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Emergency Flashcards

1
Q

Drugs that can cause hypoglycemia

A

Excess antidiabetic agents - insulin, glicazide

Excess paracetamo, apsirin, sulphonylureas

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2
Q

Treatment of hypoglycemia
1- conscious + can swallow
2- conscious+ cant swallow
3-unconscious

A

1- 200ml fruit juice oral oral glucose gel
2- 200ml 10% glucose IV or 1mg glucagon IM or SC
3- IV 75ml of 20% glucose or 1 mg glucagon IM or SC

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3
Q

When is glucagon ineffective in the treatment of hypoglycemia

A

Alcohol related hypoglycemia

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4
Q

Wallace rule of 9

A 
Each full arm - 9
Head+ neck = 9
Ant leg = 9
Post leg = 9
Ant chest = 9
Post chest = 9
Ant abdomen = 9
Post abdomen = 9 
Perineum = 1%
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5
Q

Superficial epidermal burn appearance

1st degree

A

Red + painful

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6
Q

Pale pink painful blistered skin after house fire

Type of burn?

A 
Partial thickness (superficial dermal)
2nd degree
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7
Q

Non blanching erythema, reduced sensation at site of burn

Type of burn

A

Partial thickness, deep dermal

2nd degree

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8
Q

White/ brown/black burn
No blisters
Not painful
Type?

A

Full thickness

3rd degree

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9
Q

Immediate management burns
Thermal
Chemical
Electrical

A

ABC
Remove non adherent clothing
Thermal - remove them from source of heat, irrigate wound with cool water b/w 10-30 mins, cover with cling film (layered not wrapped)
Chemical - brush any powder off and then irrigate for 1 hour - do not attempt to neutralise

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10
Q

When to refer to secondary care in burn cases

A

All full thickness cases
Deep dermal > 5 % in adults, all deep dermal burns in children
Superficial dermal burns - face hands feet, perineum, genitalia, flexures or circumferential burns of abdomen , limbs or torso or neck
Any inhalation injury
Any electrical or chemical burn
Suspicion of non accident injury

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11
Q

Management of burns

A

ABC, referral criteria
Sup epiderm al analgesia, emollient
Sup dermal - cleanse wound, leave blister intact
= avoid topical creams and apply non adherent dressing - review 24 hrs

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12
Q

Management of severe burns

A

Stop burn process and resuscitate
Analgesia
IV fluids , insert catheter
= > 10% TBSA in children , >15% in adults
Echarotomies - in circumferential full thickness burns of torso or limbs

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13
Q

IV fluid calculation in burns

Parkland formula

A

TBSA% x Kg x 4 = ml
50% given in first 8 hrs
50% over best 16 hrs

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14
Q

Starting point of resuscitation in burns

A

Time of injury

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15
Q

Referrals for burns (burns unit)

A

> 5% children
10% adults

Give IV fluids if > 10, 15% adults

Burns of hands perineum face

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16
Q

RFs for paracetamol overdose

A

Liver enzyme inducing drugs - CRAP GPs
Malnourished patients - anorexia, bulimia, hepatitis C , cystic fibrosis, HIV
Patient who have not eaten for few days

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17
Q

Management

  • investigations
  • treatment
A

FBC UE LFT INR blood gas glucose
-Serum paracetamol @ >=4 hr post ingestion if >150mg/kg consumed or unknown amount (NOT post admission)
-Admit anyone with ingestion within 8 hrs >150mg/kg (>24 pills) or unknown amount
- if presents within 1 hr with >150mg/kg - activated charcoal
-N- acetyl cysteine = 5 situations
Liver transplant

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18
Q

When should n acetyl cysteine be given in paracetamol overdose (5)

A
  • staggered overdose - all tablets were not taken within 1 hr
  • doubt over paracetamol ingestion - regardless of plasma paracetamol concentration
  • if plasma conc paracetamol (@ 4 hrs) is above appropriate line
  • > 8hrs (late presentation) + ingested >150mg/kg or dose unknown
  • jaundice or liver tenderness
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19
Q

Features of paracetamol poisoning

  • 24 hrs
  • 48 hrs
A

Initial - nausea , vomiting, pallor
24 0- hepatic enzymes rise
48- jaundice, enlarged liver

Hypoglycaemia, hypotension, encephalopathy, coagulopathy, coma can also occur

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20
Q

Liver transplant criteria in paracetamol overdose ?

