Emergency care Flashcards
1
Q
What acid-base imbalance does aspirin overdose initially cause and then turn to?
A
Starts as respiratory alkalosis (initial respiratory centre stimulation)
Turns to metabolic acidosis (compensation for high resp rate)
2
Q
Into which categories can shock be classified?
A
Class 1 - Compensated
Class 2 - Tachycardia
Class 3 - Hypotension
Class 4 - Loss of consciousness
3
Q
How can cardiogenic, septic and hypovolaemic shock be distinguished clinically?
A
Cardiogenic: only one with raised JVP
Septic: warm peripheries (others will be cold)
4
Q
What is the management for cardiogenic vs septic vs hypovolaemic shock?
A
Cardiogenic: dobutamine, dopamine
Septic: noradrenaline
Hypovolaemic: blood
5
Q
Define sepsis vs septic shock
A
Sepsis: life-threatening organ dysfunction caused by dysregulated host response to an infection
Septic shock: sepsis + lactate >2 despite fluid resus OR
patient needs vasopressors to maintain MAP > 65mmHg
6
Q
Recall the management of sepsis
A
Cannulate (+ bloods)
Catheterise
3 out: - lactate (VBG) - UO (catheterise) - Blood cultures 3 in: - 15L/min oxygen (even if sats okay) - ABx (as per local guidelines) - Fluids
Investigate for the source of infection
7
Q
Recall some key elements to ask in the history in suspected spesis
A
AMPLE Allergies Medications Past medical history Last meal Events surrounding
8
Q
Recall the immediate management of anaphylaxis
A
Secure airway –> remove cause –> raise legs
Then (alphabetical order, (doses on different card)):
- Adrenaline
(insert IV line for following drugs)
- Chlorphenamine IV
- Hydrocortisone IV
9
Q
Recall the dosing for adrenaline in anaphylaxis in each different age group, and the max dose you can give
A
> 12y: 500mcg doses, up to 0.5mg
6-12y: 300mcg doses, up to 0.3mg
6m-6y: 150mcg doses, up to 0.3mg
0-6m: same as above
10
Q
Recall the dosing for chlorphenamine in each different age group given in anaphylaxis
A
> 12y: 10mg
6-12y: 5mg
6m-6y: 2.5mg
0-6m: 250mcg/kg
11
Q
Recall the dosing for hydrocortisone in each different age group given in anaphylaxis
A
> 12y: 200mg
6-12y: 100mg
6m-6y: 50mg
0-6m: 25mg
12
Q
Describe the changes to the A to E approach in trauma
A
Before A to E:
- If massive haemorrhage, tamponade the massive bleeding prior to A to E
A
- Never do head tilt (just jaw thrust) because you always assume C spine injury until proven otherwise
B same as usual
C
- If significant haemorrhage, replace with 1-1-1 plasma, platelets and packed rbcs when you get to circulation
- If history of haemorrhage or ongoing bleeding (less massive) then give type O blood
- FAST scan
13
Q
At what GCS do you intubate?
A
<8
14
Q
What is the Canadian C-Spine rule used for?
A
Criteria that, if any are met, mean you need to immobilise the spine
15
Q
What are the NEXUS criteria used for?
A
If any of these criteria are met you cannot clear the C spine clinically
16
Q
What is the gold-standard form of imaging for investigating a possible cervical spine fracture?
A
CT neck (or MRI in children <16y)
17
Q
What is a FAST scan?
A
A point of care ultrasound scan used to identify intraperitoneal free fluid (assumed to be haemoperitoneum in the context of trauma)
18
Q
Systematically recall some causes of coma
A
Metabolic: COMA CAUSES
Cold (hypothermia)
Oxygen (hypoxia)
Medication OD (eg TCAs)
Addisonian…
Crisis Alcohol Underactive thyroid (myxoedema) Sepsis Encephalopathy (uraemic or hepatic) Sugars high/ low
Vascular: THEISM
Trauma Haemorrhage Epilepsy Infection Stroke Malignancy
19
Q
Recall the elements of the Glasgow Coma Scale in people >5 years old
A
Eyes: 1: no response 2: open to pain 3: open to voice 4: open spontaneously C = closed by swelling or bandage
Voice: 1: no response 2: sounds 3: words 4: confused 5: orientated T = intubated
Motor:
1: no response
2: abnormal extension (decerebrate)
3: abnormal flexion (decorticate)
4: withdraw from pain
5: localise pain
6: obey commands
20
Q
What is Cheyne-Stokes hyperventilation?
