Emergency Flashcards
patient with sepsis, low BP
given IV 0.9% saline at 125ml/h
noradrenaline/norepinephrine!!!
adequate if not overhydration, needs vasoconstriction
A 48 year old woman develops nausea and abdominal pain 2 days after a
total abdominal hysterectomy. Two days later, while still in hospital, she
develops nausea and constant abdominal pain. Her pulse is 110 bpm and BP
80/40mmHg. Her abdomen is distended and tender. Her urine output for the
past 6 hours has been 100 mL
most appropriate immediate management?
IV 0.9% sodium chloride
This is a post operative bleed. start fluids and call surgeon immediately
amytriptiline hydrochloride overdose 4 hours ago
ECG shows QRS prolongation
most appropriate immediate management?
IV sodium bicarbonate!!!
bicarbonate is the treatment of choice in patients with prolonged QRS following a tricyclic antidepressant overdose
(within 1 hour and no qrs prolongation = activated charcoal)
26 yo. Head injury in car accident.
Eyes closed but opens them when asked to. Confused about where she is and what happened but attempts to talk about it. Repeatedly attempting to remove cannula from right wrist.
Best estimate of GCS score?
UKMLA ppq
12!!!
E3, V4, M5
Man weighting 70kg with underlying cardiac disease. What is the most appropriate volume of maintenance fluids to prescribe in next 24hours?
20-25ml/Kg in patients with underlying cardiac disease.
70 x 25 (upper limit) = 1750
Patient experiencing a myaesthenuc crisis. Most appropriate tests to monitor respiratory function?
FVC
how does fat embolism present?
Multiple fractures followed by early onset (within 24 hours) of hypoxia, dyspnea, and
tachypnea are the most frequent findings. Neurologic manifestations range
from the development of an acute confusional state and altered level of
consciousness to seizures and focal deficits and usually follow respiratory
symptoms. A petechial rash is the last component to appear and only appears
in about a third of cases. Patients with PE may present in the same time frame
(ie, 24 to 72 hours), but neurologic abnormalities are not explained by this.
A 46 year old man has a cardiac arrest in the Emergency Department after an
episode of chest pain. He remains in ventricular fibrillation after three DC
shocks, and he is treated with a bolus of intravenous adrenaline/epinephrine.
what other drug treatment should be administered at this time?
amiodarone
If VF/VT persists after a third shock, resume
chest compressions immediately and then give adrenaline 1 mg IV and
amiodarone 300 mg IV while performing a further 2 min C
A 74 year old man is brought to the emergency department after falling down the stairs. he has no pain. he has atrial fibrillation and takes apixaban.
He has significant bruising to the left side of his face and left arm. His pulse rate is 80 bpm, irregular, BP 150/95 mmHg and oxygen saturation 96% breathing air. His GCS score is 14.
most appropriate next step in management?
UKMLA ppq
cervical spine immobilisation!!
sequence of care in trauma patients is airway!! -> then cervical spine!!!
a CT head will be required and a CXR most likely but later!!
A 55 year old man is brought to the Emergency Department with 2 hours of severe left sided chest pain A pre-hospital ECG shows left bundle branch block, for which paramedics gave aspirin and glyceryl trinitrate spray.
He is sweating and distressed. His pulse rate is 85 bpm, BP 99/54 mmHg, respiratory rate 22 breaths per minute and oxygen saturation 96% breathing air. His GCS score is 15/15.
Which is the most appropriate management?
A. Continue breathing air
B. Start 28% oxygen via a Venturi mask
C. Start 40% oxygen via a Venturi mask
D. Start oxygen 2 L/min via nasal cannulae
E. Start oxygen 15 L/min via a non-rebreathe mask
UKMLA ppq
Correct Answer(s): A
Justification for correct answer(s): Airway is patent and does not require intervention. Oxygen will increase mortality for STEMI with sats of >94%.
A 25 year old man has taken an overdose of 16 paracetamol tablets. He became very sad earlier that day after an argument with a friend. His mood changes between being happy and sad several times per week. He struggles with concentration and gets angry easily. He has frequently been excessively drunk on nights out. He has never experienced psychotic symptoms.
Which is the most likely diagnosis?
A. Adjustment disorder
B. Bipolar disorder
C. Borderline personality disorder
D. Dissocial personality disorder
E. Unipolar depressive episode
UKMLA ppq
Correct Answer(s): C
Justification for correct answer(s): Frequent changes in mood suggests borderline PD, not pervasive depression. Mood changes too rapid for bipolar disorder. Also impulsive self-destructive behaviours and unstable relationships are
A 71-year-old man who is known to have atrial fibrillation comes for review. He had a transient ischaemic attack two weeks ago and takes bendroflumethiazide for hypertension but is otherwise well. His latest blood pressure is 124/76 mmHg. You are discussing management options to try and reduce his future risk of having a stroke. What is his CHA2DS2-VASc score?
4!
One point for hypertension, one point for being over the age of 65 years (but under the age of 75 years) and two points (‘S2’) for the recent TIA.
