Emergencies Flashcards
AEDs are not designed for infants under 1y. Should you use it in an event that arrest occurs?
Yes
The recovery position involves all limbs at 90 degrees at the elbow and knee. One hand against the patient’s cheek and the farther leg brought towards you more. When should you flip the patient to the opposite side?
After 30 mins
What is the paediatric and adult dosages of adrenaline?
Adult and child >12 = 0.5ml
Child 6-12 = 0.3ml
Child<6 = 0.15ml
All 1:1000
In other scenarios 1ml of 1:10000 are used
After an anaphylactic attack has subsided with treatment, what is the next course of action?
Prescribe autoinjectors to the patient advising them of the technique and to always carry 2
!!! Admit to A&E regardless
What is the correct technique patients should follow when having an allergic reaction
Lie flat, elevate legs (unless breathless, then they can sit upright). Place orange part on outer mid thigh and click the button. Yes it can go through clothes
What is the protocol for anaphylaxis
ABCDE, call for help, Administer 0.5ml 1:1000 IM
When equipment is available:
IV fluid challenge (500-1L or 20ml/kg)
Chlorphenamine (IM or IV)
Hydrocortisone (IM/IV)
What is Kernig’s sign?
Sign indicating meningism (may also be seen in SAH)
When hips are fully flexed, patient resists passive knee extension.
How do you assess for a stiff neck for meningism?
Check if they can put chin on chest
A patient presents to your clinic with stiff neck, photophobia, nausea, vomiting, and a non-blanching petechial rash. What is your next course of action?
1) Call emergency ambulance for transfer
2) While waiting perform ABCDE and give fluids and oxygen if available
3) Give IV/IM Benzylpenicillin or Cefotaxime
If patient is shocked, lie flat and raise legs above waist
A patient presents to your clinic with stiff neck, photophobia, nausea, vomiting, and a non-blanching petechial rash. You decide to give IM benzylpenicillin but a note says that they previously had a rash to it. Will you still give the dose or switch to cefotaxime?
A rash in not a contraindication only anaphylaxis
Benzylpenicillin is the drug of choice for treating meningococcal disease. When should it be withheld?
Only withheld if there is an anaphylactic reaction previously to it.
No signs of meningococcal disease, only meningitis
What is the difference between meningitis and meningococcal disease?
Meningococcal disease has meningitis + Rash (non-blanching petechial). Other than that is it just more rapid onset and severe.
Meningitis and encephalitis are notifiable diseases. Contact tracing is undertaken by the local public health department. For a single case, only close contacts require prophylactic antibiotics and vaccination. What are these?
Antibiotics: Ciprofloxacin or Rifampicin
Vaccines: Routine childhood vaccination should have been given but in all cases, give the confirmed serotype (typically A and C)
Give 3 long-term effects of meningococcal disease
1) Hearing loss (refer for audiology)
2) Neurological: Fits, hemiparesis
3) Orthopaedic: Bone and joint damage, poor limb growth
4) Psychosocial effectsF
Define cardiogenic shock
Inability of the heart to maintain sufficient bloodflow due to MI, tamponade, arrhythmia
What is the typical presentation of hypovolemic shock
How is it managed in primary care?
Initially tachycardia (>100), pallor, sweating followed by decompensation with sudden bradycardia and hypotension
Lie patient flat, raise legs above waist and call for emergency ambulance
Gain IV access (2x large bore cannulas) and take blood for FBC and crossmatching!!
Start IV fluids 1L over 15 mins
Give 100% oxygen (15L/min unless hypercapnic like in COPD then give 24% oxygen)
Treat underlying cause
Use this for all heavy bleeding in primary care
How does an AAA present?
Hypovolemic shock + Backpain + Pulsatile mass in abdomen
How does a Dissecting Thoracic Aneurysm present
How is it managed in primary care
Sudden tearing chest pain +/- LOC radiating to the back
+ Hypovolemic shock
+ occlusion of the branches of the aorta
a) coronary arteries -> MI
b) Subclavian arteries -> Unequal pulses and BP in both arms
c) Carotid artery -> Hemiplegia
d) Spinal arteries -> Paraplegia
e) Renal arteries -> Acute renal failure
Lie patient flat, raise legs above waist and call for emergency ambulance
Gain IV access (2x large bore cannulas) and take blood for FBC and crossmatching!!
Start IV fluids 1L over 15 mins
Give 100% oxygen (15L/min unless hypercapnic like in COPD then give 24% oxygen)
A patient presents with frank bleeding on toilet paper when wiping. You determine that this is a haemorrhoid (or anal fissure). What is your management plan in primary care.
As this is very benign and not a source of heavy bleeding, no further investigation is needed => treat as haemorrhoid which is rest, ice, soften stool with ispaghula and give analgesia. Only refer when not settled.
A patient presents with bleeding PR. Who will you refer to and when is it indicated for urgent referral?