A
Type of central sleep apnoea where there are periods of apnoea followed by fast ventilation
If seen when patients are awake it indicates a poor prognosis
21
Q
What is apneustic breathing?
A
Regular deep inspirations with an inspiratory pause followed by inadequate expiration
Caused by injury to the pons
22
Q
What is ataxic breathing?
A
Completely irregular pattern of breathing that eventually becomes agonal breathing
23
Q
If pupils are mid-position (3-5mm) and non-reactive (may be irregular or not), what does this indicate?
A
Midbrain lesion
24
Q
If pupils are unilaterally fixed and dilated what does this indicate?
A
3rd nerve compression
25
If pupils are small but reactive what does this indicate?
Pontine lesion or drugs
26
How can you test the vestibulo-ocular reflex?
Doll's head manoevre:
Head is moved laterally quickly
Normal if eyes keep looking at same point in space
Abnormal if eyes turn in opposite direction of rotation
27
In the most simplistic terms, how do you decide between a PCI or a CABG to manage ACS?
PCI for 1 or 2 vessel disease, not including LAD
| CABG for >2 vessel disease, or including LAD
28
Recall the reversible causes of MI
```
5 Hs and 4 Ts
Hypoxia
Hypovolaemia
Hypothermia
Hypokalaemia/ hyperkalaemia
Hypoglycaemia
```
Toxins
Tamponade
Thrombosis
Tension pneumothorax
29
Recall the possible complications of an MI
```
DARTH VADER
Death
Arrhythmia
Rupture (left ventricular free wall, interventricular septum)
Thrombosis
Haemorrhage
Valvular heart disease
Aneurysm
Dressler's syndrome
Embolism
Re-infarct
```
30
In what time period might LVFW rupture occur post-MI?
5 days to 2 weeks
31
What are the differentials for cardiac rupture 3-5days post MI?
1) Acute mitral regurgitation due to papillary muscle rupture
2) Ventricular septal rupture
32
What are the signs and symptoms of papillary muscle rupture?
Acute mitral regurgitation
Pulmomary oedema
Hypotension
New pansystolic murmur (harsh thrill)
33
What are the signs and symptoms of ventricular septal rupture post MI?
Chest pain
Biventricular failure
Shock
New PSM
34
What are the signs and symptoms of LVFW rupture post-MI?
Heart failure
| Tamponade
35
What are the signs of cardiac tamponade?
Raised JVP
Muffled heart sounds
Hypotension
Pulsus paradoxus
36
How should heart block be managed following an anterior vs inferior MI?
If they had an anterior MI then got heart block:
- Temporary transcutaneous pacing --> permanent pacemaker
If they had an inferior MI then got heart block:
- Medical management with atropine
37
What is the most common cause of death post-MI?
Ventricular fibrilation
38
Describe the broad principles of immediate management of MI (this is your big 'ol card when you turn over warning)
Offer 300mg aspirin loading dose asap
For symptom mx: 10mg IV morphine and 10mg IV metoclopramide (O2 if SpO2 <94%)
Immediately assess suitability for reperfusion therapy
- Can offer reperfusion therapy within 12 hours of symptom onset (or slightly otherwise in some circumstances)
- If it's >12 hours since symptom onset --> medical mx only
Reperfusion options:
1. PCI - if you can offer within 120 mins (need to add aspirin + one other antiplatelet for this, choice depends on a number of factors)
2. Fibrinolysis - if you can't offer PCI within 120 mins (1st line is enoxaparin - can also use unfractionated heparin/ fondaparinux)
3. If GRACE score low --> just fondaparinux
Medical mx:
- Aspirin and ticagrelor (180mg PO) unless high bleeding risk
Source: https://www.nice.org.uk/guidance/ng185/resources/visual-summary-stemi-pdf-8900623405
39
When would beta blockers be contra-indicated in immediate management of an MI?
Bradycardia
Hypotension
Heart failure/ block
COPD/asthma
40
Recall the long-term management of MI
```
ACE inhibitor (although consider spironolactine in HF)
Beta blocker (OR verapamil/ dilitiazem)
Cardiac rehab (diet and exercise)
DAPT (aspirin + ticagrelor)
Statin
```
41
Systematically recall some causes of acute onset pulmonary oedema
Cardiovascular (LVF --> elevated PAWP)
ARDS (normal PAWP)
Fluid overload
Neurogenic (head injury)
42
Recall the management of acute pulmonary oedema
(1) Sit them up - high flow O2 if sats low
(2) IV diamorphine (3mg) + IV metoclopramide (10mg)
(3) IV furosemide
(4) GTN spray x 2 SL (can use IV if SBP >100)
(5) Continue furosemide and nitrate infusions until stable
43
How can RA/RV/PAWP be measured?
