EMERGENCIES- all topics

Question 1

What is adrenaline?

Answer 1

This is a sympathomimetic agent with both alpha and beta adrenergic stimulating properties

Question 2

What is adrenaline used for and what are the doses?

Answer 2

anaphylaxis: 0.5mg 1:1,000 IM

cardiac arrest: 1mg every 3-5 minutes as required, a 1 in 10,000 solution is recommended

Question 3

What should alcoholic patients be offered, nutrition wise?

Answer 3

SIGN recommends alcoholic patients should receive oral thiamine if their ‘diet may be deficient’

Question 4

What are the drugs used for alcohol withdrawal?

Answer 4

Benzodiazepines are used for acute withdrawal

Disulfram promotes abstinence

alcohol intake causes severe reaction due to inhibition of acetaldehyde dehydrogenase. Patients should be aware that even small amounts of alcohol (e.g. In perfumes, foods, mouthwashes) can produce severe symptoms. Contraindications include ischaemic heart disease and psychosis

acamprosate: reduces craving, known to be a weak antagonist of NMDA receptors, improves abstinence in placebo controlled trials

Question 5

When is allopurinol used and what is it’s mechanism of action?

Answer 5

Allopurinol is used in the prevention of gout. It works by inhibiting xanthine oxidase.

Initiating allopurinol prophylaxis
it has traditionally been taught that urate-lowering therapy (ULT) should not be started until 2 weeks after an acute attack, as starting too early may precipitate a further attack. The evidence base to support this however looks weak

Question 6

What can be used when starting a patient on allopurinol?

Answer 6

Colchicine cover should be considered

Question 7

What are the risks of allopurinol?

Answer 7

The most significant adverse effects are dermatological and patients should be warned to stop allopurinol immediately if they develop a rash:
severe cutaneous adverse reaction (SCAR)
drug reaction with eosinophilia and systemic symptoms (DRESS)
Stevens-Johnson syndrome

Certain ethnic groups such as the Chinese, Korean and Thai people seem to be at an increased risk of these dermatological reactions.

Patients at a high risk of severe cutaneous adverse reaction should be screened for the HLA-B *5801 allele.

Question 8

What are alpha blockers used in?

Give examples of alpha blockers

Answer 8

They are used in the management of BPH and hypertensiom

Doxasozin and tamsulosin

Side effects…

• postural hypotension
• drowsiness
• dyspnoea
• cough

Caution should be exercised in patients who are having cataract surgery due to the risk of intra operative floppy iris syndrome

Question 9

What are the adverse reactions with Amiodarone?

Answer 9

Adverse effects of amiodarone use
thyroid dysfunction: both hypothyroidism and hyper-thyroidism
corneal deposits
pulmonary fibrosis/pneumonitis
liver fibrosis/hepatitis
peripheral neuropathy, myopathy
photosensitivity
'slate-grey' appearance
thrombophlebitis and injection site reactions
bradycardia
lengths QT interval

Important drug interactions of amiodarone include:
decreased metabolism of warfarin, therefore increased INR
increased digoxin levels

Question 10

How does aspirin work?

Answer 10

It works by blocking the action of both cyclooxygenase 1 and 2 (cyclooxygenase is responsible for prostaglandin, prostacyclin and rhromboxane synthesis)

Question 11

When is clopidogrel used?

Answer 11

First line for ischaemic heart disease

Can be used in ischaemic stroke and TIAS, however….

NICE now recommend clopidogrel first-line following an ischaemic stroke and for peripheral arterial disease. For TIAs the situation is more complex. Recent Royal College of Physician (RCP) guidelines support the use of clopidogrel in TIAs. However the older NICE guidelines still recommend aspirin + dipyridamole - a position the RCP state is ‘illogical’

Question 12

What does aspirin potentiate?

Answer 12

Oral hypoglycaemics
Warfarin
Steroids

Question 13

Who shouldn’t aspirin be used in?

Answer 13

Shouldn’t be used in children under 16 due to the risk of Reye’s, an exception is kawasaki where the benefits outweigh the risk

Question 14

What are the features of a beta blocker overdose?

Answer 14

bradycardia
hypotension
heart failure
syncope

You can use atropine for this

Question 15

What is hyrdrocortisone, when is it used, what dose do you use?

Answer 15

It is a corticosteroid- it has equal glucocorticoid and mineralcorticoid activity

It is used in anaphylaxis and in severe acute asthma

Asthma= (can be used IV if patients can’t tolerate oral prednisolone- 100mg every 6 hours until conversion to oral pred is possible

Anaphylaxis= 100-300mg administered as sodium succinate

Question 16

What is the management of anaphylaxis in adult?

