, consider ICU)

5pts or 3 in any = Vitals minimun once every hour.

Question 3

Differential dx of breathlessness with wheezing

Answer 3

Asthma
COPD
HF
Anaphylaxis

Question 4

Differential dx of breathlessness with stridor

Answer 4

Foreign body or tumour
Acute epiglottitis
Anaphylaxis
Trauma (laryngeal fracture)

Question 5

Differential dx of breathlessness with crepitations

Answer 5

HF
Pneumonia
Bronchiectasis
Fibrosis

Question 6

Differential dx of breathlessness with chest clear

Answer 6

PEmbolism
Hyperventilation
Metabolic acidosis (DKA)
Drugs (salicylates)
Shock (air hunger)
Pneumocystis jirovecci pneumonia
CNS causes

Question 7

Other differential dx of breathlessness

Answer 7

Pneumothorax
Pleural effusion

Question 8

Key investigations of breathlessness

Answer 8

O2 sat, pulse, temp, peak flow
ABG if SpO2 <94%
ECG
CXR
Baseline bloods (glucose, FBC, U&E, consider drug screen)

Question 9

Life threatening chest pain differential dx

Answer 9

Acute MI
ACS (angina)
Aortic dissection
T. pneumothorax
PE
Oesophageal fracture

Question 10

Key investigations of chest pain

Answer 10

CXR
ECG
FBC and U&E
Troponin
Consider D dimer if suspicion of PE (Wells score)

Question 11

Management of coma

Answer 11

1. ABC
2. IV access
3. Stabilize cervical spine (if trauma is a possibility)
   Blood glucose (fingerprick and lab)
4. Control seizures
5. Tx potential causes (IV glucose, thiamine, naloxone and other antidotes)
6. Brief history & examination
7. Investigations (ABG, FBC, U&E, LFT, CRP, ethanol, toxin screen, drug lvls, blood cultures, urine culture, malaria?, CXR, CT head)
8. Reasses

Question 12

Management of sepsis adults

Answer 12

1. Recongnize the need of sepsis assessment
2. Gather info (try to identify source)
   2.1 Determine if in shock
3. High risk = senior review
   Moderate - high risk= Clinican review within 1h or senior within 3h
   Low risk = manage according to clinical judgement
4. Investigations: serial ABGs or VBGs for lactate, blood cultures, U&E, CRP, FBC, LFT, clotting screen, sputum and urine samples for MC&S, swab wounds, joint aspirates.
5. Tx: antibiotics ± other
   fluids
   O2 and review by critical care, surgeons, others.
6. Review immediately if
   SBP <90, RR >30, GCS <15, Lactate not reduced 20% (1h after tx and fluids)
   Consider critical care referral.

Question 13

Anaphylactic shock management

Answer 13

1. Secure AIRWAY (O2 100% and intubate if resp. obstruction imminent)
2. Remove cause;stop IV meds (consider raising feet)
3. IM adrenaline 0.5mg (1:1000) every 5 min guided by BP, pulse & resp function until better.
4. IV access = Chlorphenamine 10mg & Hydrocortisone 200mg IV
5. Saline 500mL for 15 mins up to 2L. Titrate/adjust according to BP
6. If wheeze tx for asthma, consider ventilatory support.
   If still hypotensive consider adrenaline infusion ± aminophyline and nebulized salbutamol
   SENIOR
7. Admit, serum tryptase 1-6h after anaphylaxis, cholrphenamine 4mg/6h PO if itching, MedicAlert bracelet, teach self injected adrenaline, skin prick tests

Question 14

Acute STEMI management

Answer 14

1. ABC & ECG 12 lead monitor
2. IV access and FBC, U&E, glucose, lipids, troponin
3. Brief assessment: Hx of CV disease, risk factors.
   Examine pulse, scars (cardiac surgery), CXR if will not delay.
   Check contraindications for ICP or thrombolysis
4. Aspirin 300mg AND
   Ticagrelor 180mg or
   Prasugrel 60mg or
   Clopidogrel 300mg
5. Morphine 5-10mg and metoclopramide 10mg IV
6. PCI available within 120 mins since 1st medical contact? yes = ICP
   no = fibrinolysis