Refer to lower GI team within 2 weeks IF (basically if it looks bad, use common sense)
Only if abdominal/rectal mass
Unexplained rectal bleeding >50
Unexplained rectal bleed <50 with abdominal pain, change in bowel habit, weight loss or iron deficiency anaemia
A patient presents with Epigastric/RUQ pain + coffeeground vomit. There is no circulatory compromise. What is your next step in management?
Refer urgently to an upper GI team within 2 weeks
A patient presents with haematemesis via coffee-ground vomit. There is no circulatory compromise. What is your next step in management?
Refer routinely to Upper GI team for endoscopy
It would be an urgent referral if abdominal mass, Epigastric/RUQ pain. dysphagia, or aged >55, weight loss
A patient presents with cardiogenic shock. Give 3 most likely ddx
MI
Arrhythmia
Acute LVF
Tamponade
How would you acutely treat an MI in primary care?
Call an ambulance + MONABASH
Morphine
Oxygen (100% 15L/min)
Nitrate GTN
Aspirin
Beta blocker
ACEi
Statin
Heparin LMWH
How would you acute LVF in primary care?
Morphine + furosemide + GTN spray
Remember acute LVF basically means acute heart failure => think pulmonary oedema
How would you treat acute bradycardia in primary care?
Atropine
Are troponin levels raised in unstable angina?
No but they are in NSTEMI and STEMI
Differentiate between Type 1 and Type 2 brittle asthma
Type 1: Wide PEFR variability (>40% diurnal variability >50% of the time)
Type 2: Sudden severe attacks on a background of apparently well-controlled asthma
How is a moderate asthma exacerbation managed in primary care?
SABA via spacer
If no improvement, give nebulized salbutamol 5mg
Then give 40-50mg prednisolone (or IV hydrocortisone 100mg)
Always give written asthma management plan
Note same management for paediatrics
A patient presents with moderate asthma exacerbation and is instructed to have SABA via spacer. How is it given in this scenario
Given 1 puff at a time every 60 seconds up to a maximum of 10 puffs
How is Severe asthma exacerbation managed in primary care?
Give 100% oxygen to maintain SpO2 94-98%
+ Nebulized SABA 5mg salbutamol
Then give Prednisolone 40-50mg or IV hydrocortisone 100mg
Always give written asthma management plan
If no response -> Admit
Note same management for paediatrics
How is a life threatening asthma exacerbation managed in primary care?
Arrange for ambulance for admission
Give 100% oxygen to maintain SpO2 94-98%
+ Nebulized SABA 5mg salbutamol + 0.5mg Ipratropium bromide x3
+ Prednisolone 40-50mg or IV hydrocortisone 100mg immediately
Arrange for followup 2 days after discharge from hospital
Always give written asthma management plan
Note same management for paediatrics except in paeds its given every 20 minutes
You are managing a paediatric patient with an acute asthma exacerbation that has not settled with nebulized salbutamol, ipratropium not hydrocortisone. You arrange for an ambulance. What will you do until ambulance arrives?
Stay with patient until ambulance arrives
Repeat SABA via oxygen-driven nebulizer until arriving at hospital (so also must be given in ambulance)
Send written assessment and referral details
What is the dose of salbutamol and ipratropium given in the management of acute asthma in primary care for <5 and >5
Do same for prednisolone and hydrocort
> 5 Salbutamol 5mg Ipratropium 0.25mg Pred 30-40, Hydrocort 100
<5 Salbutamol 2.5mg and Ipratropium 0.25 Pred 20, hydrocort 50
If a patient is vomiting would you give prednisolone or hydrocortisone
Hydrocort lol
A mother brings their 18 month old child to your clinic with a moderate asthma exacerbation. How will you manage them
Directly arrange for admission to hospital
Give the management of a fit in primary care
Include dosages
First fit -> call ambulance directly
If known epilepsy -> Call ambulance if it does not stop for 5 mins
Check capillary glucose!
If >5 mins => status epilepticus ( do not give meds before)
1) Buccal midazolam 10mg
2) Rectal diazepam 10mg
3) IV lorazepam 4 mg or 0.1mg/kg for max of 4
A patient presents to your clinic with tachycardia, tremor, raised BP and sweating. They are a known diabetic. What do you suspect they have?
How will you confirm? (include result you are suspecting)
Give your action plan
Hypoglycemia => check blood capillary glucose (<4)
1) Give 3 glucose tablets/lucozade etc… If not, IM glucagon 1mg
2) Once regained consciousness, give simple carbs and then complex carbs
3) Monitor cap glucose after 15 mins, then hourly for 4 hours then 4 hourly for 24 hours
4) If cap still <4 despite effort, admit (or obviously if they havent regained consciousness
A patient presents with a 1 day history of deterioration after getting a light chest infection. Their breathing is a deep sighing breath with reduced consciousness and explained they have vomited which made them come here. You note that they look dehydrated. What do you suspect they have?