Answer 16

Remove trigger if possible
Call for help early
ABCDE assessment
Administer oxygen and
Lie patient flat and raise legs
Administer adrenaline (Adult dose is 500 micrograms IM)
Administer chlorphenamine and hydrocortisone
IV fluid challenge if hypotensiv

When skills and equipment are available:

Manage airway
Attach patient to monitoring
Consider Intensive Care referral

Question 17

What is the dose of chlorphenamine for adult allergic reactions?

Answer 17

10mg, repeated as necessary, max 4 doses per day

Question 18

How do you manage anaphylaxis in children?

Answer 18

Remove trigger if possible 
Call for help 
Lie patient flat and lift their legs 
A —> E assessment 
Administer adrenaline

Question 19

The management of a STEMI can be remembered as MMONAC, what does this stand for?

Answer 19

Morphine
Metoclopramide
Oxygen ( if sats <94%) 
Nitrates (GTN) 
Aspirin 300 mg 
Clopidogrel 300mg (although similar drugs are now being used as alternatives- ticagelor)

Question 20

What is the acute management of ischaemic stroke?

Answer 20

A- E 
Airway protection (in impaired consciousness) and aspiration precautions (swallowing problems) are very important

Question 21

How does alteplase work?

Answer 21

It is a tissue plasminogen activator

Question 22

When should you start aspirin following a stroke?

Answer 22

If hyper acute treatment are not offered then aspirin 300mg should be started immediately once daily for two weeks

If hyper acute treatments are offered then aspirin is usually started 24 hours after the treatment following a repeat CT head that excludes any new haemorrhage stroke

Question 23

What is the chronic management of an ischaemic stroke?

Answer 23

Can be remembered by HALTTS

H= Hypertension= studies show there is no benefit in lowering the blood pressure acutely (may impair cerebral perfusion) unless there is malignant hypertension, however antihypertensives should be initiated 2 weeks post stroke

A= Anti platelet therapy- patients should be administered clopidogrel 75mg OD for long term anti platelet therapy

HOWEVER IF THEY HAD A STROKE DUE TO AF YOU GIVE AN ANTICOAGULANT INSTEAD- DOAC (RIVAROXABAN/APIXABAN) OR WARFARIN 2 WEEKS AFTER THE STROKE

LIPID LOWERING THERAPY- ATORVASTATIN 20-90MG ONCE NIGHTLY

Tobacco- offer smoking cessation support
Sugar- screen for diabetes and manage appropriately
Surgery- Patients with ipsilateral carotid artery stenosis more than 50% should be referred for carotid endarterectomy

Question 24

What is a PE?

Answer 24

Sudden blockage of a major blood vessel of the lung, usually by a clot

Question 25

What are the risk factors for PE?

Answer 25

Can be remembered as A EMBOLISM…

A= Age 
Ex= previous DVT/PE 
M= MALIGNANCY- CANCER CARE 
B= BABY (PREGNANCY)- OBSTRETICS
O= Oestrogen (OCT/HRT) 
L= Large (obesity) 
I= immune conditions/ inherited thrombophilias- antiphospholipid/ factor V Leiden 
M= MOBILITY (OPIC)

Question 26

What are the ECG findings in a PE?

Answer 26

The most common in SINUS TACHYCARDIA
Other features- right heart strain (RBBB, right axis deviation, T wave inversion, ST segment changes)
S1Q3T3 (S wave in lead 1, Q and T wave inversion in lead 2)

Question 27

How do you investigate a pregnant woman with a PE?

Answer 27

• don’t do D dimers
• Do a CXR, ECG, V/Q perfusion scan or CTPA (CTPA in preference to V/Q when clinical suspicion of PE and CXR is abnormal)
• complex duplex ultrasound if they are suspected of having a DVT

You also need to take some bloods before commencing pregnant women on anticoagulation

• FBC
• U and ES
• Coagulation screen
• Liver function tests

Question 28

How do you manage a a pregnancy woman with DVT/PE?

Answer 28

LMWH if strong clinical suspicion you shouldn’t wait for IX to come back
The LMWH dose should be based on the booking clinic/ early pregnancy weight

Enoxaparin should be given for the duration of the pregnancy
Warfarin should not be given- it has a teratogenic effect although its use preclude breast feeding

Approaching delivery of the baby discuss with the obstretic team and consider the following…

1) substitute with unfractionated heparin, as this can be reversed readily
2) 6 hours before delivery you want to stop or reduce the heparin dose

Question 29

What are massive PEs?

Answer 29

PEs which are significant enough to cause circulatory collapse

Question 30

How do you investigate a PE normally?

Answer 30

Wells score
If it is low then D dimer
If high then CTPA

ECG

Question 31

What is the usual treatment of a PE?

Answer 31

LMWH followed by an oral anticoag treatment (rivoroxaban, dabigatran)