A 
Arterial ph <7.3, 24 hrs after ingestion 
Or all of the following :
- PT > 100 s
- creatinine > 300 umol/l
- grade III or IV encephalopathy
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21
Q

Hepatic encephalopathy grading

A

1 - behavioural changes, mild confusion, slurred speech, disordered sleep
2- lethargy, moderate confusion
3- stupor, incoherent speech, sleeping but arousable
4- coma, unresponsive to pain

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22
Q

Aspiration of FB in child

Next step?

A

Indirect laryngoscopes +- fibre optic examination of pharynx

If ^ not given and you see direct , pick that

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23
Q

Magills forecps

Where are they used?

A

Direct laryngoscopy

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24
Q

Treatment of opioid overdose

A

IV naloxone
- fast action , short duration

Can be repeated every 2-3 minutes if no response
Shorter half life than methadone

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25
Q

Features of opioid overdose (4)

A

Symmetrical Miosis
Respiratory depression
Bradycardia
Altered consciousness

= low RR BP HR and pinpoint pupils

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26
Q 
NICE guidelines on head injury - 
Immediate CT (within 1 hr )
Adults (7)
A
  1. GCS <13
  2. GCS <15 @ 2hrs post injury
  3. Open/depressed skull frx
  4. Any sign if basal skull fracture
  5. post traumatic seizure
  6. Focal neurological deficit
  7. > 1 episode of vomiting
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27
Q

Signs of basal skull fracture (4)

A

Haemotympanum
Panda eyes
CSF leakages - ear nose
Battles sign

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28
Q

NICE guideline CT head - head injury
Within 8 hours
Adults (6)

A

Adult + Loss of consciousness or amnesia + RFs:

  • > = 65 years old
  • history of bleeding or clotting disorders/ on warfarin
  • dangerous mechanism of injury
  • > 30 mins of retrograde amnesia - can’t remember events before injury
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29
Q

What GCS is an indication for intubation

A

= 8

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30
Q

CT guidelines head injury - within 1 hr

Children (6)

A 
Seizure
GCS < 14 - initial assessment 
GCS <15 after 2 hrs of injury
Basal skull fracture signs 
Tense fontanelle/open skull fracture/ depressed fracture
Focal neuro deficit
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31
Q

CT head within 1 hr in children

According to RF in head injury (6)

A 
Head injury + >/= 2 of the following 
- LOC >/= 5 mins
Amnesia >/= 5 mins
>/= 3 episodes vomiting 
FFH> 3 metres
RTA high speed
Abnormal drowsiness

If only 1 RF - observe for at least 4 hrs after injury

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32
Q

Management of anaphylaxis

A

ABC , high flow O2, lay patient flat
IM adrenaline - ant lateral aspect middle 1/3 thigh
Observe for 6-12 hrs after onset of symptoms
Serum tryptase - sometime taken to establish anaphylaxis
- remain elevated up to 12 hrs
If hypotensive - give IM adrenaline 1st then IV fluids

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33
Q 
Doses of epinephrine/hydrocortisone/chlrophenamine 
<6 mo
6mo - 6 years
6-12 years
Adults/ children > 12
A

<6 mo - 150mcg/ 25mg / 250mcg/kg
6-6 yrs - 150mcg / 50mg / 2.5mg
6-12 - 300 mcg / 100mg/ 5 mg
Adults - 500 mcg / 200mg / 10 mg

Adrenaline/ epinephrine
(MCG/1000= ml ) 1 in 1000
E.g 0.15 ml 1 in 1000

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34
Q

What causes tingling in panic attacks

A

Hypocalcemia

- caused by resp alkalosis due to CO2 washout

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35
Q

Management of panic attacks

A

Upcoming attack - beta blocker
During : Breathing excercise - paper bag
If severe and ongoing
- benzo

