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
patient on ipatroprium for COPD and this has not been enough to control breathlessness. next step in management?
Stop inhaled ipratropium, start inhaled formoterol, tiotropium and salbutamol
discontinue SAMA -> MAKE it SABA, LAMA and LABA
This patient currently has a short-acting muscarinic antagonist (SAMA) (ipratropium) which is inadequate for his symptom control. The next management step depends upon the presence/absence of asthmatic features. As the patient does not have asthmatic features (atopy, diurnal variation in symptoms), he should be started on a long-acting muscarinic antagonist (LAMA) (tiotropium) and long-acting beta-agonist (LABA) (formoterol). Ipratropium (a SAMA) should be stopped as LAMA (e.g. tiotropium) and SAMA act on the same receptor and so dual muscarinic receptor antagonism is unnecessary. A SABA (e.g. salbutamol) should be given instead for short-acting relief.
if patient was asthmatic you would just add on a LABA + ICS
features of asthma can be identified by either: a large (over 400ml) response to bronchodilators or a large (over 400ml) response to 30mg oral prednisolone daily for 2 weeks or serial peak flow measurements showing 20% or greater diurnal or day-to-day variability.
Name a drug that causes torsades de pointes
azithromycin, erythromycin
essentially macrolides!!
what groups of patients are at an increased risk of developing hepatotoxicity following a paracetamol overdose?
high risk if chronic alcohol (not acute) HIV, anorexia or P450 inducers (rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St John’s Wort)
STEMI
His blood pressure is 82/60mmHg, respiratory rate 31/min, heart rate 152bpm, temperature 37.5ºC. His oxygen saturations are 93%.
Morphine, oxygen, GTN spray, aspirin and clopidogrel are prescribed. The patient starts to deteriorate clinically and goes into shock.
What drug could have caused the deterioration?
GTN spray!!!
nitrates contraindicated in patients with hypotension (< 90 mmHg)
A 67-year-old female attends the emergency department with a 3-week history of cough productive of clear sputum and intermittent low-grade fever. She denies shortness of breath, chest pain, weight loss or haemoptysis. She has no history of respiratory illness, but takes metformin for type 2 diabetes and has a 25-pack-year smoking history. She has no known drug allergies.
A chest x-ray is performed in the emergency department which is normal. Blood tests show CRP of 108
next step in management?
Oral doxycylcine!!!!
as CRP is >100!!!
Amoxicillin is the treatment of choice for acute bronchitis in pregnant women and young people aged 12-17.
patient has acute bronchitis
CXR excludes pneumonia
No other focal chest signs (dullness to percussion, crepitations, bronchial breathing) in acute bronchitis other than wheeze.
A 58-year-old man presents to the Emergency Department with recent shortness of breath and pleuritic chest pain. His medical history includes a recent surgery. Meanwhile, the patient suddenly collapses. An immediate assessment reveals pulseless electrical activity (PEA). CPR is initiated, and an intravenous dose of 1 mg of adrenaline is administered. However, PEA persists.
What is the next best step in the management of this patient?
IV alteplase 50 mg
Thrombolytic drugs should be considered during CPR if a PE is suspected
when is long term oxygen therapy given for COPD?
secondary polycythaemia
peripheral oedema!!!
pulmonary hypertension
subarachnoid hemorrhage.
ECG is performed. Her ventricular rate is 180 bpm and irregular.
Which finding is most likely to be seen on the ECG?
Torsades de pointes
A 24-year-old woman presents to the emergency department after ingesting 30 paracetamol 500 mg tablets. She finished taking them 9 hours ago. weighs 70 kg
What is the most appropriate next step in her management?
Start acetylcysteine now
of more than 150 mg/kg
In ALS, a further dose of amiodarone 150 mg should be given to patients who are in VF/pulseless VT after 5 shocks have been administered
IM adrenaline 500mcg (0.5ml of 1 in 1,000
A 72-year-old man is admitted to the Emergency Department. His wife reports that he has recently been depressed and around four hours ago he took 28 atenolol 50mg tablets. On admission his pulse is 40 / min and blood pressure is 96/60 mmHg. What is the most appropriate first-line treatment?