Swan-Gantz catheter
| Inserted through a central vein
44
What is the management of VF?
Non-synchronised DC shock (no R waves to trigger defib)
45
What is the management of VT?
Synchronised DC shock (synchronise to R waves)
Medical:
- Amiodarone, lidocaine, procainamide
- VERAPAMIL is a contraindication
46
How is Torsades de Pointes managed?
Depends on aetiology
Congenital: high dose beta blockers
Drug-induced: MgSO4
47
How is stable, regular, broad complex tachycardia managed?
IV amiodarone
48
How is narrow-complex tachycardia managed?
Vagal manoevres --> IV adenosine
49
How is bradycardia managed?
Give O2 if hypoxic
ECG, IV access, BP
Identify reversible causes (eg electrolyte imbalances)
If adverse signs (shock/ syncope, HF, myocardial ischaemia): IV ATROPINE 500mcg
If no adverse signs: assess risk of asystole (recent asystole? mobitz II? complete heart block?)
If risk --> atropine
If no risk --> continue observation
If atropine does not --> satisfactory response you can repeat it every 3-5 mins (3mg/6 doses max)
50
When would you admit someone for an acute exacerbation of asthma?
```
If no response to treatment in A&E or
CHEST:
Cyanosis
Hypotension
Exhaustion (PEFR <33%)
Silent chest
Tachyarrhythmia
Near fatal (pCO2 raised)
(Asthma management cards in respiratory deck)
```
51
How should tension pneumothorax be managed?
NB. these are NEW ATLS GUIDELINES 2018 - it USED to be 2nd ICL at MCL but NOW IS:
```
Safety triangle - aim for 4th/5th ICS MAL
Boundaries:
- lateral edge of pec major
- 5th ICS
- Base of axilla
- Lateral edge of lat dorsi
```
Insert 14-16g needle - plunger removed - partially filled with saline (facilitates a one way valve)
https://www.fortunejournals.com/articles/changing-trends-in-the-decompression-of-tension-pneumothorax.pdf
52
What score is used to determine if someone is likely to have a PE, and how many points do you need to justify a CTPA?
Well's score
>4 points
(if <5 points --> D dimer)
53
What are some possible signs of PE on ECG, and which is the most common?
Most common: sinus tachycardia
| Also: RBBB, RAD, S1Q3T3
54
How will a CXR appear in PE?
Normal
55
How should pulmonary embolism be managed if a patient is haemodynamically stable?
For all PEs: O2 if hypoxic, morphine/ anti-emetic for pain/ distress, IV fluids if low BP, get IV access
1st line: DOAC
3 months if provoked
Minimum 6 months if unprovoked
2nd line: IVC filter
56
Recall some provoking factors for PE
```
Immobility
Trauma
Surgery
COCP/ HRT
Pregnancy/ puerperium
```
57
How should pulmonary embolism be managed if a patient is haemodynamically unstable?
For all PEs: O2 if hypoxic, morphine/ anti-emetic for pain/ distress, IV fluids if low BP, get IV access
If no contra-indication to thrombolysis:
Unfractionated heparin + alteplase --> DOAC
If contra-indication to thrombolysis:
Unfractionated heparin WITHOUT alteplase --> DOAC
Consider embolectomy
If contraindication to thrombolysis AND anticoagulation:
Noradrenaline OR dobutamine
Consider embolectomy
58
What are some absolute contraindications to thrombolysis?
```
Brain things:
Previous intracerebral haemorrhage
Ischaemic stroke
Cerebral malignancy
Major trauma/surgery to head
```
Bleeding things:
- GI bleeding
- Bleeding disorder
- Aortic dissection
- Non-compressible punctures (eg LP/ liver biopsy)
59
What are the markers of mild, moderate and severe ARDS?
Based on PaO2/FiO2 ratio
Mild: 200-300mmHg
Moderate: 101-200mmHg
Severe <101mmHg
60
What are some signs and symptoms of ARDS?
BL CXR opacities
| Respiratory failure not explained by HF or fluid overload
61
What are the appropriate investigations for ARDS?
```
Sepsis 6
Bloods: BC, FBC, U&E, LFT, glucose, clotting, FDPs, D-Dimer, G&S
MSU
ECG
CXR
```
62
How should ARDS be managed?
