Emergencies

Question 1

Bloods in anaphylaxis

and what to give with cannula in

Answer 1

Mast cell tryptase

+ IV 0.9% normal saline may be needed, titrate to BP

Question 2

early vs late phase anaphylaxis

Answer 2

within minuutes: mast cell degranulation and histamine/tryptase release
+ leukotrienes incr vasc permeability and induce bronchial constriction
Late phase: 2-24hrs
- eosinophils recruited, release enzymes and stimulate mast cells
- amplify and sustain initial response

Question 3

Drugs in anaphylaxis

And paeds variation

Answer 3

Anaphylaxis 0.5ml 1:1000 repeat every 5 mins
Chlorphenamine 10mg IV
hydrocortisone 200mg IV
salbutamol nebs if wheeze

Adrenaline paeds doses
6-12: 300mcg
6months - 6: 150mcg
<6mo: 100-150mcg

Question 4

Narrow complex tachycardias definition

differentials

Answer 4

RAte >100bpm
QRS < 120ms

Sinus tachy
AF, flutter, atrial tachy
AVNRT
AVRT

Question 5

Adverse signs considering cardioversion

Answer 5

BP <90
heart failure
reduced consicousness
HR>200

Always seadte and cardiovert

Question 6

no adverse features SVT management

Answer 6

1. vagal manoeuvres (carotid sinus massage, valsalva) to transiently block AV and unmask underlying atria rhythm
2. adenosine 6mg IV bolus as transient AV block unmasks atrial rhythm and can cardiovert AVNRT/AVRT
3. adenosine 12mg, then another 12
4. unsuccessful? one of: digoxin, amiodaone, verapamil, atenolol
5. 4. cardiovert

Question 7

Contraindications to thrombolysis

(for STEMI)

Answer 7

Aortic dissection
GI bleeding
Allergic reation prev
Major surgery last 14 days
Cerebral neoplasm
Stroke history
Severe HTN >200
Trauma

Question 8

STEMI drugs for everyone

Answer 8

Aspirin
Ticagrelor (anti platelet)
Unfractionated heparin if going for PCI

O2 if hypoxic

Question 9

ECG changes in STEMI

Answer 9

Early: peaked T wave, raised ST
within 24hr: inverted T waves, ST returns to normal
Within days: pathological Q waves

STEMi diagnositic if ST incr >1mm 2 consecutive leads
or >2mm V2/V3

Question 10

STEMi locations

Answer 10

I, aVL, V5, V6 = lateral
II, III, aVF: inferior
V1, V2 = septal
V3, V4 = anterior

Question 11

PCI timing vs thrombolysis

Answer 11

If possibly within 120 mins onset of pain
Should be considered for all presenting within 12 hours
If PCI not available within 120 mins, give thrombolysis eg streptokinase - most effetive within first hour, but can be up to 12 hours

Question 12

Opiate overdose reversal

Answer 12

Naloxone
competitively binds opiod receptors
Half life is shorter than opioids, so need to continue monitoring

Typically in presence of CNS and resp depression

Question 14

Benzo overdose reversal

Answer 14

Flumenazil is reversal agent, competitively binds benzos
Reduces sedative/drowsiness effect.
Half life shorter so multiple doses may be needed

Beware long term benzo abusers, can induce withdrawal seizures

Question 15

Benzo overdose symptoms

Answer 15

Agitation, euphoria, blurred vision, slurred speech, ataxia, slate-grey cyanosis

Question 16

Signs of aspirin overdose

Answer 16

Tinnitus, lethargy, dizziness, nausea and vomiting
More serious: dehydration, sweating, bouding pulse, deafness, breathlessness, glucose disturbance, confusion
Life threatening: pulmonary oedeam, metabolic acidosis

500mg/kg is severe

Question 17

Management of aspirin overdose

Answer 17

Activated charcoal if >125ml/kg ingested <1hr ago
Gastric lavage if >500mg/kg ingested <1hr ago
Consider glucose
Incr alkalinity o urine to incr salicylate.
Haemodialysis for severe cases

Question 18

Sympathomimetics overdose symptoms

Eg cocaine, amphetamines

Answer 18

tachycardia, mydriasis, euphoria, formication (insects crawling), agitation, tremor, dilated pupils, tachycardia, arrhythmias, convulsions

Give benzos

Question 19

Cannabis overdose symptoms

Answer 19

Dry cough, increased appetite, social withdrawal and paranoia, altered perception of time

Question 20

Carbon monoxide poisoning symptoms

Answer 20

Headache
Tachycardia, reduced reflexes, pulmonary oedema, shock, metabolic acidosis, flushed cherry pink skin, coma

Give hyperbaric oxygen

Question 21

Antidote for antifreeze (ethylene glycol) poisoning

Answer 21

Ethanol

Question 22

Antidote for cyanide poisoning

Answer 22

Dicobalt edetate

Question 23

Antidote for lead poisoning

Answer 23

Sodium calcium edetate

Question 24

Antidote for organophosphate poisoning

Eg farmers with fertilisers or chemical weapons

Answer 24

Atropine

Question 25

antidote to heparin overdose

Answer 25

Protamine sulphate

Question 25

Signs of paracetamol overdose

Answer 25

nausea/vomiting
abdo pain
RUQ tenderness
Hepatic necrosis -> jaundice, RUQ pain, encephalopathy, hypoglycaemia
REnal failure
Oliguria
Metabolic acidosis

Often asymptomatic until 24-72 hrs after

Question 25

ECG in tricyclic overdose

Answer 25

Sinus tachy (due to muscarinic blockafe)
Prolonged QRS ( if >100 predicts seizures)
Unusual R wave?

Question 25

Management of TCA overdose

Answer 25

IV bicarbonate (if widened QRD or ventricular arrhytmia)
Other Arrhythmia management
IV lipid emulsion = bind free drug and reduce toxicity
Dialysis is NOT effective

Question 25

Features of tricyclic overdose

Answer 25

Sedation
Confusion
Arrhythmias
Seizures
Hypotension
Anticholinergic effects: hyperthermia, flushing, dilated pupils
Nausea/vomiting
Headache

SNRI reuptake inhibitors -> block Na channels, also anticholinergic

Question 26

Ix paracetamol OD

Answer 26

Paracetamol level 4hrs after ingestion
LFTs (partic ALT) at presentation and 2hrs before completion of NAC

Question 27

Management of paracetamol OD

Answer 27

Activated charcoal if <1hr after overdose (this is howevere extremely unpleasant. need awake, cooperative adult)
NAC give dependent on nomogram curve. greatest effect if <12hrs after ingestion
Consider liver transplant if INR >3 at 48hrs post ingestion, or 4.5 at any time. Or otherwise unwell