IV atropine!!
for beta blocker overdose
gastric lavage only if presents within 1-2 hours of overdose
broad complex tachycardia qrs value?
> /= 0.12
where is IM adrenaline injected
in the anterolateral aspect of the
middle third of the thigh
A 34-year-old man with a history of depression is admitted to the Emergency Department. He states he has taken an overdose of both diazepam and dosulepin. On examination blood pressure is 116/78 and the pulse is 140 bpm. His respiratory rate is 8 per minute and the oxygen saturations are 97% on room air. What is the most appropriate next course of action?
obtain an ecg!!
due to marked tachycardia. if QRS widening seen, give IV bicarbonate!!!! as this is a coexisting tricyclic antidepresant overdose -> antimuscarinic signs
if it was only a benzo overdose youd give flumazenil
what vaccinations should a patient with copd recive?
Annual influenza + one-off pneumococcal
53%
Paracetamol overdose: if presentation > 24 hours: acetylcysteine should be continued if the paracetamol concentration or ALT remains elevated whilst seeking specialist advice
A 48-year-old smoker, who was diagnosed with COPD 10 years ago, is experiencing shortness of breath and a productive cough with purulent sputum. These episodes have become more frequent within the last few years.
What is the most common causative agent of these exacerbations?
Haemophilus influenzae
The most common organism causing infective exacerbations of COPD
Pulmonary embolism and renal impairment. ix of choice?
V/Q scan
what score is recommended by BTS guidelines to be used to help identify patients with a pulmonary embolism that can be managed as outpatients
PESI score
His ECG is now showing ST elevation with third-degree heart block and slow junctional escape rhythm.
What is the most likely region affected by infarction?
inferior
AV block can occur following an inferior MI
evidence of heart failure and persisten ST elevation following an MI. most likely diagnosis?
left ventricular aneurysm
salicylates overdose abg findings?
Respiratory alkalosis followed by metabolic acidosis
name a cause of pneumonia that can cause Guillain-Barre syndrome and other immune-mediated neurological diseases
mycoplasma
atients with a GRACE score > 3% should have coronary angiography within X hours of admission
72
a diagnosis of A FIB does not mean you need to anticoagulate. you need to calculate chadsvasc score first. if this is zero, what is the next step in management?
arrange an echocardiogram
management of normal pulmonary embolism?
management of pulmonary embolism with hypotension?
DOAC!!
if renal impairment is severe (e.g. < 15/min) then LMWH, unfractionated heparin or LMWH followed by a VKA
if the patient has antiphospholipid syndrome (specifically ‘triple positive’ in the guidance) then LMWH followed by a VKA should be used
Instability = thrombolyse with ALTEPLASE!!!
One day following a thrombolysed inferior myocardial infarction a 72-year-old man develops signs of left ventricular failure. His blood pressure drops to 100/70mmHg. On examination he has a new early-to-mid systolic murmur. Diagnosis?
Four weeks after an anterior myocardial infarction a 69-year-old presents with pulmonary oedema. The ECG shows persistent ST elevation in the anterior leads. diagnosis?
A 65-year-old man has a cardiac arrest two days after being admitted to hospital following a myocardial infarction. diagnosis?
papillary muscle rupture/left ventricular free wall rupture
left ventricular aneurysm
ventricular fibrillation
third degree heart block management?
transvenous pacing!!
in the interim = atropine etc
Patients with tachycardia and signs of shock, syncope, myocardial ischaemia or heart failure should receive up to 3 synchronised DC shocks
liver transplant criteria in paracetamol overdose?
pH < 7.3 more than 24 hours after ingestion
alt level only guides acetylcysteine treatment
intracranial hemorrhage with contusion and diffuse edema.
first step in management?
IV mannitol!!!!
osmotic diuretic choice in raised ICP
suspected ongoing anaphylactic shock, of unknown cause. They were given intramsucular (IM) adrenaline 3 minutes previously, but are still struggling to maintain a secure airway.
next step in management?
