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Emergencies Flashcards

1
Q

What NEWS score is considered significant?

A

5 or more in total or 3 or more in one domain

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2
Q

How do you assess the airway?

A

Protect cervical spine if an injury is possible
Look inside the mouth and remove objects/dentures
Assess for signs of obstruction
○ Use wide-bore suction under direct vision if secretions are present
If vocalising, can assume airway is patent
Listen for stridor, snoring or gurgling
Establish a patent airway using:
○ Manoeuvres (e.g. chin lift, jaw thrust)
○ Adjuncts (e.g. oropharyngeal airway (Guedel))
If airway still impaired –> CALL ARREST TEAM (2222)

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3
Q

How do you assess breathing?

A

Look for chest expansion (equal? Fogging of mask?)
Listen for air entry (equal?)
Feel for expansion and percussion (equal?)
Start 15 L oxygen via a non-rebreather
Use a bag valve mask if there is poor or absent respiratory effort
Monitor SaO2 and RR
Check for tracheal deviation and cyanosis
If NO respiratory effort –> CALL ARREST TEAM (2222)
○ Intubate and ventilate
If breathing is compromised, give 15 L oxygen through a non-rebreather mask

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4
Q

How do you assess circulation?

A

Look for pallor, cyanosis and distended neck veins (JVP)
Feel for central pulse (carotid/femoral) - rate and rhythm
Monitor defibrillator ECG and BP
Gain venous access and send bloods if time allows
12-lead ECG
Treat shock
If NO cardiac output –> CALL ARREST TEAM (2222)

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5
Q

How do you assess disability?

A

Consciousness (GCS/AVPU)
Pupils
Blood glucose

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6
Q

What are some common causes of peri-arrest?

A 
Arrhythmia
MI
Hypovolaemia
Sepsis 
Hypoglycaemia 
Hypoxia 
Pulmonary oedema 
PE
Metabolic (hypo or hyperkalaemia)
Tension pneumothorax
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7
Q

What are the components of qSOFA?

A

RR > 22
GCS < 15
SBP < 100

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8
Q

What is the difference between severe sepsis and septic shock?

A

Severe sepsis: sepsis with evidence of organ hypoperfusion (e.g. hypoxaemia, oligaemia, confusion)

Septic shock: severe sepsis with hypotension despite adequate fluid resuscitation

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9
Q

What are the sepsis 6?

A 
Give oxygen (15 L through non-rebreather) 
Give IV fluids (bolus = 20 mL/kg)
Give broad-spectrum antibiotics

Take blood cultures
Take lactate
Monitor urine output

ALL WITHIN 1 HOUR

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10
Q

When should sepsis patients be escalated further?

A

SBP fails to reach > 90 mm Hg

Lactate remains > 4 mmol/L

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11
Q

How should haemorrhagic shock be managed?

A

2 L of crystalloid
If this fails to resuscitate –> X-match
Give FFP and packed red cells (1:1) aiming for platelets > 100 and fibrinogen > 1

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12
Q

Which medications are used in the management of anaphylaxis?

A 
Adrenaline 0.5 mg IM (0.5 mL of 1:1000)
Repeat every 5 mins as necessary 
Chlorphenamine 10 mg IV 
Hydrocortisone 200 mg IV
IV fluid bolus if shocked
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13
Q

What should be done after the a patient with anaphylaxis has been stabilised?

A

Admit to ward
Monitor ECG
Continue chlorphenamine 4 mg per 6 hours PO if itching
Suggest MedicAlert bracelet
Prescribe autoejector
Consider skin-prick testing or specific IgE

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14
Q

Outline the management of aortic dissection.

A

Fast bleep cardiothoracic surgery
Transfer to ITU
Use hypotensives (e.g. labetalol) to maintain SBP 100-110
Document and debrief

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15
Q

Outline the management of a ruptured AAA.

A 
Fast bleep vascular surgery and anaesthetics 
Take the patient straight to theatre 
Gain IV access 
Administer O- if necessary 
Keep SBP < 100 mm Hg
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16
Q

Outline the initial management of a STEMI.

