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Finals > Emergencies > Flashcards

Emergencies Flashcards

1
Q

What to do in Airway?

A

Check patency - airway maneuvers, suction

Sats - 15L O2 NRM;
aim for 88-92% in COPD –> titrate using 24-28% venturi mask if T2RF

Protect C-spine if necessary

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2
Q

What to do in Breathing?

A

RR

Examine the chest –> look, palpate, percuss + auscultate for signs or resp distress [symmetrical chest expansion? tracheal deviation?]

Squeeze calves to look for DVT!

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3
Q

What to do in Circulation?

A

HR - ?arrhythmias
BP
CRT
Auscultate the heart + ECG
UO + Catheter
2xLarge bore cannulae [send blood for FBC, U+Es, LFT, cross match, clotting, G+S]
Fluids - 500ml bolus of normal saline (+rpt)

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4
Q

What to do in Disability?

A 
AVPU --> if abnorm --> GCS
Pupils (PEARL)
Glucose
Temp
\+/- abdo/neuro examinations
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5
Q

What to do in Exposure?

A

Expose patient

Look for bleeding, rash, trauma etc

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6
Q

What to do after ABCDE?

A 
Continue monitoring
Full colateral hx
R/v notes/charts
R/v lab/radiolog results
?escalate care --> HDU/ICU
Document + handover
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7
Q

What to do before ABCDE assessment?

A 
SBAR handover
Check notes, drug chart, vital signs, ecg, bm
Quickly eyeball pt ?critically ill
Brief hx including relevant PMH 
If help needed, get help early --> 2222
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8
Q

Signs to assess for in a patient with acute breathlessness?

A 
wheeze
stridor
crepitations
chest clear
other
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9
Q

DDx of acute breathlessness + wheeze

A

ashtma
copd
HF
anaphylaxis

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10
Q

DDx of acute breathlessness + stridor

A 
foreign body
tumour
epiglottitis
anaphylaxis
trauma (laryngeal fracture)
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11
Q

DDx of acute breathlessness + crepitations

A

HF
pneumonia
bronchiectasis
fibrosis

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12
Q

DDx of acute breathlessness + clear chest

A 
PE
hyperventilation 
metabolic acidosis eg DKA
anaemia
drugs (aspirin OD)
shock 
PCP
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13
Q

Breathlessness +

Hyper-resonant to percussion?

Stony dull to percussion

A

pneumothorax

pleural effusion

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14
Q

Life threatening causes of chest pain? (3 categories)

A

CARDIAC [acute MI, ACS, aortic dissection]
RESP [tension pneumothorax, PE]
GI [oesophageal rupture]

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15
Q

what is coma?

A

unrousable unresponsiveness

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16
Q

how to quantify coma?

when do you need to intubate?

A

GCS

intubate when <8

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17
Q

Causes of coma? (2 categories)

A

METABOLIC [drugs, poisoning, hypoglycaemia, hypoxia, hypercapnia, septicaemia, hypothermia, hepatic/uraemic encephalopathy]

NEUROLOGICAL [trauma, infection, tumour, vascular, epilepsy]

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18
Q

Scoring for best motor response?

A 
6 - obeys commands
5 - localise to pain
4 - withdraw to pain
3 - flex to pain
2 - extends to pain 
1 - no response
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19
Q

scoring for best verbal response?

A 
5 - oriented
4 - confused
3 - inappropriate speech
2 - sounds 
1 - none
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20
Q

scoring for eye opening?

A

4 - spontaneous
3 - to speech
2 - to pain
1 - none

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21
Q

How to cause pain in assessing GCS?

A

fingernail bed pressure
supraorbital pressure
sternal pressure

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22
Q

What is shock?

A

circulatory failure –> inadequate organ perfusion

SBP < 90 / MAP <65

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23
Q

Calculate MAP?

A

MAP = CO x SVR

So shock results from a drop in CO or a loss of SVR or both..

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24
Q

Causes of shock? (CATEGORISE) 2

A

INADEQUATE CARDIAC OUTPUT
hypovolaemia –> bleeding / fluid loss
pump failure –> cardiogenic shock, 2dary cause

LOSS OF SVR
sepsis --> vasodilation
anaphylaxis
neurogenic
endocrine failure
other
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25
Q

Management for septic shock?

A

ABCDE (primarily ‘C’)
2xLarge bore cannulae, check ECG, signs of ischaemia
Septic shock –> BCs, abx in 1h (Tazocin + gentamicin + vancomycin) fluid bolus, ? refer to ICU

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26
Q

Management of anaphylactic shock?

including 3drugs and doses

A

Type 1 - IgE mediated hypersensitivity

A/B - secure airway; 100% O2; ?intubate if obstruction
Remove the cause, raise feet
C - ADRENALINE IM 0.5mg (rpt every 5mins as needed)
IV access ->
CHLORPHENAMINE 10mg IV
HYDROCORTISONE 200mg IV
IV fluids, 500ml boluses, up to 2L

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27
Q

Further management of anaphylactic shock..?

A 
Admit + monitor ECG
Measure mast cell tryptase 1-6h
Continue chlorphenamine
Education about epipen
Skin prick tests to find allergens
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28
Q

How does sepsis cause shock?

