Emergencies

Question 1

Ectasy(MDMA) poisoning

MOA?

What does it cause?

Management? -> anxiety, narrow complex tachy, hypertension, hypertermia

What would you monitor?

Answer 1

Ecstasy is a semi-synthetic, hallucinogenic substance (MDMA, 3,4-methylenedioxymethamphetamine). Acts on the serotonin transporter - increases serotonin release(affects mood and sleep), dopamine(causing euphoria and increased energy) and noradrenaline(sympathomimmetic). Can also inhibit monamine reuptake

Causes: increased alertness and self-confidence, euphoria, extrovert behaviour, increased talkativeness with rapid speeech, lack of desire to sleep or eat, tremor, dilated pupils, tachychardia, hypertension.

More severe association: excitable, agitated, parnoid delusions, hallucinations with violent behaviour, hypertonia and hyperreflexia.

Serious problems: Convulsions, rhabdomyolysis, hyperthermia, hyponatremia, aki.

Hyperthyroxinaemia may be found in chronic use.

• Administration of activated charcoal and monitoring of BP, ECG, and temperature for at least 12h (rapid cooling may be needed).
• Monitor urine output and U&E (AKI pp298–9), LFT, CK, FBC, and coagulation (DIC p352). Metabolic acidosis may benefi t from treatment with bicarbonate.
• Anxiety: lorazepam 1-2mg IV as a slow bolus into a large vein. Repeat doses may be administered until agitation is controlled (see p826).
• Narrow complex tachycardias (p806) in adults: consider metoprolol 5mg IV.
• Hypertension can be treated with nifedipine 5–10mg PO or phentolamine 2–5mg IV. Treat hypotension conventionally (p790).
• Hyperthermia: attempt to cool, if rectal T° >39°C consider dantrolene 1mg/kg IV (may need repeating: discuss with your senior and a poisons unit). Hyperthermia with ecstasy is akin to serotonin syndrome, and propranolol, muscle relaxation, and ventilation may be needed.

Question 2

In ABCDE what do you check for in the preliminary assessment for each one?

Answer 2

Disability - dont forget to check for hypoglycaemia

Question 3

What to do if someone arrests

Answer 3

Question 4

what are red flas signs of headaches?

Answer 4

• First and worst headache—subarachnoid haemorrhage (p478).
• Thunderclap headache—subarachnoid haemorrhage (p478: p480 for other causes).
• Unilateral headache and eye pain—cluster headache, acute glaucoma (p456).
• Unilateral headache and ipsilateral symptoms—migraine, tumour, vascular (p458).
• Cough-initiated headache— ICP/venous thrombosis (p480).
• Worse in the morning or bending forward— ICP/venous thrombosis (p480). •Persisting headache ± scalp tenderness in over-50s—giant cell arteritis (p556).
• Headache with fever or neck stiff ness—meningitis (p822).
• Change in the pattern of ‘usual headaches’ (p456).
• Decreased level of consciousness (p456).

Question 5

Why where have you been and might you be pregnant important to ask if someone has a headache?

Answer 5

• Where have you been? (Malaria, p416).
• Might you be pregnant? (Pre-eclampsia; especially if proteinuria and BP, p458.)

Question 6

What might have no signs on examinations?

What conditions might have signs of meningism?

What can cause decrease conscious level or localising signs?

What can cause papilloedema?

What can cause high ESR and tender scalp over temporal arteries

What can cause painful red eye and needs pressure checked immediately

What can cause neck pain and cerebellar/medullary signs?

What condition occurs due to the disks dehydrate and shrink, signs of osteoarthritis develop, including bony projections along the edges of bones?

What is wrong if the person feels full around the nose?

What problem occurs due to high alp and but normal pth

Answer 6

No signs on examination

•Tension headache (p456). •Migraine (p458). •Cluster headache (p457). •Post-traumatic (p456). •Drugs (nitrates, calcium-channel antagonists) (p114). •Carbon monoxide poisoning or anoxia. (p842) •Subarachnoid haemorrhage (p478).