A

Morphine 5-10 mg IV (repeat after 5 mins if necessary)
Metoclopramide 10 mg IV
Oxygen 15 L via non-rebreather (if <92)
Nitrates
Aspiring 300 mg PO (with clopidogrel or ticagrelor)

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17
Q

What doses of second antiplatelet agents are used with aspirin in the prevention of atherothrombotic events in ACS?

A

Clopidogrel 300 mg followed by 75 mg

Ticagrelor 180 mg STAT followed by 90 mg BD

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18
Q

Which medications should patients who have had an MI take home?

A 
Dual antiplatelet therapy (continue for 12 months)
GTN spray 
Beta-blocker 
ACE inhibitor 
Statin
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19
Q

Outline the management of acute heart failure.

A

Diamorphine 1.25-5 mg IV (caution in liver failure or COPD)
Furosemide 40-80 mg IV
GTN spray 2 puffs sublingual (consider isosorbide mononitrate infusion 2-10 mg/hour)

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20
Q

What should be considered if a patient in acute heart failure deteriorates?

A

Further dose of 40-80 mg furosemide
Consider CPAP
Increase nitrate infusion
Refer to ITU

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21
Q

How should a patient with acute heart failure be managed once they have been stabilised (not just medication)?

A

Monitor daily weight and observations
Repeat CXR
Switch to oral furosemide or bumetanide
ACE inhibitor if LVEF < 40%
Consider beta-blocker and spironolactone
Consider biventricular pacing or transplantation
Consider digoxin and warfarin

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22
Q

Outline the management of broad complex tachycardia in a haemodynamically UNSTABLE patient.

A
  • DC cardioversion
  • Hypokalaemia and hypomagnesaemia
  • Amiodarone 300 mg IV over 10-20 mins through a central line
  • Procainamide and sotalol in refractory cases
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23
Q

Outline the management of broad complex tachycardia in haemodynamically STABLE patients.

A

Correct electrolyte abnormalities
Amiodarone 300 mg IV over 10-20 mins
If it fails –> DC cardioversion

NOTE: after correction of VT, patients should be given maintenance antiarrhythmic therapy (e.g. sotalol)

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24
Q

Outline the management of torsades des pointes.

A

Stop predisposing drugs (e.g. TCAs)
Correct hypokalaemia
Give magnesium sulphate 2 g over 10 mins

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25
Q

Outline the management of narrow complex tachycardia.

A

Vagal manoeuvres
Adenosine 6 mg IV bolus (followed by 0.9% saline flush)
If unsuccessful –> after 2 mins give 12 mg bolus
If unsuccessful –> after 2 mins give 18 mg bolus
Alternative: verapamil 2.5-5 mg over 2 mins

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26
Q

How should AF in an unstable patient be treated?

A

Emergency cardioversion
If unavailable –> IV amiodarone
Control ventricular rate: verapamil 40-120 mg/8 hrs PO or bisoprolol 2.5-5 mg/day PO
Start anticoagulation with LMWH

NOTE: cardioversion is only recommended if it can be done within 48 hours of the onset of symptoms

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27
Q

Which medications should patients with AF be given to take away?

A 
Use CHADS-Vasc to calculate need for anticoagulation (1 or more requires warfarin) 
Rate control (beta-blocker or CCB) 
Rhythm control (flecainide if no structural heart disease, otherwise amiodarone)
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28
Q

Outline the investigations that you would request for a suspected acute asthma attack.

A

Bedside: PEFR, ECG, ABG, SaO2
Bloods: FBC, U&E
Imaging: CXR?

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29
Q

Outline the management of severe acute asthma.

A

Nebulised salbutamol 5 mg with oxygen
IV hydrocortisone 100 mg (or PO prednisolone 40-50 mg)
If it worsens
- add ipratropium bromide nebuliser 0.5 mg
- stat dose of magnesium sulphate 1.2-2 g IV over 20 mins

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30
Q

If a patient with a severe asthma is showing signs of improvement, how should they be cared for?

A

Nebulised salbutamol every 4 hours
Prednisolone 40-50 mg OD for 5-7 days
Monitor PEFR and oxygen saturations

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31
Q

How should a patient with life-threatening acute asthma be escalated if initial treatment fails to cause an improvement?

