Emergency

Question 1

AMPLE

Answer 1

allegies
meds
past hx
last ate/ drank
event

Question 2

3 major radiographs of trauma

Answer 2

chest
lateral cervical spine
pelvis

Question 3

Secondary survey

Answer 3

4 people to log roll
examine thoracolumbar spine, listen to lung fields, examine perineum, do rectal exam
Ix, documentation etc

Question 4

In cardiac arrest, who should get adrenaline and when?

Answer 4

In shockable rhythms, 1 mg IV adrenaline after alternate shocks
Or every 3-5 mins

Question 5

Emergency medical mx STEMI

Answer 5

Aspirin 300 mg (thereafter 75 mg/ daily)
Ticagrelor 180 mg (thereafter 90 mg BD - don’t give if hx bleeding or already anticoagulated)
Morphine 2.5-5 mg (1 mg/min) - further dose if needed
Cyclizine 50 mg IV

GTN spray - consider IV if BP ok/ no sildenafil

Question 6

Emergency medical mx acute HF

Answer 6

IV furosemide 40-80 mg bolus
(followed by infusion 5-20 mg/h)

consider IV GTN

stop CCBs and NSAIDs, if possible
if hypotensive can omit beta-blockers/ ACEi - but try not to stop

Question 7

Emergency medical mx sinus bradycardia

Answer 7

only needs mx if symptomatic

atropine 600 - 1200 mcg IV

if persistent, pacing

Question 8

How best to terminate AF of recent onset?

Answer 8

IV fleicainide

Question 9

How best to treat AF in presence of HF or acute ischaemia?

Answer 9

IV amiodarone

consider cardioversion

Question 10

Medical mx stable VT

Answer 10

Lidocaine 1.5 mg/kg IV

Question 11

Mx DVT

Answer 11

Book USS (if can’t be done within 4 hours, treat)

Rivaroxaban 15 mg BD (from day 22 just 15 mg OD maintenance)

If contraindicated, dalteparin, UH or warfarin (dalteparin bridging)

Question 12

Mx PE

Answer 12

If life-threatening, IV heparin (alteplase too if haemodynamcally unstable). Arrange echo and/ or CTPA.

If non life-threatening, do Wells.
Either D-dimer, or rivaroxaban therapy.
(LMWH if preg)

Question 13

Mx opiate OD

Answer 13

naloxone 0.4 mg IV (repeat every 2-3 mins until depression is reversed)

can be given IM/ SC if no access

doesn’t work well for buprenorphine

Question 14

Mx benzo

Answer 14

IV flumazenil

caution if pt may have taken other psychotropic drugs, or if benzo-dependent (eg epileptic)

Question 15

Mx acute asthma

Answer 15

2.5 - 5 mg salbutamol nebs (oxygen-driven, at least 6 L/ min) - REPEAT EVERY 15-30 MINS

500 mcg ipratropium bromide - every 6 hours (helps in 1/3 patients)

40-50 mg oral pred, or hydrocortisone 100 mg IV 6-hourly (CONTINUE FOR 5 DAYS)

Consider IV Mg, aminophylline

Should be reviewed by GP within 2 days of asthma attack and by asthma specialist within 4 weeks

Question 16

When should spontaneous pneumothorax be admitted

Answer 16

tension!
Primary - usually not
Secondary (ie underlying lung disease)

aspirate usually if over 2 cm

Question 17

Mx acute upper GI bleed

Answer 17

Endoscopy!