Signs of meningism?

•Meningitis (may not have fever or rash—p822). •Subarachnoid haemorrhage (p478—examination may be normal). Decreased conscious level or localizing signs? •Stroke (p470). •Encephalitis/meningitis (p822). •Cerebral abscess (p824). •Subarachnoid haemorrhage (pp478–9, fi gs 10.17, 10.18). •Venous sinus occlusion (p480—focal neurological defi cits). •Tumour (p498). •Subdural haematoma (p482). •TB meningitis (p393).

Papilloedema?

•Tumour (p498). •Venous sinus occlusion (p480—focal neurological defi cits). •Malignant (accelerated phase) hypertension (p138). •Idiopathic intracranial hypertension (p498). •Any CNS infection, if prolonged (eg >2wks)—eg TB meningitis (p393).

Others

•Giant cell arteritis (p556—ESR and tender scalp over temporal arteries). •Acute glaucoma (p456—painful red eye—get pressures checked urgently). •Vertebral artery dissection (p470—neck pain and cerebellar/medullary signs). •Cervical spondylosis (p508). •Sinusitis. •Paget’s disease (p685—ALP). •Altitude sickness (OHCS p770).

Question 7

Breathlessness - check collateral history and see if they are able to speak

What problems precipitate in breathless with:

Wheezing

Stridor

Crepitation

Chest being clear

Pain, increases resonance, tracheal deviation

stony dullness

What key investigations need to be ordered?

Answer 7

Wheezing? •Asthma (p810). •COPD (p812). •Heart failure (p800). •Anaphylaxis (p794).

Stridor? (Upper airway obstruction.) •Foreign body or tumour. •Acute epiglottitis (younger patients). •Anaphylaxis (p794). •Trauma, eg laryngeal fracture.

Crepitations? •Heart failure (p800). •Pneumonia (p816). •Bronchiectasis (p172). •Fibrosis (p198).

Chest clear? •Pulmonary embolism (p818). •Hyperventilation. •Metabolic acidosis, eg diabetic ketoacidosis (p832). •Anaemia (p324). •Drugs, eg salicylates. •Shock (may cause ‘air hunger’, p790). •Pneumocystis jirovecii pneumonia (p400). •CNS causes.

Others •Pneumothorax (p814—pain, increased resonance, tracheal deviation if tension pneumothorax). •Pleural eff usion (p192—‘stony dullness’).

Key investigations •Baseline observations—O2 sats, pulse, temperature, peak fl ow. •ABG if saturations <94% or concern about acidosis/drugs/sepsis. •ECG (signs of PE, LVH, MI?). •CXR. •Baseline bloods: glucose, FBC, U&E, consider drug screen.

Question 8

Chest pain: differential diagnosis

What are life threatning causes of chest pain?

What are other causes of chest pain?

What key investigation can you order?

apart from msk pain what else can cause pain on palpation of chest?

Answer 8

Life-threatening

• Acute myocardial infarction (pp796–9). - dull pain, radiating to jaw, arm or stomach, assocaited with pain on excertion
• Angina/acute coronary syndrome (pp796–9). •Aortic dissection (p655). •Tension pneumothorax (p814). •Pulmonary embolism (p818). •Oesophageal rupture (p820).

Others

• Pneumonia (p816). •Chest wall pain: • Muscular. • Rib fractures. • Bony metastases. • Costochondritis. •Gastro-oesophageal refl ux (p254). •Pleurisy (p166). •Empyema (p170). •Pericarditis (p154). •Oesophageal spasm (p250). •Herpes zoster (p404). •Cervical spondylosis (p508).
• Intra-abdominal: • Cholecystitis, Peptic ulceration Pancreatitis •Sickle-cell crisis (p340)

Key investigations

•CXR. •ECG. •FBC, U&E, and troponin (p118). Consider D-dimer only if low probability of venous thromboembolism. See ‘Modifi ed Wells’ score for PE,

PE can also cause pain on palpation of chest