A

Refer to ICU
May need ventilatory support (e.g. intubation)
May need intensified treatment (e.g. IV aminophylline, IV salbutamol)

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32
Q

Outline the management of an infective exacerbation of COPD.

A

BOAS

BRONCHODILATOR: nebulised salbutamol 5 mg/4 hr + nebulised ipratropium 0.5 mg/6 hr
OXYGEN: at 24-28% via venturi mask aiming for 88-92%
ANTIBIOTICS: trust guidelines (e.g. amoxicillin or doxycycline)
STEROIDS: IV hydrocortisone 200 mg (or oral prednisolone)

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33
Q

How should the treatment of a patient with an infective exacerbation of COPD be escalated if they fail to respond to initial treatment?

A

Consider IV aminophylline
Consider NIV
Consider intubation and ventilation
Consider respiratory stimulant (e.g. doxapram)

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34
Q

Which investigations may be useful in patients with acute pancreatitis?

A

Bedside: glucose
Bloods: amylase, lipase, FBC, U&E (calcium), LFTs, ABG, glucose
Imaging: USS, erect CXR, AXR (rule out other causes of acute abdomen), ERCP

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35
Q

Outline the management of acute pancreatitis.

A

Assess severity using Modified Glasgow Criteria
NBM
IV fluids to achieve normal vital signs (3rd spacing)
Insert catheter to monitor urine output
Analgesia (IM pethidine 75-100 mg/4 hr or morphine)
If worsening –> ITU (may need ERCP)

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36
Q

Outline the management of a primary pneumothorax.

A

No SOB + < 2 cm rim of air on CXR –> consider discharge and repeat CXR in a few weeks
SOB + > 2 cm rim of air on CXR –> aspiration
- if unsuccessful –> repeat aspiration
- if unsuccessful –> insert chest drain

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37
Q

Outline the management of a secondary pneumothorax.

A

No SOB, age < 50 yrs + < 2 cm rim of air –> aspiration
- if successful –> admit for 24 hours
- if unsuccessful –> insert chest drain
SOB, age > 50 yrs and > 2 cm rim of air –> insert chest drain

38
Q

Outline the management of tension pneumothorax.

A

FIRST LINE: Insert a large-bore needle that is partially filled with saline into the safe triangle: or the fourth or fifth intercostal space in the mid-axillary line

PREVIOUS: Insert a large-bore needle that is partially filled with saline into the 2nd ICS in the MCL on the side of the suspected pneumothorax - remove plunger to allow air to bubble through the syringe

39
Q

Outline the management of PE in a stable patient.

A

Oxygen
Morphine 5-10 mg IV with 10 mg metaclopramide
1st line: Apixaban or rivaroxaban
2nd line: LMWH

40
Q

How does the systolic BP affect the management of PE?

A

Haemodynamically unstable = thrombolysis

Stable: DOAC

41
Q

Describe the ongoing management of PE after the immediate situation has been dealt with.

A 
Provoked = 3 months anti coagulation 
Unprovoked = 6 months anti coagulation

Compression stockings etc

42
Q

How is a massive PE in a haemodynamically compromised patient treated?

A

10 mg alteplase followed by 90 mg infusion over 2 hours

43
Q

What crucial blood tests should be requested in patients with an acute upper GI haemorrhage?

A 
FBC 
Group and save 
X-match 6 units of blood 
Clotting screen 
LFT
44
Q

Outline the immediate management of shocked patients with an acute upper GI bleed.

A

Protect airway and keep NBM
Insert two large-bore cannulae
Rapid IV crystalloid infusion up to 1 L
If grade III-IV shock, give O- blood until X-match is complete
Correct clotting anomalies (e.g. PCC, vitamin K)
Consider ICU referral for central venous line
Catheterise to monitor urine output (aim > 30 mL/hour)
Monitor vital signs
Notify surgeons
Endoscopy within 4 hours for variceal bleed and within 12-24 hours if unstable on admission

45
Q

Outline the medical management of acute upper GI bleeds.

A

Major ulcer bleeding –> omeprazole 80 mg IV stat over 40-60 mins followed by 8 mg/hour for 72 hours
Variceal bleeding –> resuscitate then urgent endoscopy for banding or sclerotherapy + terlipressin 2 mg SC QDS

NOTE: if large bleed, Sengstaken-Blakemore tube may be used to tamponade the bleed and lactulose may be given to reduce absorption of nitrogenous products

46
Q

Outline the management of bacterial meningitis.