Low-risk: 40 mg BD oral omeprazole

High-risk: HDU, restore fluid volume, if no imminent OGD give IV omeprazole (same dose)

Question 18

Mx bleeding oesophageal varices

Answer 18

Resuscitate

Terlipressin 2 mg IV (repeat every 4-6 h) - start before diagnostic endoscopy

Abx prophylaxis (send blood cultures + MSU)

15-20 ml TDS oral lactulose (prevent encephalopathy)

(beta-blockers are prophylaxis)

Question 19

Immediate Ix for bloody diarrhoea

Answer 19

Blood (FBC, U&Es, CRP, LFTs)
Stool x2 (MC&S + C.diff toxin)

Sigmoidoscopy

AXR

Question 20

Mx acute severe UC

Answer 20

Mild-to-moderate: topical mesalazine suppositories (proctitis), foam enemas (distal) or liquid enemas (L-sided colitis)

Fluids + potassium
LMWH

Question 21

How to differentiate between DKA and HHS?

Answer 21

Urinary ketones in DKA only

Question 22

Initial investigations for DKA

Answer 22

Bloods: FBC, U&E, BG, lactate, VBG, culture

Urinalysis, ECG, CXR

Question 23

Mx DKA

Answer 23

NaCl 1 litre (over 10-15 mins)
NaCl 1 litre (over 1 hour)
Catheterise if oliguric

Actrapid 50 units in saline (up to a volume of 50 mL)

If 14 mmol or less, infuse 10% glucose at 100 mL/h - don’t stop insulin

Check electrolytes every 2h via VBG
Check BM every 1h

Question 24

Mx hypoglycaemia if conscious

Answer 24

X2 glucogel, x4 glucotabs, or other high-sugar
check BM after 15 mins

follow up with starchy food

don’t omit insulin dose

Question 25

Mx hypoglycaemia if unconscious

Answer 25

If IV access, 100 mL 10% glucose

or 1 mg IM glucagon

Question 26

Immediate mx Addisonian crisis

Answer 26

Cannula. Take bloods (U&Es, glucose, cortisol)

0.9% saline (corrects dehydration and hyponatraemia)

100 mg IV bolus hydrocortisone
repeat 6-hourly for 1-2 days (until able to take oral

Question 27

Thrombolysis time for stroke

Answer 27

4.5 h

Question 28

What stroke assessment should be done in A&E?

Answer 28

Rosier

Question 29

Stroke Ix

Answer 29

FBC
ESR
Coag screen (consider thrombophilia screen if under 60)
U&Es
Glucose
Cholesterol 

ECG
CXR
Echo if under 65/ significant cardiac pathology

(Urgent echo and cultures if suspected endocarditis)

If ischaemic, doppler carotid/ vertebral

Question 30

Mx stroke

Answer 30

thrombolysis if indicated
300 mg aspirin
300 mg clopi

lower BP gradually if super-high (if moderately high, is pretty normal)

Question 31

Imaging for ?carotid dissection

Answer 31

MRI with cross-sectional views of carotid artery

Question 32

Seizure mx

Answer 32

Make pt safe
TIME

Give oxygen, check glucose
(IF ALCOHOL, GIVE PABRINEX BEFORE GLUCOSE)
Inter-ictal establish IV access

Question 33

Status epilepticus mx

Answer 33

4 mg IV lorazepam (2 mins)
OR 10 mg IV diazepam
OR 10 mg buccal midazolam

[STAT doses not PRN]

repeat within 10-20 mins

Give usual AEDs if already on treatment

STAGE 2 (skip to this if already had 2 doses in last 24h)
Phenytoin (others not licensed, but may be preferable)

After 30-90 mins, may need GA

Question 34

What is apomorphine?

Answer 34

Anti-Parkinsonian med!

Question 35

What is the dose of adrenaline for anaphylaxis?

Where is it administered?

Answer 35

0.5 mL 1:1000 (i.e. 0.5 mg)

antero-lateral medial aspect of thigh. Repeat as needed every 5 mins

Question 36

Mx for anaphylaxis

Answer 36

Adrenaline

ABCDE

Fluids 500 mL - 1000 mL, keep repeating
10 mg chlorphenamine, IM or slow IV

Consider corticosteroids
Consider salbutamol

Measure tryptase levels within 4 h

Observe for 6-12 h