Long term - CBT , SSRIs

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36
Q

Diaphragmatic rupture

  • dx
  • features
A

Chest and abdominal pain , resp distress, diminished breath sounds
Usually left side affected

Dx - initial - CXR - unreliable (curt NGT in stomach is pathognomonic)
Thoracoabdominal CT - diagnostic

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37
Q

Confusion + ataxia + squint in
chronic alcoholics
Treatment

A

Chronic alcohol syndrome
Urgent IV thiamine
Vitamin B1

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38
Q

Confusion ataxia and squint
+ retrograde amnesia + confabulation
Dx?

A

Wernicke’s korsakoff syndrome

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39
Q

Aspirin overdose
Symptoms - earliest, clinically significant
Acid-base abnormality

A

Tinnitus , impaired hearing - early

Hyperventilation, nausea, vomiting, dehydration fever double vision
Feeling faint

Early - resp alkalosis
Late - metabolic acidosis

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40
Q 
Excessive sedation, dry mouth, skin
Tachycardia, dilated pupils 
ECG - prolonged QRS, QT, PR 
Suspected overdose?
Treatment?
A

TCA
IV fluid bolus 250ml NS
IV sodium bicarbonate 50-100ml 8.4% slowly - corrects ECG changes
Aim for pH 7.5-7.55

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41
Q

Organophosphate overdose

Features

A 
Increased saliva ,tear production, diarrhoea
Vomiting 
Small constructed pupils
Sweating 
Muscle tremors
Confusion
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42
Q

Plummer Vinson syndrome
Triad -
Treatment

A

Dysphagia
Glossitis
IDA

Treatment - iron supplementation, dilation of webs

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43
Q

Boerhaave syndrome

A

Severe vomiting - oesophageal rupture

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44
Q

Management of Mallory Weiss tear

A

If vitally stable and hemodynamically stable =
- discharge with advice or repeat FBC or observe vitals for fear of deterioration

Discharge low risk blatchford score patients

Severe - resuscitation ( high flow O2, IV fluids, IV blood)

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45
Q

Blatchford score : low risk

A 
SBP >/= 110
Urea < 6.5 
Hb >/= 13 males or >/= 12 females 
Pulse < 100 
Absence of melena , liver disease, HF, syncope
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46
Q

Admission and early endoscopy for GI bleed + calculation of Rockall score if :

A

SBP <100 and pulse >/= 100 - hemo disturbance
Continued bleeding
Age >/= 60, all patients over 70 should be admitted
Liver disease, HF , known varices

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47
Q

Class 1 hemorrhage can shock

A 
<750 ml blood loss / <15%
Pulse < 100
Normal BP
RR 14-20
UO >30 ml 
Normal sx
48
Q

Class II hemorrhagic shock

A 
750-1500 ml blood loss (15-30%)
Pulse 100 199
Normal BP
RR 20-30
UO. 20-30 ml 
Anxious
49
Q

Class III hemorhhagic shock

A 
1500-2000 ml blood loss / 30-40%
Pulse 120-139
Decreased BP 
RR 30-40
UO 5-15ml 
Confused
50
Q

Class IV hemorhhagic shock

A 
>2000 ml blood loss / >40%
Pulse > 140 
Decreased BP 
UO < 5 ml 
Lethargic
51
Q

CO poisoning
Causes
Features
Investigation of choice

A

Cause - car exhaust, fires, faulty gas heaters, paints
Paint = methylene chloride (dichloromethane) from paint fume

IOC - carboxyhaemoglobin levels

Features- severe dizziness, headache (tension), malaise, vomiting
If severe - pink skin and mucosa, fever, hyperventilation, arrhythmia, coma

52
Q

Management of CO poisoning

A

ABC
100% oxygen via tight fitting mask - if conscious
If unconscious / SBP <100 - intubate + ventilate IPPV 100% O2