Repeat 500micrograms (0.5ml) adrenaline intramuscularly in 2 minutes if symptoms do not improve
In the treatment of anaphylaxis, you can repeat adrenaline every 5 minutes
siezures in alcohol withdrawal occur at what time?
delirium tremens at what time?
seizures: 36 hours
delirium tremens: 72 hours
patient with copd
He asks if there is anything that can be done to reduce the frequency of his exacerbation.
referral to secondary care for consideration of prophylactic antibiotic treatment - azithromycin!!!
note oral pred would be given in the acute setting!! for an exacerbation
recurrent pneumothorax management?
Referral for video-assisted thoracoscopic surgery (VATS)
A 74-year-old female presents with worsening shortness of breath for the past week. She has a background of COPD and smokes around 10 cigarettes a day. She has a chronic cough which she has had ‘for years.’ The cough has not changed in character recently. On chest auscultation, she has reduced air entry throughout, diffuse wheeze, and no focal crepitations. Her respiratory rate is 23 breaths/min, her temperature is 37.80ºC, and her oxygen saturations are 95% on air. Her heart rate and blood pressure are normal.
Which of the following is the most appropriate management?
Increase use of bronchodilator inhaler and prescribe a five day course of oral prednisolone
NICE only recommend giving oral antibiotics in an acute exacerbation of COPD in the presence of purulent sputum or clinical signs of pneumonia
dose of amiodarone in CPR?
300mg
tension pneumothorax causes what type of shock?
obstructive shock
A child aged 6-11 years should be administered adrenaline at a dose of??
300 micrograms (0.3ml), repeated every 5 minutes if necessary
Fawzia is a 76-year-old woman with a history of hypertension who undergoes catheter ablation to treat her atrial fibrillation. She is subsequently found to be in sinus rhythm. Prior to this, she was taking warfarin for stroke prevention.
What is the correct longterm management of her anticoagulation?
continue warfarin
A 31-year-old woman presents to the emergency department with a severe headache. The pain started five weeks ago and has become persistently worse with associated visual blurring in the past week. She has no past medical history and has been taking only paracetamol and ibuprofen for her pain.
On examination her heart rate is 81 bpm, her blood pressure is 131/84 mmHg, her temperature is 37.2ºC. Eye abduction is limited bilaterally with all other eye movements normal. On fundoscopy, there is obvious bilateral optic disc blurring. Peripheral neurological examination is normal and she has no cognitive deficit.
What is the most likely diagnosis?
idiopathic intracranial hypertension -> papilloedema, 6th nerve palsy
Acute angle-closure glaucoma can cause headache and visual blurring but most commonly occurs unilaterally. However, the main symptoms are eye pain and progressive acute visual loss. Redness of the eye and a fixed, oval pupil are also common features of acute angle-closure.
ectopic pregnancy localised to where increases the risk of rupture?
isthmus
A 65-year-old man presents to the emergency department with a 4-hour history of right-sided loin to groin pain. He has never experienced pain like this before and regular analgesia has not relieved his symptoms. His past medical history includes hypertension for which he takes amlodipine and indapamide.
His observations are as follows:
Temperature 35.5ºC
Heart rate 110bpm
Blood pressure 99/55mmHg
Respiratory rate 24 breaths/min
Saturations 95% on air
On examination, he is clammy to touch. His chest is clear and heart sounds are normal. There is generalised abdominal tenderness and central guarding. Bowel sounds are present.
What is the most appropriate next step in the management of this patient?
urgent vascular review!!
presence of shock means AAA needs to be ruled out
A 65-year-old man presents to the emergency department with central crushing chest pain 2 hours ago. His ECG on admission showed ST elevation in leads II, III and aVF. Suddenly, the patient develops worsening breathlessness. Upon cardiac auscultation, a new pan-systolic murmur is heard.
What complication is the most likely cause of this patient’s breathlessness?
Acute mitral valve regurgitation
a chadsvasc score of what makes you offer treatment?
2
mycoplasma is diagnosed using?
serology for antibodies
A 63-year-old woman presents to the emergency department complaining of 2 hours of epigastric pain. It is a burning pain with no radiation and was not relieved by Gaviscon. She feels sweaty and nauseous but has not vomited. She has no changes to her bowel habits and no urinary symptoms. She has a past medical history of hypercholesterolaemia and hypertension. She is teetotal but has a 40-pack-year smoking history. On examination, her abdomen is soft and non-tender.
