Emergencies & Trauma

Question 1

What are the causes of shok=ck?

Answer 1

CHOD

Cardiogenic - MI, arrhythmia

Hypovolaemic - haemorrhage, endocrine (Addisons/DKA), Excess loss

Obstructive - PE, tension pneumo

Distributive - sepsis, anaphylaxis, neurogenic

Question 2

What medications and doses should be given in anaphylactic shock?

Answer 2

500mcg adrenaline (0.5ml of 1:1000)
200mg hydrocortisone
10mg chlorphenamine
salbutamol nebs

Question 3

What type of shock would you not prescribe fast fluid resuscitation for?

Answer 3

Cardiogenic

Question 4

What blood test should be done to confirm the diagnosis of anaphylactic shock?

Answer 4

Mast cell tryptase (released by mast cell degranulation due to IgE cross linking)

Question 5

What should be done before discharge of a patient with anaphylactic shock?

Answer 5

Teach adrenaline self injection and provide >=2 epipens
Advise medic alert bracelet
Educate re allergen exposure
Arrange OPD followup

Question 6

What are the four classes of SVT?

Answer 6

Sinus tachy

Atrial (AF, flutter, tachy)

AVNRT

AVRT

Question 7

What is the management priniciple of SVT?

Answer 7

§ If adverse signs, sedate and DC cardiovert

N-B - If pt in AF:

a) Rate cont w. B blocker or digoxin
b) Cardiovert w amiodarone if <=48 hours/DC shock
c) Consider heparin

1. Vagal manouvres (carotid sinus massage, valsalva)
2. Adenosine 6mg IV bolus, then 12, then 12
3. Choose from Digoxin, Atenolol, Verapamil, Amiodarone
4. DC Cardiovert

Question 8

What signs in an SVT patient might prompt you to skip adenosine and immediately DC cardiovert?

Answer 8

BP<90
HF
LoC
HR>200

Question 9

What are the side effects of adenosine?

Answer 9

Feeling of impending death
Dyspnoea
Flushing
Headache

Question 10

What are the differential sfor a broad complex tachy?

Answer 10

VT
TdeP
SVT w BBB

Question 11

What are the causes of VT?

Answer 11

IM QVICK

Infarction
Myocarditis
QT prolongation
Valve abnormality
Iatrogenic 
Cardiomyopathy (dilated)
K/Mg/02 low

Question 12

What is the management of a broad complex tachy?

Answer 12

1. Assess for adverse signs
   a) If present -> sedate + DC
   b) If not -> 2.
2. Correct electrolyte imbalance (KCl/MgSO4)
3. Assess rhythm:
   a) Regular (VT) -> Amiodarone 300mg over 30 mins then 900mg over 23 hrs
   b) Irregular - AF (rate control)
4. If failure -> DC cardiovert

Question 13

What drugs are given acutely in STEMI?

Answer 13

Oxygen 2-4L aiming for 94-98%

Antiplatelets:
Asp 300 PO then 75mg daily
Clopi 300 PO then 75 daily

Analgesia:
Morphine 5-10mg IV
Metoclopramide 10mg IV

Anti-ischaemia:
GTN
B-Blocker e.g. atenolol 5mg IV

DVT proph:
Enoxaparin 40mg SC OD

Question 14

What is the secondary prevention regimen for STEMI?

Answer 14

ACEi started <24hrs post MI
B-blocker e.g. bisoprolol
Cardiac rehab
DVT proph till fully mobile
Atorvastatin 80
Continue Clopi for1 month
COntinue Aspirin indefinitely

Lifestyle - smoking, diet, exercise

Question 15

What are the causes of cardiogenic shock?

Answer 15

MI HEART

MI
Hyperkalaemia
Endocarditis
Aortic dissection
Rhythm disturbance
Tamponade

Question 16

What drug should be considered in cardiogenic shock?

Answer 16

Dobutamine (B-agonist)

Question 17

What are the signs seen in cardiac tamponade?

Answer 17

Beck’s triad:
Hypotension
Raised JVP
Muffled heart sounds

Kussmaul’s sign - Raised JVP on inspiration

Pulsus paradoxus - pulse fades on inspiration

Question 18

What medications should be given in suspected bacterial meningitis?

Answer 18

Community - IM Benpen
<50 - Ceftriaxone 2g
>50 - Cef 2g & Ampicillin 2g
Dexamethasone

Question 19

What is the first step in the management of encephalitis?

Answer 19

10mg/kg/8hr IVI Aciclovir

Question 20

What is done/looked for on A-E in head injury?

Answer 20

A - ?intubate, immobilise C-spine
B - 100% O2, RR
C - HR, BP, IV access
D - GCS, pupils, treat seizures
E - Expose for other injuries

Question 21

What should be looked for on 2ary survey in head injury?

Answer 21

Lacerations
Skull deformation
CSF leakage
Skull base fracture signs
TM blood
C-spine tenderness

Question 22

When would you do a CT scan for a head injury?

Answer 22

BANGS LOC

Break/depressed/base of skull
Amnesia >30 mins
Neuro deficit/seizure
GCS <13 @ any time or <15 2 hrs post injury
Sickness - >= 1 vomit
LOC w. dangerous mechanism, age>65 or coagulopathy

Question 23

What is neuroprotective ventillation and when is it used?

Answer 23

Aim for:
PaO2>13kPa
PaCO2 4.5kPa

Used in case of raised ICP

Question 24

What are the different types of herniation?

Answer 24

Tonsillar - cerebellum through posterior fossa

Transtentorial/uncal - temporal lobe against free margin of tentorium cerebelli

Subfalcine - Cingulate gyrus (MFL) under falx cerebri

Question 25

What is used to treat b-blocker poisoning?

Answer 25

Atropine

Question 26

What is used to treat ethylene glycol poisoning?

Answer 26

Ethanol

Haemodialysis

Question 27

What is used to treat lithium toxicity?

Answer 27

Saline

Question 28

When would you use activated charcoal for an aspiriin/paracetamol OD?

Answer 28

IF ingested <1hu=r

Question 29

What are the components of the secondary survey in trauma?

Answer 29

Hx - allergies, meds, PMH, last ate/drank, events

Exam - every system

Ix
Trauma series (C spine lat + peg, CXR, pelvis)
FAST scan (focussed assessement sonography in trauma), CT when stable)

Question 30

What is a FAST scan?

Answer 30

Basically an abdo USS looking for free fluid