Question 15

Acute cardiac chest pain Mx

Answer 15

1. ABC and ECG while in pain
2. SpO2 <90%, breathless or low-flow = O2
3. Analgesia (morph 5-10mg + metoclopramide 10mg IV
4. Nitrates (GTN spray or sublingual tablets)
5. Aspirin 300mg
   If confirmed ACS give Ticagrelor 180mg or
   Prasugrel 60mg or
   Clopidogrel 300mg
6. GRACE score and measure troponin
   -low risk= no chest pain, signs of HF, normal ECG and -ve baseline troponin =consider discharge.

high risk = high GRACE score, rise in troponin, ST or T wave changes, DM2, CKD, LVEF <40%, early angina after MI, recent PCI, prior CABG.

Fondaparinux 2.5mg or LMWH 1mg/kg/12h
+ 2nd antiplatelet (ticagrelor, prasugrel, clopidogrel)
+IV nitrate if still in pain (GTN 50mg in 50mL 0.9% saline 2-10mL/h) >SBP 100
+B-blocker (CI: asthma, cardio shock, HF, COPD, heart block) if CI calcium channel blocker (diltiazem or verapamil)
Caridologist review

Question 16

Acute HF Mx

Answer 16

1. ABC and sit upright
2. High flow O2 if ↓SpO2
3. IV acces and ECG
   =Treat arrythmias
4. Investigations (CXR, ECG, U&E, troponin, ABGs, consider echo, BNP)
5. Diamorphine 1.25-5mg IV slowly (caution in Liver Failure and COPD)
6. Furosemide 40-80mg IV slowly (↑larger dose in CKD)
7. GTN spray 2 puffs or 2x0.3mg tablets (DONT if SBP <90)
8. History, examination and further investigations.
9. If worsening another furosemide 40-80mg
   Consider CPAP
   If SBP ≥100 nitrate infusion (isosorbide 2-10mg)

Question 17

Caridogenic shock Mx

Answer 17

1. ABC and oxygen 94-98% (88-92% if COPD)
2. Diamorphine 1.25-5mg if pain
3. Investigations and close monitoring (ECG, U&E, troponin, ABG, CXR, echo, consider CT thorax for PE or aortic dissection)
4. Correct arrythmias, U&E abnormalities or acid-base disturbance
5. Optimize filling pressure (Swan-Ganz, BP, transeso doppler, JVP/CVP)
6. If underfilled = plasma expander 100mL aim for MAP 70, CVP 8-10
   Well/over filled = inotropic support (dobutamine 2.5-10mcg/kg/min) aim for MAP 70
7. Consider MI or PE (thrombolysis or ICP or surgery)

Question 18

Broad complex tachycardia with pulse Mx

Answer 18

1. O2 for >SpO2 90% and ECG
2. Adverse signs? Shock (SBP <90 and HR >100), chest pain, HF, syncope
   yes = expert help and sedation
   no= Correct electrolyte problems.
3. yes= 3 synchronized DC shocks (120-150J 1st, then 150-360J)
4. yes= Correct electrolytes (K, Mg & Ca)
5. yes= Amiodarone 300mg IV over ≥20 min and consider repeating shock, then 900mg amiodarone/24h infusion via central line
6. yes= consider further shock
7. yes = Refractory? Procainamide and/or overdrive pacing and expert help
8. No= Assess rythm
   regular= Amiodarone 300mg IV over ≥20 min then 900mg/24h via central line
   irregular= seek expert (AF with bundle brack block, Pre-excited AF consider amiodarone, Polymorphic VT, give Mg 2g IV infusion.
9. If or becomes unstable = sedation and synchronized shock 150-200J (150-360J mono)

Question 19

Acute Asthma Mx

Answer 19

1. Assess severity (PEF, ability to speak, RR, HR, SpO2; warn ICU if severe or life threatening)
2. O2 for SpO2 94-98%
   Salbutamol 5mg nebulized with O2
   If life threatening add ipratropium 0.5mg (500mcg)/6h to nebulizers
   Hydrocortisone 100mg IV or prednisone 40mg PO
3. Reassess every 15 mins
   If PEF <75% repeat salbutamol every 15-30min or 10mg continously and add ipratropium if not already given.
   ECG watch for arrythmias
   Consider single dose of magnesium sulfate (MgSO4) 1.2-2g IV over 20min
4. If not improving consider IV salbutamol, IV aminophyline and referral to ICU
5. If improving continue nebulized salbutamol every 4-6h (+ipratropium if started)
   Prednisolone 40-50mg PO OD for 5-7 days
   Peak flow and O2 sat, aim for 94-98% with supplemental if needed
   If PEF >75% 1h after initial tx, consider discharge with outpatient follow up.