What is the most appropriate next step?
order an ECG
Acute coronary syndrome may present with atypical chest pain especially in female patients
necrotising fasciitis, type 2 diabetic, what drug is most likely to have contributed?
Dapagliflozin
(SGLT2 inhibitors)
how to differentiate HHS and DKA?
HHS or DKA? - HHS has no acidosis/significant ketosis (ketones may be slightly raised), the history is longer and the glucose is often significantly raised eg >30mmol/L
how to calculate anion gap?
what is normal?
Anion gap = (sodium + potassium) - (bicarbonate + chloride)
up to 14
Broad complex tachycardia following a myocardial infarction is almost always due to?
ventricular tachycardia!!
NOT VF
Paediatric BLS: In an infant, the appropriate places to check for a pulse are?
brachial and femoral arteries
lithium toxicity signs
COARSE tremor, polyuria, hyperreflexia
most important test to confirm anaphylaxis?
serum mast cell tryptase
ectopic pregnancy, foetal heartbeat!, management?
Laparoscopic salpingectomy
A 68-year-old man with ischaemic heart disease is experiencing worsening breathlessness and chest pain. There is bilateral pitting oedema extending to his thighs, and bibasal crackles are noted on auscultation. His pulse is 120 beats per minute, blood pressure is 105/65 mmHg, and oxygen saturation is 80% despite receiving 15L/min of oxygen. He has already been administered the maximum dose of bumetanide.
An ECG is requested, which turns out to be normal.
Blood tests are ordered, which return as follows:
Troponin T 3 ng/L (< 14)
What is the most appropriate next step in management?
CPAP!! -> As this is acute heart failure not responding to treatment
What dose of adrenaline should be given during a CARDIAC ARREST?
1mg
chronic subdural bleeds management?
burr hole evacuation
IV N-acetylcysteine over 1 hour is correct. Guidelines recommend continuing acetylcysteine treatment if there is jaundice, hepatic tenderness or ALT level above the normal limit (all of which the patient has above). only liver transplant if ph <3
Following a TIA, anticoagulation for AF (apixaban) should start immediately once imaging has excluded haemorrhage
Head elevation to 30º is a simple first-step in the management of patients with raised ICP
PE + hypotension management?
thrombolyse!!! not apixaban
if CTPA is negative, next investigation to diagnose?
Proximal leg vein ultrasound scan
A 64-year-old man is admitted to the emergency department as his wife is concerned that he is becoming confused following a recent bad chest infection. She reports that he has not improved after a course of amoxicillin.
On examination, his respiratory rate is 30/min, blood pressure 88/60 mmHg, heart rate 120/min. Crackles are noted on the right side of his chest.
diagnosis ?
sepsis!!
confusion
low BP
high resp rate
red flags!!
A 58-year-old man, Wayne, presents to the emergency department complaining of a cough, high fever, fatigue and palpitations. Wayne informs you that his palpitations started 12 hours ago. His temperature is 38ºC, his heart rate is 110bpm and his ECG shows an irregularly irregular rhythm with the absence of P waves. His blood pressure is 120/70 mmHg and his respiratory rate is 17/minute. His X-ray shows right lower-lobe consolidation. He is otherwise well, with no comorbidities. He is started on treatment for his underlying pneumonia. Which of the following management options should be considered for this patient’s AF
The NICE guidelines for AF advice are to ‘Offer rate control as the first-line strategy to people with atrial fibrillation, except in people: 1. whose atrial fibrillation has a reversible cause’. As this acute onset of AF is secondary to pneumonia (a reversible cause), rate control would not be appropriate for this patient.
also use rhythm control if there is heart failure
The defibrillator recognises a shockable rhythm and so the team follows the appropriate ALS guidelines. After the third shock, the patient remains in ventricular fibrillation and the team is now looking to administer some medication.
What is the next appropriate treatment plan?
Intravenous adrenaline 1 mg; intravenous amiodarone 300 mg