53
Q

Management of upper GI bleed due to varices

A
  1. Initial step - IV fluids
    2- terlipressin - 2mg IV repeat every 4-6 hrs + prophylactic antibiotics
    - cipro or cephalosporin
    3- endoscopy -
    Oesophageal - band ligation
    Gastric -N butyl 2 cyanoacrylate inj
  2. Transjugular intrahepatic portsystemic shunt (TIPS) - if bleeding not controlled with above measures

Avoid PPI unless known peptic ulcer pt
INR prolonged - Vitamin K
Liver disease + haematemesis + raised INR = FFP
Active bleeding + Plt < 50000 - transfusion of platelet s

54
Q

Pelvic fracture with urinary retention

Next step

A

Suprapubic catheter
- why?
= post urethral tear usually associated with pelvic frx

55
Q

When should you suspect urethral injury in pelvic frx

How do you manage it?

A

perineal bruising, blood at external meatu s
PR = abnormal high rising prostate or inability to palpate prostate

Refer to urology - suprapubic cath +- retrograde/ascending urethrogram imaging to assess injury

56
Q

Management of flail chest

A

Avoid over hydration and fluid overload
1-Vitally stable + normal vitals + normal sats
= analgesia
- paracetamol/NSAIDs/opiates/intercostal block*/thoracic epidural up to T4

2- vitally unstable
= ABC / high flow O2 and analgesia

3-drowsy, laboured breathing, worsening RR
- intubate (double lumen ETT)

57
Q

Hereditary angioedema
Cause?
Inheritance pattern

A

Autosomal dominant

Low plasma levels of C1 esterase inhibitor (C1-INH) protein - during attack
Low C2 C4
Serum C4 - most reliable , screening tool

58
Q

Hereditary angioedema

- symptoms

A

Recurrent episodes of facial and tongue swelling
Family history
Attacks may be proceeded by painful macular rash
Occasionally presents as abdominal pain - viscera oedema

Urticaria not really a feature

59
Q

Hereditary angioedema
- management
= acute , prophylaxis

A

Acute
- IV C1 inhibitor concentrate
^ FFP if not available

Prophylaxis
- anabolic steroid Danazol may help

60
Q

When does heroin withdrawal begin & peak

A

12 hours after last dose - starts

Peak - 24-48hrs

61
Q

When does benzodiazepine withdrawal begin

A

1-4 days - begins

Peaks @ 2 weeks

62
Q

Cocaine

  • withdrawal starts
  • peaks at
A
  • within hours of last dose

Peaks in few days

63
Q

Alcohol withdrawal sx

  • 6-12 hours
  • incidence of seizure
  • delirium tremens
A

Sx - tremors sweating tachycardia anxiety
Seizure - 36. Hrs is peak incidence
Peak incidence of delirium - 48-72 hrs
= coarse tremor , confusion, delusions, auditory and visual hallucinations, fever, tachycardia

64
Q

Management of acute alcohol

A

1 - Chlordiazepoxide (benzodiazepine)
2- if seizure use - lorazepam or diazepam
3- vitamin B1 - IV pabrinex

65
Q

Drug for alcohol abstinence

A

Disulfiram

66
Q

Drug to reduce craving for alcohol withdrawal

A

Acamprosate

67
Q

Metabolic disturbance in ecstasy overdose

A

Metabolic acidosis

- increased venous lactic acid

68
Q

Sx of ecstasy overdose

A

Tachycardia tachypnea
Thirst
Agitation confusion
Hyperthermia, spots of colours (flashing)
Uncontrolled body movements, muscle rigidity

69
Q

Treatment of ecstasy

A

Supportive : ABC + treat metabolic acidosis
IV diazepam or lorazepam - for agitation
Dantrolene for hyperthermia

70
Q

LSD overdose

Sx

A 
Delusions and hallucinations
Mydriasis 
Flushing sweating TremorsHyperreflexiaDiarrhoea
Paraesthesia 
Smells colours sees sounds 
Sees colours when eyes are closed
71
Q 
Thoracic aortic rupture
Clinical features
CXR changes
Site injured commonly 
Dx
A

Contained hematoma = persistent hypotension
CXR - wide mediastinum, trachea/oesphagus to the right
Dx - CT aortogram
Proximal descending aorta

72
Q

Femur frx management

A

Stable (SBP >100 ) - Thomas splint first, then IV fluid ABCDE
- align frx to reduce further blood loss

Not stable ABCDEs (ATLS)

73
Q

Burn injury + evidence of airways obstruction

What do you do?