How will you confirm (including result)
Give your action plan
Diabetic ketoacidosis
=> cap glucose >20
=> Urine dipstick for ketones (catheter)
Patient is dehydrated and probably in shock => lie flat and raise legs
ABCDE
Oxygen + 2x IV catheter -> administer IV fluids 3x1L
Note: Gliflozins may cause diabetic ketoacidosis with normal glucose
A T2DM patient presents with a 5 day history of deterioration after getting a light chest infection. They have reduced conciousness and appear severely dehydrated. What do you suspect they have?
How will you confirm (including result)
Give your action plan
Hyperosmolar hyperglycaemic State or HONK-Hyperglycaemic Hyperosmolar Non-ketotic Coma.
=> Cap glucose >35
=> Dipstick shows no ketones (do it anyways cuz type 2 can still have ketoacidosis)
Admit to hospital as acute medical emergency
A 70 year old patient presents with hyporeflexia, bradycardia, cyanosis and altered conciousness. They have a past medical history of radioactive iodine therapy which has resolved her hyperthyroidism as well as heart failure. What is the most likely diagnosis?
What is your action plan?
Myxoedema Coma => Hypothyroidism
Admit as acute medical emergency
While awaiting admission, keep warm and give O2 to maintain SpO2 94-98%
Heart failure => IV Furosemide
A 45 year old patient presents with fever, agitation, confusion, vomiting, diarrhoea, and tachycardia. On examination, they are 3 days post-thyroid surgery. What is the most likely diagnosis?
What is your action plan?
Hyperthyroid crisis/thyrotoxic storm
Admit to hospital as acute medical emergency
A patient with rheumatoid arthritis is well-controlled on steroids. They have presented with vomiting and evidence of shock on exam. What is the most likely diagnosis?
Give 3 reasons why this might occur
What is your action plan?
Hypoadrenal/Addisonian Crisis
1) Suddenly stopped steroids
2) Intercurrent illness without increasing dose
3) Dental treatment or surgery without increasing dose
4) Presenting feature of addison’s disease
Admit to hospital as acute medical emergency
Administer 100mg hydrocortisone while awaiting admission
what would you advise a patient to prevent a hypoadrenal crisis?
Warn all patients taking long-term steroids to not stop them abruptly
Tell any doctor about your condition including dentists
Double dose of steroids prior to dental treatment or intercurrent illness
If vomiting replace oral steroid with IM hydrocortisone
Advice to hold a steroid card or MedicAlert bracelet
A mother is asking if she can take codeine for her headache after suffering a minor head injury as it has helped for her back pain. so….
Dont taker codeine but take paracetamol instead
How would you estimate the extent of a burn?
Rule of 9s
Exclude areas of erythema only
Palm and Genitals, each 1%
Arm and head, each 9%
Leg, front, and back, each 18%
A patient presents to your clinic with a red, painful blistered arm after a burn. Is this a partial or full thickness burn. Define the other
This is a partial thickness burn
A full thickness burn would be painless and white/grey
What is the threshold for a burn to be referred to A&E?
If you are referring to A&E what is your action plan until the ambulance arrives
> 3% in adults and >2% in children or if evidence of smoke inhalation regardless
Remove clothing from the affected area and place under cold running water for atleast 10 minutes or until pain is relieved
Do not burst blisters
Prescribe/give analgesia
Cover burns with cling film prior to transfer
A patient presents to your clinic with a red, painful blistered arm after a burn. You correctly determine that this is a partial thickness burn but is not significant enough to refer to A&E. What is your action plan for treating the burn in the community?
When would you tell the patient to go to A&E?
Remove clothing from the affected area and place under cold running water for atleast 10 minutes or until pain is relieved
Do not burst blisters
Prescribe/give analgesia
Check tetanus immunity
Cover burn with a non-adherent dressing. Apply a non-fibrous secondary absorbent dressing such as a dressing pad and secure well with a light weight confirming bandage or a gauze bandage.
Refer to A&E if burn is not healed in 10-12 days
How does a sun burn develop?
Tingling is followed 1-12hr later by erythema. Redness is maximal at 24hrs and fades over 2-3 days. Desquamation and pigmentation follow.
A severe sunburn may cause blistering, pain, and systemic upset. How would you manage that?
Calamine lotion and Paracetamol for pain
If a patient with a sunburn is referred to hospital what is the most likely cause?
Dehydration
A patient presents with a chemical burn, how will you manage?
Wear gloves to remove contaminated clothing
Irrigate with cold running water for 20 minutes
Do not attempt to neutralize the chemical as it can exacerbate the injury
Refer to A&E
A patient presents with 2 skin burns at his arm and the bottom of his foot. What is the most likely cause? How will you manage
Electric shock
Refer all patients to A&E as cardiac damage and renal damage may occur due to rhabdomyolysis
A patient presenting to you with low mood expresses thoughts of self harm. They are determined to be low risk. How will you manage?
Low risk should have someone arranged to stay with them until follow-up + liaise with community mental health services
High risk should be admitted as a psychiatric emergency under the mental health act