A

Sepsis 6
Cefotaxime 2 g IV (add ampicillin 2 g/6 hrs IV if immunocompromised or > 55 years)
Call critical care team
If meningitis only: consider adding dexamethasone 4-10 mg/6 hrs IV

47
Q

Outline the ongoing management of a patient with bacterial meningitis who has been stabilised.

A

Discuss antibiotic treatment with microbiology
Isolate in side-room for 24 hours
Treat contacts with ciprofloxacin 500 mg PO

48
Q

Which drug treatment is used for suspected encephalitis?

A

IV aciclovir (10 mg/kg/8 hrs IV)

49
Q

How much insulin should be given to patients with DKA?

A

50 u actrapid in 50 mL of 0.9% saline
Infused continuously at 0.1 u/kg/hour
Aim for a fall in ketones of 0.5 mmol/L/hour
OR rise in venous bicarbonate of 3 mmol/L/hour with a fall in glucose of 3 mmol/L/hour

NOTE: check VBG at 1 hour, 2 hours and 2 hourly thereafter

50
Q

When should glucose be added to the infusion in DKA?

A

10% glucose at 125 mL/hour alongside saline when glucose < 14 mmol//L

51
Q

Outline the management of acute abdomen.

A

Gain IV access
Catheterise and place on fluid balance chart if hypotensive
Analgesia: 100 mg diclofenac PR for renal pathology, or 5-10 mg morphine IV for intra-abdominal pathology
Send blood sample for FBC, U&E, amylase, LFT, CRP and G&S
IV antibiotics if indicated
NBM

52
Q

Outline the management of stroke.

A

15 L/min oxygen if low saturations or SOB
NBM
100 mL/hour 0.9% saline
Treat arrhythmias
Get exact timescale of symptom onset
Request urgent CT scan
Once haemorrhagic stroke ruled out: aspirin 300 mg STAT and thrombolyse with tPA of < 80 yrs and < 4.5 hours or > 80 yrs and < 3 hours

53
Q

Outline the treatment of hyperkalaemia.

A

10 mL 10% calcium gluconate IV over 2 mins (repeat every 15 mins up to 5 doses)
10 IU Actrapid with 50 mL 50% dextrose IV over 10 mins
Consider 5 mg salbutamol nebuliser
Monitor ECG and have access to crash trolley
Check ABG for acidosis

54
Q

How are pre-renal and post-renal causes of AKI treated?

A

Pre-renal: fluid resuscitation with 0.9% saline (250-500 mL bolus) followed by infusion of 20 mL + last hour’s urine output
Post-renal: catheterise

NOTE: pulmonary oedema should be treated with furosemide IV

55
Q

List the indications for dialysis in AKI.

A

Hyperkalaemia unreponsive to medical treatment in an oliguric patient
Pulmonary oedema unresponsive to medical treatment
Uraemia (e.g. encephalopathy)
Severe metabolic acidosis (pH < 7.2)

56
Q

Outline the management of hypokalaemia.

A

Monitor U&E and ECG
40 mmol/L KCl in 1 L of 0.9% saline (unless oliguric –> insert catheter to ensure accurate assessment of urine output)
Admit to ICU for insertion of a central line if > 10 mmol/hr needed
If MILD: oral K+ supplementation (SandoK)

57
Q

Which investigations would be useful in a patient with hyponatraemia?

A

Hypovolaemic –> low urine sodium
Euvolaemic –> TFT, SST, plasma and urine osmolality
Hypervolaemic –> low urine sodium

58
Q

Outline the management of hyponatraemia.

A

Do NOT correct faster than 8-10 mmol/L/24 hrs
Hypovolaemic –> 0.9% saline
Euvolaemic –> fluid restriction

59
Q

Outline the management of hypocalcaemia.

A

Mild and asymptomatic: monitor, consider vitamin D supplements and calcichew
Severe tetany: 10 mL 10% calcium gluconate IV over 10 mins

60
Q

Outline the management of hypercalcaemia.