A

Systemic Inflammatory response syndrome (SIRS)

cytokine cascade, free-radical production and release of vasoactive mediators.

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29
Q

Management of ACS? (STEMI)

A 
Aspirin 300mg PO
Morphine 5-10mg IV (+anti-emetic)
GTN
Oxygen (if <95%)
Restore coronary perfusion --> PCI within 120mins; if PCI not available fibrinolysis 
Anticoagulation
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30
Q

Management of ACS? (NSTEMI)

A 
Aspirin 300mg PO
Morphine 5-10mg IV (+anti-emetic)
GTN 
Oxygen (if <90% or breathless)
Beta-blocker 
Fondaparinux
IV nitrate if pain continues
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31
Q

Mx of severe pulmonary oedema?

If does not improve

A 
Sit upright
O2
Investigate
Diamorphine 1.25-5mg IV 
Furosemide 40-80mg IV 
GTN

If no improvement –> further dose of furosemide +/- CPAP, nitrates (if systolic >100)

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32
Q

Causes of severe pulmonary oedema?

A

LVF
ARDS
Fluid overload
Neurogenic

33
Q

Mx of cardiogenic shock?

A

O2
Diamorphine 1.25-5mg (for pain + anxiety)
Correct arrhythmias, electrolyte disturbance
Find any reversible causes (e.g. MI, PE)
?filling pressure –> under filled give plasma expander
–> over filled give inotropes

34
Q

Causes of cardiogenic shock?

A 
MI
Arrhythmia
PE
tension pneumothorax
cardiac tamponade
myocarditis
endocarditis
aortic dissection
35
Q

Define broad complex tachycardia? (2 things)

A

Rate > 100bpm

QRS > 120ms (>3 small squares)

36
Q

DDx of broad complex tachycardia?

A

VT

TdP

37
Q

Mx of broad complex tachy?

A

O2
Correct electrolytes
If regular –> amiodarone
If irregular –> TdP give Mg

+/- DC shock

38
Q

Define narrow complex tachycardia?

A

Rate > 100bpm

QRS < 120ms (<3 small squares)

39
Q

DDx of narrow complex tachycardia?

A 
Sinus tachy
Atrial tachyarrhythmias (AF, AFlut, junctional)
40
Q

Mx of narrow complex tachy?

A 
O2
continuous ECG trace
Vagal manoeuvres 
Adenosine
\+/- cardioversion [DC / amiodarone]
41
Q

Acute severe asthma - how to assess severity?

A 
LIFE THREATENING = 33,92,CHEST
PEFR < 33%
O2 < 92%
Cyanosis
Hypotension
Exhaustion
Silent chest
Tachycardia
42
Q

Mx of severe asthma attack?

A 
OSHITMS + escalate to ICU
O2
Salbutamol neb 5mg
Hydrocortisone IV 100mg
Ipratropium 0.5mg add to neb
Theophylline
MgSO4 2g IV
43
Q

AECOPD?

A

common medical emergency

viral or bacterial infection

44
Q

Mx of AECOPD?

A 
Neb bronchodilators --> salbutamol + ipratropium
Controlled O2 therapy (monitor rpt ABGs)
Steroids --> IV hydrocortison 200mg
Abx --> amoxicilline/doxy/clarithro
\+/- aminophylline 
\+/- NIPPV / intubation
45
Q

When to suspect PE?

A

sudden collapse 1-2weeks post surgery

46
Q

RFs for PE

A 
malignancy
surgery
immobility
COCP
prev VTE
47
Q

Mx of large PE

A

O2 if hypoxic
Morphine 5-10mg IV (+anti-emetic)
If peri-arrest consider thrombolysis (50mg alteplase)
Otherwise, IV heparin/LMWH
If systolic <90 –> ICU input; colloid infusion, +/- dobutamine, adrenaline
If systolic >90 –> warfarin loading.

48
Q

Causes of acute upper GI bleed

A 
PUD
Gastroduodenal erosions
Oesophagitis
Mallory-Weiss
Varices
Malignancy
49
Q

Mx of upper GI bleed

A

Protect airway, NBM, 2xLarge-bore cannulae
Bloods [FBC, U+E, LFT, clotting screen, crossmatch]
IV crystalloid
Blood transfusion
Correct any clotting abnormalities
Urgent endoscopy for diagnosis +/- control bleeding

50
Q

pre-hospital mx of meningitis

A

IM benzylpenicillin

51
Q

Hospital mx of meningitis (no signs of septicaemia)

A

ABC: IV fluids
Cefotaxime 2g (+ ampicillin if >55yo)
Dexamethasone 4-10mg/6h IV

52
Q

Hospital mx of meningococcal septicaemia

A

ABC: IV fluids
Cefotaxime 2g (+ampicillin if >55yo)
ICU –> intubation, ionotropes, aim for MAP>70
Careful monitoring

53
Q

Mx of viral encephalitis

A

Aciclovir 10mg/kg/8h IV for 14d
+ supportive treatment
+phenytoin if seizures

54
Q

Sx of encephalitis

A 
Prodrome of raised, temp, rash, lymphadenopathy, cold sores etc +:
odd behaviour
reduced consciousness
focal neuro
seizure
55
Q

Define status epilepticus

A

seizures > 30min

rpt seizures without intervening consciousness

56
Q

Mx of status epilepticus

A

A- maintain airway, lay in recovery position, insert airway +/- intubate
B - O2 100% + suction as required
1 - lorazepam 01.mg/kg
2 - rpt lorazepam if no response in 10mins
3 - phenytoin
4 - GA

57
Q

what other drugs (non-anti-epileptics) could be useful in treating the cause of status epilepticus?