Question 20

Acute asthma severe attack

Answer 20

Unable to complete sentences in one breath
RR ≥25
PR or HR ≥110
PEF 33-50%

Question 21

Acute asthma life threatening attack

Answer 21

PEF <33%
Silent chest, cyanosis, feeble respiratory effort
Arrythmia or hypotension
Exhaustion confusion or coma
ABG: normal/high PaCO2 >4.6kPa OR PaO2 <8kPa or SpO2<92%

Question 22

PE Mx

Answer 22

1. O2 10-15L/min if hypoxic
2. Morphine 5-10mg and metoclopramide 10mg IV
3. start LMWH/Fondaparinux
4. If SBP <90 give 500mL fluid bolus and get ICU input
5. Haemodynamically unstable?
   Yes= consider vasopressors (dobutamine 2.5-10mcg/kg/min) aim for SBP>90
   No= consider thrombolysis (alteplase)
6. Initiate long term anticoagulation

Question 23

Status epilepticus Mx

Answer 23

1. ABC, open and secure airway, remove false teeth if poorly fitting
2. O2 100% + suction
3. IV access (U&E, FBC, glucose, Ca, Toxicology, anticonvulsant lvls)
4. IV bolus lorazepam 4mg IV. Give 2nd dose if no response after 10-20min
5. Thiamine 250mg IV over 30min if alcoholism or malnourishment suspected
   Glucose 50mL 50% IV unless glucose normal
   Treat acidosis if severe (contact ICU)
6. Correct hypotension with fluids
7. If seizure continues start phenytoin 15-18mg/kg IV infusion at 50mg/min.
   Monitor ECG and SBP>100.
8. NEVER SPEND >20min with someone in status epilepticus WITHOUT BEDSIDE ANESTHESIOLOGIST

Question 24

DKA Mx

Answer 24

Dx. Acidaemia (venous pH <7.3 or HCO3 <15mmol)
Hyperglycaemia (glucose >11mmol)
ketonaemia (≥3 mmol/L) or significant ketonuria (2++ on dipstick)

1. ABC and 2 large bore cannulae
   1L 0.9% saline over 1h (if SBP <90 give 500mL over 15min and reassess and continue 500mL bolus untilk better or consider ICU involvement)
2. VBG for pH, bicarbonate, bedside and lab glucose and ketones, U&E, FBC, CRP, CXR, ECG
3. Insulin 50UI human insulin to 50mL 0.9% saline. Infuse continously at 0.1UI/kg/h.
   Continue patient’s long acting insulin at usual doses and times.
   Aim for a fall in blood ketones of 0.5mmol/L/h or rise in venouse bicarbonates of 3mmol/L/h with a fall in glucose of 3mmol/L/h.
   If not achieving, increase insulin infusion by 1UI/h until target rates achieved.
4. Check capillary blood glucose and ketones hourly
   Check VBG (pH, HCO3, K) at 2h, 4h, 8h, 12h and 24h
5. Continue fluids and assess need for K
6. Consider catheter if not passed urine by 1h. Aim for U. output of 0.5mL/kg/h
   Consider NG tube if vomiting or drowsy
   Start ALL patients on LMWH
7. Avoid hypoglycaemia. When glucose <14mmol start 10% glucose infusion at 125mL/h alongside saline.
8. Continue fixed-rate insulin until ketones <0.6mmol/L, venous pH >7.3 and venous HCO3 >15mmol/L. DO NOT RELY ON URINARY KETONES to indicate resolution. (they stay + after resolved).
9. Find and treat trigger.