A 45-year-old man presents to the Emergency Department due to severe pain in the perineal area over the past 6 hours. On examination the skin is cellulitic, extremely tender and haemorrhagic bullae are seen. What is the most appropriate management?
IV antibiotics and surgical debridement
Necrotising fasciitis
no pulse, broad complex tachycardia. next step in management?
broad complex tachycardia with pulse. treatment?
unsynchronised shock/defibrilation!! (this is different from synchronised cardioversion used in unstable a fib!!!)
used for VF or pulselessness VT
non shockable rhythms would be PEA and asystole. NOTE. for non shockable rhythms, adrenaline 1 mg as soon as possible!
question 2 = most likely VF = amiodarone
adenosine is used for narrow complex tahcycardias eg SVT
stemi management?
secondary prevention?
300mg aspirin
morphine
nitrates
O2 only given if sats less than 94!!
PCI if presenting within 12 hours of onset and PCI posisible within 120 minutes rather than fibrinolysis. PCI=Praugrel, unfractionated heparin
Following an ACS, all patients should be offered:
dual antiplatelet therapy (aspirin plus a second antiplatelet agent eg ticalegror)
ACE inhibitor
beta-blocker
statin
name a drug that is contraindicated in VT
verapamil
patient found unconsious with abg showing metabolic alkalosis and hypokalemia. most likely cause?
prolonged vomiting!!!
Diarrhea causes loss of bicarbonate and metabolic acidosis!!
methanol poisoning causes metabolic acidosis
bradycardia with Mobitz type II atrioventricular (AV) block
allergic to atropine
what drug to give?
Isoprenaline/adrenaline infusion is an alternative treatment to atropine/transcutaneous pacing for a symptomatic bradycardia
if all the above dont work. consult a specialist for transVENOUS pacing
type 2 (Mobitz II)?
third degree?
PR interval is constant but the P wave is often not followed by a QRS complex
no association between the P waves and QRS complexes
Liver transplantation criteria in paracetamol overdose?
pH < 7.3 more than 24 hours after ingestion
learn stemis in which leads correlate to what
NSTEMI managment?
300mg aspirin
fondaparinaux if no immediate PCI planned
GRACE risk score <3 conservative management with ticalegror. if >3 then conduct PCI
what lab values/findings seen in legionella penumonia?
lymphopaenia!
hyponatraemia
deranged liver function tests!!!!
erythema multiforme is seen in mycoplasma
A 63-year-old woman presents to the emergency department with a sudden onset of central chest pain and profuse sweating. The pain started 6 hours ago and it is now improving. She looks pale and clammy.
An ECG is ordered, which shows inverted T waves in V2-3 and a 0.5mm ST depression in the same leads. The troponin levels are normal.
What is the most likely diagnosis?
unstable angina!!!
no elevated troponins so cant be NSTEMI
lithium toxicity first line treatment?
IV Saline!!
STEMI is diagnosed and fibrinolysis performed as PCI was not available at this hospital or the closest tertiary centre, within an appropriate time frame. Around 90 minutes after fibrinolysis the patient’s ECG still demonstrates persistent ST elevations in the lateral leads.
What is the most appropriate next step in management?
Transfer the patient for percutaneous coronary intervention (PCI)
patients who have had a pneumothorax avoid deep-sea diving indefinitely!!
Air travel only needs to avoided until there has been confirmation of the resolution of the pneumothorax
a primary spontaneous pneumothorax (PSP) which carries a lower risk of recurrence than a secondary spontaneous pneumothorax (SSP) (underlying lung disease)
Car accident
Thirty minutes later, the patient was noticed to have sinus tachycardia and hypotension with profuse sweating. An examination revealed asymmetrical chest expansion and tracheal deviation. Moments later, a nurse notices he has no pulse.
Which arrest rhythm is likely to be seen in this patient?
pulselessness electrical activity
Tension pneumothorax is a reversible cause of PEA in cardiac arrest resulting from trauma
(GCS) is 13/15, pupils are dilated and divergent. He is tachycardic with a heart rate of 110/min, his blood pressure is 124/70mmHg. His ECG shows sinus rhythm, with a lengthened QTc duration of 480msec. He is dry to the touch.
amytryptilline!! - anticholinergic effects = dilated pupils, dry skin, confusion, urnary retention, tachycardia
Cocaine produces sympathetic effects - agitation, restlessness, increased heart rate and blood pressure. In severe toxicity hyperthermia and rhabdomyolysis may occur. It would not cause a reduced GCS or altered QRS duration on ECG.
MDMA (ecstasy) excess presents similarly to cocaine, with increased psychomotor agitation, palpitations and hyperthermia. Additionally teeth grinding (bruxism) is noted frequently.