A

Correct dehydration with 0.9% saline (3-6 L in 24 hours with the first 1 L going in over 1 hour)
Furosemide may be needed in elderly patients who are prone to pulmonary oedema
Insert catheter to monitor urine output
IV bisphosphonate for bone pain (takes 1 week to work)

61
Q

Which investigations are important to order in patients with status epilepticus?

A 
U&E
FBC 
LFT
Glucose 
Calcium
Toxicology 
AED levels 
CT/MRI head
62
Q

Outline the management of status epilepticus.

A

Secure the airway (may need adjuncts)
STEP 1: Slow IV bolus of IV lorazepam 2-4 mg
Second dose if no response within 10 mins
Thiamine if alcoholism is suspected
Glucose 50 mL 50% IV if hypoglycaemia is suspected
STEP 2: IV phenytoin infusion 15-20 mg/kg at < 50 mg/min
STEP 3: rapid sequence induction with thiopental and EEG monitoring

63
Q

Outline the management of pneumonia.

A

Treat hypoxia and hypotension if necessary
Antibiotics following local guidelines (e.g. CAP = coamoxiclav and clarithromycin; HAP = tazocin)
Analgesia if pleuritic chest pain
CPAP if no improvement

64
Q

Which investigations should be requested in suspected pneumonia?

A

Bedside: oxygen saturation, ABG, sputum sample, urine sample (Legionella)
Bloods: FBC, U&E, CRP, atypical serology
Imaging: CXR

65
Q

Which investigations would you request in a patient with delirium?

A

Bedside: glucose, ABG, ECG, urine dipstick
Bloods: FBC, U&E, LFTs, blood glucose, blood cultures
Imaging: CXR, CT/MRI

66
Q

Outline the management of bradycardia.

A

Sit the patient up (unless dizzy)
15 L/min oxygen if hypoxic
Give 0.5 mg atropine IV every 2-3 mins (up to max 6 doses)
If unsuccessful –> isoprenaline 5 µg/min
If unsuccessful –> adrenaline 2-10 µg/min
If unsuccessful –> transcutaneous pacing

67
Q

Outline the management of hyperosmolar hyperglycaemic state (HHS/HONK).

A

Rehydrate slowly with 0.9% saline over 48 hours (deficit is typically 110-220 mL/kg)
Equated to 8-15 L for 70 kg adult
First 1 L may be given quickly over 30 mins
Replace K+ when urine starts to flow
Use a fixed rate insulin infusion if glucose is NOT falling by 5 mmol/L/hr with rehydration
Keep glucose at 10-15 mmol/L for first 24 hours (avoid cerebral oedema)

68
Q

If a nurse contacts you regarding a patient who has become unconscious, what should you tell them to do?

A

Check for respiratory effort/pulse and begin CPR if absent

69
Q

How should an Addisonian crisis be treated?

A

100 mg hydrocortisone STAT
Followed by 100 mg/8 hrs hydrocortisone

NOTE: they may need fludrocortisone, glucose and fluids

70
Q

What are the components of a SOFA score?

A 
Respiratory rate 
Bloodpressure 
GCS 
Liver (bilirubin) 
Coagulation (platelets) 
Renal (creatinine and urine output)

Sepsis = infection + increase of 2 or more on SOFA

71
Q

Outline the management of NSTEMI.

A

Give oxygen if breathless or SaO2 < 90%
Morphine 5-10 mg IV + antiemetic
Nitrates (GTN spray or sublingual)
Aspirin 300 mg PO + second antiplatelet agent (clopidogrel, ticagrelor, prasugrel)
Oral beta-blocker (e.g. metaprolol) if hypertensive/tachycardic/low LV function
Fondaparinux 2.5 mg OD SC or LMWH 1 mg/kg/12 hours SC
IV nitrate if pain continues
HIGH RISK PATIENT
- Features: rise in troponin, dynamic ST or T wave changes, risk factors
- Begin infusion of tirofiban and refer for inpatient angiography (within 72 hours)
- Angiography may need to be within 24 hours if GRACE score > 140

72
Q

Which additional measures may be used during the A to E approach of a trauma patient?

A

Check for blood on the floor
Arrange FAST scan/pelvic X-ray
For unstable pelvic fractures use a pelvic band to reduce blood loss

73
Q

Outline the algorithm for the major haemorrhage protocol.