A

Thiamine (if alcoholism)
Glucose
Dexamethasone (for vasculitis/cerebral oedema)

58
Q

Head injury:
How to diagnose rising ICP?
Cause of rising ICP?
What to do?

A

Unequal pupils

EDH

Urgent involve neurosurgery

59
Q

Signs of basal skull fracture?

A

CSF rhinorrhoea/otorrhoea
Battle’s sign
Panda eyes
Blood behind the ear drum

60
Q

Indications for CT head?

A 
GCS < 13 at any time
GCS=13/14 at 2h post-injury
Focal neuro deficit
Suspected skull fracture
Post-traumatic seizure
Vomiting > once
LoC + [age>65, coagulopathy, dangerous mechanism, anterograde amnesia]
61
Q

Indications for ventilation post head injury

A

GCS =< 8
PaO2 <9kPa on air / <13kPa in o2
Resp irregularity

62
Q

Mx of head injury

A 
ABC
O2
Treat blood loss
Assess GCS
Involve neurosurgery
63
Q

Mx of raised ICP

A 
ABC
Correct hypotension
Brief examination (any clues to cause)
Mannitol
Dexamethasone (for reducing oedema around tumours)
Fluid restriction
Close monitoring 
If focal cause --> urgent neurosurgery (craniotomy/Burr)
64
Q

signs of raised ICP

A

Cushing’s triad!

  • Hypertension
  • Low heart rate
  • Low resp rate
65
Q

Pres of DKA

A 
gradual drowsiness --> coma
vomiting 
dehydration
abdo pain
polyuria/dipsia
ketotic breath
Kussmaul breathing
66
Q

Triggers for DKA

A 
4 Is
Infection (UTI, pancreatitis)
Infarction (MI)
Iatrogenic (surgery, chemo, antipsychotics)
Insulin (missed dose)
67
Q

Diagnosis of DKA

A

Acidaemia (pH < 7.3)
Hyperglycaemia
Ketonaemia

68
Q

Mx of DKA

A

A - patent airway
B - O2 if desat
C - 2xLarge-bore cannulae; if SBP<90 give 500mL saline –> if no response - 2nd + ICU advise. If responds (SBP>90 after 1st bolus –> start fluids)

Fluids -> insulin 50U to 50ml 0.9% saline - infusion at 0.1U/kg/h.
–> until ketones<0.3mmol/L, pH>7.3 and bicarb>18mmol/L

+/- K+ replacement

When glucose < 14mmol/L start 10% glucose @ 125mL/h alongside insulin

69
Q

Pres of paracetamol OD

late signs

A

initially asympto
vomiting +/- RUQ pain

later –> jaundice + encephalopathy

70
Q

what dose of paracetamol can be fatal?

A

150mg/kg

12g in adults

71
Q

mx of paracetamol OD:
<4h?
<10h?
>10h?

A

Activated charcoal in first 4h

N-acetylcysteine (use treatment line)

N-acetylcysteine

72
Q

How to give N-AC?

A

IVI 150mg/kg in 5% dextrose

73
Q

F/U of paracetamol OD?

A

INR, U+E, LFT on day after

If continued deterioration –> liver transplant

74
Q

AKI mx

A

Urgent ABG to check K+ / ECG for signs

1) treat hyperkalaemia - Calcium gluconate; actrapid + glucose
2) Fluid input/output monitoring
3) Fluid challenge if dehydrated until SBP>100
4) If vol overload consider dialysis

75
Q

Causes of AKI

A

Pre-renal [hypotension, sepsis, cardiac dysfunct]
Renal [drugs, GN, vasculitis]
Post-renal [obstruction]

76
Q

Principles of AKI treatment

A 
Treat hyperkalaemia
Treat hypotension/sepsis [pre-renal]
Catheterise [post-renal]
Treat pulm oedema w/ diuretics
Contact renal team if no UO
Urgent USS to r/o supra-bladder obstruction
?ICU requirement
77
Q

When would someone need urgent dialysis in AKI?

A

Unresponsive hyperkalaemia
Unresponsive pulm oedema
Uraemic complications (pericarditis, encephalopathy)
Severe metabolic acidosis

78
Q

How to gauge severity of pancreatitis?

A 
Glasgow criteria
PaO2<8kPa
Age>55
Neutrophilia (WBC>15x10)
Calcium<2
Renal (Urea>16)
Albumin<32
Sugar (Glucose>10)

3 or more positive in first 48h suggests severe pancreatitis -> transfer to HDU/ITU

Finals (20 decks)

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