A

Cal senior ED/ anaesthetist

Urgent tracheal intubation

74
Q

CPR ratio

A

Adults - 30:2
Paeds
- layman 30:2
- professional 15:2

75
Q

Splenic trauma

Management

A

FAST US - Iofchoice or CT scan- subcapsular hematoma
Stable - observation
Unstable + free peritoneal fluid - emergency laparotomy

76
Q

Urticaria

Treatment

A

Oral antihistamine

IM adrenaline - if in anaphylactic shock

77
Q

Unilateral dilation of pupil

Suspect

A

Space occupying lesion

78
Q

Bilaterally constructed pupils

Suspect

A

Opiate overdose - heroin morphine

CVA affecting brainstem

79
Q

Bilaterally dilated pupils

A

TCA overdose

Cocaine overdose

80
Q

Side effects of benzodiazepines

A 
Respiratory distress - apnea
Hypotension 
Anterograde amnesia
Sedation
Cognitive impairment
81
Q

Mild vs severe airway obstruction

Treatment

A

Mild - able to speak , cough, breathe
Severe - wheezy breath, silent coughs

Mild - encourage them to cough

Severe - 5 back blows if unsuccessful - 5 Heimlichs or for kids < 1 yr - 5 chest thrusts

If unconscious - call ambulance , start cpr

82
Q

Aspirin and paracetamol cause what metabolic disturbance

A

Metabolic acidosis

Aspirin/as;icy late - early = resp alkalosis
Late = met acidosis

83
Q

ACEi and NSAIDS

A

Metabolic alkalosis

84
Q

Acid base disturbance caused by benzodiazepines

A

Respiratory acidosis

85
Q

MAIIAD

A 
Metabolic acidosis drugs 
Metformin
Aspirin 
Isoniazid 
Iron
Alcohol
Digoxin
86
Q

Causes of metabolic acidosis

A

MAIIAD
Diarrhoea
Renal insufficiency
Addisons

87
Q

Metabolic alkalosis causes

A 
ACEi, NSAIDs
Diuretic
Vomiting 
Hypovolemia, HypOkalemia 
2ry hypoparathyroidism
88
Q

Respiratory acidosis causes

A

Any cause of airway obstruction
Benzos, organophosphates
COPD
Pneumothorax, haemothorax, ascites

89
Q

Respiratory alkalosis causes

A 
Any cause of hyperventilation - high RR
Pulm embolism 
Salicylate, aspirin (early poisoning)
Mechanical ventilation - rapid ventilation
Panic attack
90
Q

Mixed acidosis seen in

Treatment

A

Cardiac arrest

Low pH, high pCo2, low HCO3
= accumulation of CO2 , kidneys not perfused due to low cardiac output

Increase ventilation

91
Q

Pulmonary embolism vs panic attack

A

Respiratory alkalosis
PE - low PaO2
PA - normal PaO2

92
Q

qSOFA

A

Heightened risk of mortality if score = or > 2
RR > 22/min
Altered mental state
SBP <100

93
Q

Red flag sepsis criteria

A 
Unresponsive/ responds to voice or pain
SBP = 90 or >40 mm drop from normal
HR > 130
RR >/= 25 /min 
UO /= 2 mmol/l
94
Q

Sepsis 6

A 
Started if any red flags seen 
Admit patient 
Give 3 
1.High flow oxygen 
2. IV fluids - 500ml bolus over <15mins 
3. IV broad spectrum ABx 
Take 3
1.blood culture 
2. FBC UE clothing’s lactate 
3. UO hourly
95
Q