A

Take baseline blood samples (FBC, G&S, X-match, Clotting, fibrinogen)
If trauma < 3 hrs: give tranexamic acid (1 g over 10 mins, then 1 g/8 hrs infusion)
Limit use of O-negative blood and use group-specific blood as soon as possible

74
Q

What is the definition of major haemorrhage?

A

Loss of more than one blood volume in 24 hrs
Loss of 50% blood volume in 3 hours
Bleeding in excess of 150 mL/minute

75
Q

Which extra parts of an A to E would you do in a patient with suspected spinal cord compression?

A

D - palpate for spinal tenderness and perform a lower limb neurological examination to assess tone, power, reflexes and sensation
E - percuss the bladder (urinary retention), perform a rectal examination (tone and saddle anaesthesia) - important to consider cauda equina as a differential

76
Q

Outline the management of cord compression.

A

Ix: urgent MRI whole spine within 24 hours
Rx: dexamethasone 16 mg PO
Discuss with neurosurgery
Definitive: RADIOTHERAPY or decompressive surgery

77
Q

What must be done before a CTPA is performed in a patient with suspected PE?

A

Check renal function and ask about allergy to contrast

78
Q

What must always be done before thrombolysing a patient?

A

Discuss with a senior

79
Q

What is Cushing’s reflex?

A

Irregular breathing (Cheyne-Stokes)
Hypertension
Bradycardia

80
Q

Who could angry patients be directed towards?

A

PALS

NOTE: always gain consent from the patient before discussing their care with a family member

81
Q

What is the first step in managing a patient with VT?

A

Put out a peri-arrest call

82
Q

What are the 4 Hs and 4 Ts of cardiac arrest?

A 
Hypoxia 
Hypovolaemia 
Hypokalaemia/hyperkalaemia 
Hypothermia
Toxic 
Thromboembolic 
Tamponade
Tension pneumothorax
83
Q

Which medications should be continued after correction of VT?

A

Establish and treat the cause

Maintenance: amiodarone infusion for 12-24 hours followed by oral sotalol or amiodarone

84
Q

How can recurrence of VT be prevented?

A

Ablation of arrhythmogenic area OR ICD

85
Q

Outline the management of hypothermia.

A 
Prepare crash trolley
Confirm temperature with low-reading thermometer (PR) and check every 30 mins 
Set up ECG (bradycardia and J waves) 
Remove wet clothing 
Give warmed humidified oxygen 
Slowly rewarm at 0.5 degrees per hour 
CARDIAC MONITORING IS ESSENTIAL
86
Q

What is the difference between the Glasgow Blatchford and Rockall scores?

A

Blatchford - used at first presentation

Rockall - used after intervention to determine risk of re-bleed/death

87
Q

Which investigations are important to request in someone who has taken a paracetamol overdose?

A 
Paracetamol levels (4 hrs post-dose) 
LFTs 
Clotting studies 
U&E 
FBC 
Bone profile 
ABG (acidosis and lactate)
88
Q

Outline the management of bowel obstruction.

A 
IV 0.9% saline 
5-10 mg morphine IV 
NBM 
NG tube aspiration 
Correct electrolyte imbalance 
Consider giving antibiotics if septic/perforated (co-amoxiclav and gentamicin)
89
Q

Outline the management of acute limb ischaemia.

A

URGENT open surgery and angioplasty
ALERT the vascular surgeons
If embolic: surgical embolectomy or thrombolysis (tPA)
Anticoagulate with LMWH after either procedure and look for source of emboli (e.g. AF, aneurysms)
WARNING: post-op reperfusion injury can lead to compartment syndrome
Compartment syndrome is treated with fasciotomy
It is very painful so patients should be given morphine

90
Q

Who is part of the cardiac arrest team?

A 
Medical team on call (Med reg, SHO, FY1)
Anaesthetist 
Nurse 
Porters 
CCOT
91
Q

What are some contraindications for NIV?

A

Pneumothorax

Drowsiness

92
Q

For the treatment of hyperkalaemia, what do you mix the insulin in?

A

10 U Actrapid in 100 mL of 20% dextrose given over 30 mins

PACES (13 decks)

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