Diazepam ingestion could cause a reduced GCS due to its sedative effects. However it would not generally affect pupil size, heart rate or ECG
activated charcoal should be given if presents within X hours of overdose.
acetylcysteine is given also if indicated by treatment line or by what other indicator
1 hour
clearly jaundiced or have hepatic tenderness, their ALT is above the upper limit of normal, staggered overdose (dose taken over >1 hour)
He had been drinking alcohol throughout the day and impulsively ingested 64 tablets of paracetamol, which he says he had taken this over a period of 2 hours. Then he phoned his ex-girlfriend, 90 minutes ago, who persuaded him to go to the hospital. A collateral history confirms this timeline.
What is the most appropriate management of this patient?
N-acetylcysteine immediately!!
dont need to check paracetamol levels as staggered overdose
hospital 10 days earlier with an ST-elevation myocardial infarction, which was managed with percutaneous coronary intervention.
On examination, he has a raised JVP, diminished heart sounds, and on inspiration, his systolic blood pressure drops by 20 mmHg (pulsus paradoxus)
Given the above, what is the most likely cause of his presentation?
Left ventricular free wall rupture!
contrast dresslers syndrome = pericaridits
recognising complete heart block on ecg
pneumothorax management?
asymptomaatic = conservative
symptomatic no high risk = needle aspiration !!!!!
symptomatic with high risk features = chest drain!!!!
high risk features:
Haemodynamic compromise (suggesting a tension pneumothorax)
Significant hypoxia
Bilateral pneumothorax
Underlying lung disease
≥ 50 years of age with significant smoking history
Haemothorax
Long term mechanical ventilation in trauma patients can result in tracheo-oesophageal fistula formation - choking,aspiration
how would ventialtion associated pneumonia present differently?
fever, purulent secretions, and new radiographic infiltrates
name drugs used first line in COPD
A SABA (salbutamol, terbutaline) or SAMA (ipatroprium!!) is the first-line pharmacological treatment of COPD
NOTE!! salmeterol and formeterol or LABAs and are second line!!
hypothermia causes what waves on ecg?
J waves!!
A 55-year-old man presents to the emergency department with a worsening cough. His cough has been present for 3 days, and was initially dry but is now productive. He reports having a sore throat and a runny nose. He denies any other symptoms but on examination, a mild bilateral wheeze is heard. No bronchial breathing or dullness to percussion is heard.
diagnosis?
criteria for management with antibiotics?
antibiotic options?
acute bronchitis
have pre-existing co-morbidities
have a CRP >100mg/L !!!
the BNF currently recommends doxycycline first-line!!!
doxycycline cannot be used in children or pregnant women
alternatives include amoxicillin!
when will you DC cardiovert for SVT
hemodynamic instability eg low bp
in COPD, a Haemoglobin of 18.4 g/dl should prompt investigation for LTOT
in testicular torsion, which nerve carries the efferent impulses of this cremasteric reflex?
genitofemoral nerve
A 37-year-old female is admitted following a paracetamol overdose.
She is commenced on N-acetylcysteine (NAC). However, 2 hours after starting the effusion she develops urticaria and facial flushing.
What is the best management of this patient?
Stop NAC and restart at a slower rate
Refractory anaphylaxis is defined as respiratory and/or cardiovascular problems persisting despite 2 doses of IM adrenaline
next step in management?
Start IV adrenaline infusion!
A 45-year-old woman presents to the emergency department with sudden onset right-sided chest pain and associated dyspnoea. She has no history of malignancy, recent surgery/trauma requiring hospitalisation or previous thromboembolic event, and she has not had any haemoptysis.
On examination, her heart rate is 95bpm, blood pressure 130/80mmHg, O2 saturation 93% and respiratory rate 30/min. Both calves are soft, non-tender and symmetrical in size.
What is the most appropriate immediate action?
Suspected PE with a Wells PE score ≤4 - D-dimer is investigation of choice
A 78-year-old woman in the geriatric ward is experiencing acute shortness of breath. She also describes a sharp chest pain since this morning that seems to worsen when taking a deep breath. Her notes show she has a history of chronic kidney disease stage 5, type 2 diabetes and a previous myocardial infarction 7 years ago. She is currently recovering from her hip fracture surgery 4 days ago. Her chest is clear on auscultation.
Her observations are as follows:
Heart rate 123/min
Respiratory rate 22/min
Blood pressure 110/85mmHg
Temperature 37.2ºC
What investigation is needed to diagnose this patient?
wells score is above 4 so you need to do imaging!!!!
renal impairment so opt for V/Q scan over CTPA!!!
Clinical signs and symptoms of DVT (minimum of leg swelling and pain with palpation of the deep veins) 3
An alternative diagnosis is less likely than PE 3
Heart rate > 100 beats per minute 1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks 1.5
Previous DVT/PE 1.5
Haemoptysis 1
Malignancy (on treatment, treated in the last 6 months, or palliative) 1
Clues to the correct diagnosis of hyperglycaemic hyperosmolar state are hyperglycemia with increased serum osmolarity and no ketosis.
Illness and/or dehydration leads to the gradual development of hyperglycemia and increased intravascular osmolarity. There is no ketosis