TCA overdose immediate management

A

ECG - widened QRS, PR,QT, broad complex tachy

Iv fluid NS bolus. + sodium bicarbonate 8.4% slow IV injection

96
Q

Indications for adrenaline

A 
SOB 
Stridor 
Hoarseness
Wheeze
Shock
Swelling tongue face cheek
97
Q

Hypovolemic shock - physiology

A

Early -
Loss of blood - stretches the receptors in the atria > the baroreceptors in the aorta activated > vasomotor centre stimulates efferent output > catecholamine release > increased sympathetic activity
= vasoconstriction,arteriolar constriction and tachycardia to maintain blood

Late
Decreased GFR - aldosterone & ADH activated - salt and water reabsorption - activation of thirst centr e - maintain volume

98
Q

Toxic shock syndrome

Diagnostic criteria

A

S.aureus
- fever>38.9
- SBP <90
- diffuse erythematous rash
- desquamation of rash - palms soles
- involvement of 3 or more organ systems
= renal failure, hepatitis , thrombocytopenia , CNS, mucous membrane erythema , GI sx

  • high WBC plts <100,000
99
Q

Absent left psoas shadow on abdominal X ray

FAST US = free peritoneal fluids

A

Splenic rupture

100
Q

Diagnostic imaging for splenic rupture and treatment

A

CT abdomen

Urgent surgery

101
Q

Treatment of costochondritis

A

Self limiting

Mild analgesics and NSAIDs

102
Q

Liver disease + haematemesis + high INR
Treatment
Most appropriate initial step

A

FFP

Initial - IV fluid

103
Q

Investigation of choice in acute renal trauma

A

Abdomen CT.

104
Q

Orbital blowout frx

  • commonest bones affected
  • manifestations
A

Maxilla (orbital floor), ethmoid (medial wall)

Diplopia on upward gaze - impingement of superior rectus muscle

105
Q

ACS treatment

A

ST elevation - MONA then PCI (preferred) or alteplase

NSTEMI - Normal ECG + high troop in - LMWH (Fonda) + aspirin

ECG + troponin normal . Pt stable- discharge with cardi review

106
Q

Cardiac tamponade

Becks triad

A

Hypotension
Muffled heart sounds
High JVP

107
Q

CXR in cardiac tamponade

A

Enlarged globular heart

108
Q

Diagnostic imaging of cardiac tamponade

A

Echo

109
Q

Cardiac tamponade management

A

Urgent periocardiocentesis

Oxygenation and ventilation
1-2 L of IV fluid NS

110
Q

Basal skull / temporal bone fracture (Petrous part)

Features

A 
Battle sign - mastoid ecchymosis
CSF rhinorrhoea
Peri-orbital ecchymosis - raccoon eyes
Hearing loss
 Heamotympanum 
Facial n palsy
111
Q

Initial management of DKA

A

IV fluids - NS

IV infusion insulin(.1/kg/hr) + ABG

112
Q

Dx of DKA

A

pH < 7.3 , ketonemia ++, glucose >11 , bicarbonate <15

113
Q

Beta blocker poisoning

Management

A

Hypotension bradycardia dizziness
Management - supportive
IV fluids for hypotension if SBP <90
Symptomatic bradycardia- atropine

114
Q

Most appropriate test to determine asthma exacerbation

A

PEFR
Moderate = 50-75% best or predicted
Acute severe - 33-50%
Life threatening <33%

115
Q

Severe Hyperkalemia management

A

Calcium gluconate/chloride/carbonate
Insulin
Bedside Blood glucose normal -
10 units IV with 50- ml of 50% dextrose over 10-15 mins

Glucose >11.1 (high)
Iv insulin 10 units with 50 ml .9% NaCl over 10-15 mins

Insulin = act rapid - soluble short acting insulin used in hyperK

116
Q

Inhaled FB

Investigation

A

CXR +- bronchoscopy

117
Q

Haemothorax management

A

O2
2 large venous cannula - send blood fro cross match
Chest drain
Surgery - rarely

Revision (31 decks)

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