All patients:
- Central venous access --> inotropes
- Peripheral venous access --> broad spec abx, diuretics
- O2
Non-shocked: sit upright
Shocked: colloid infusion
63
Recall some causes of UGI bleed, and which of these is most common
PUD (most common)
Mallory-Weiss tear
Erosions, oesophagitis, varices, malignancy
64
What anatomical landmark separates UGI from LGI bleeds?
Ligament of Treitz (suspends duodenal-jejunal flexure)
65
Recall the headings under which UG bleeds should be managed (other cards will go into each one)
(1) Resuscitation
(2) Risk assess
(3) Endoscopy
(4) Manage
(5) Prophylaxis
66
How should patients be resuscitated following an UGI bleed?
Packed RBCs
Platelets (if active bleeding or count <50)
FFP (if active bleeding and APTT is normal)
PCC if active bleeding on warfarin (prothrombin complex concentrate)
67
How can you perform a risk assesment for an UGI bleed?
Pre-endoscopy: Blatchford score
| Post-endoscopy (to guide prognosis): Rockall score
68
When should endoscopy be performed following an UGI bleed?
Immediately if after severe acute resuscitation
| Otherwise within 24 hours
69
How should variceal bleeds be managed?
For all:
IV Terlipressin
IV antibiotics as per local guidelines
For gastric varices:
1st line = endoscopic injection of butyl cyanoacrylate
2nd line = TIPS (transjugular intrahepatic portosystemic shunt)
For oesophageal varices:
1st line: endoscopic band ligation
2nd line: Sengstaken-Blakemore tube and TIPS (definitive)
70
How should non-variceal bleeds be managed?
Endoscopic options:
- Mechanical clips
- Thermal coagulation
- Fibrin/ thrombin
PPI after endoscopy
71
How can variceal bleeding with portal HTN be prevented?
PO propranolol
72
Recall some gram pos cocci and bacilli that may cause meningitis
Cocci:
Staph aureus (coag pos)
Staph epidermidis (coag neg)
Strep (pneumoniae, viridians etc)
```
Bacilli:
ABCDL
- Actinomyces
- Bacillus
- Clostridium
- Diptheriae
- Listeria
```
73
In what type of meningitis would the opening pressure of an LP be normal rather than raised?
Viral
74
What would the expected glucose be on LP in viral vs bacterial vs TB meningitis?
Viral: normal
Bacterial: low
TB: low
75
In which types of meningitis might the WCC be normal on LP?
Viral
| TB
76
What are the 2 most common causes of acute meningitis in adults?
Strep pneumoniae
| Neisseria meningitidis
77
How should contacts be treated of someone with acute meningitis?
PO ciprofloxacin
78
Which bacterium is an important cause of both meningitis and encephalitis?
L monocytogenes
79
Which demographic groups are most likely to be affected by listeria meningitis?
Neonates and the elderly
80
Recall 3 causes of chronic meningitis
TB
Cryptococcus
Syphillis
(chronic only really affects the immunosuppressed)
81
If the MRI report read, "leptomeningeal enhancement, basal cistern enhancement, dilation of ventricles", what would be the likely diagnosis?
TB meningitis
82
What is the most common cause of aseptic/viral meningitis?
Enterovirus (coxsackie A and B, echovirus)
83
What is the most common cause of encephalitis in the UK vs worldwide?
UK: HSV-2
Worldwide: WNV
84
How should encephalitis be treated?
```
IV acyclovir (10mg/kg, TDS) is first line
If CMV/EBV --> ganciclovir
```
85
What are the signs and symptoms of cerebral abscesses?
Raised ICP + fever
86
Which types of cerebral abscess are most likely to be peripheral vs deep?
Peripheral: bacterial abscesses
Deep: toxoplasma asbscesses
87
How long does a seizure need to last to count as status epilepticus?
>5 mins
| >30 mins is OLD definition
88
Recall the stepwise management of status epilepticus
(1) Open and secure airway
(2) Oxygen and suction as required
(3) IV access and take blood:
- FBC, U&E, LFT
- Glucose
- Ca2+
- Toxicology screen if indicated
- Anticonvulsant levels
(4) IV bolus
- Lorazepam 4mg IV
- Give 2nd dose of lorazepam if no response after 10 minutes
(4.5)
If alcoholism/ malnourishment suspected --> thiamine
If glucose is low --> 50% glucose IV
If hypotensive --> correct with fluids
(5) (If seizures continuing)
- Phenytoin (monitor ECG and BP)
(6) If continuing seizures after 60 mins --> general anaesthesia
89
What should be done in addition to an A to E assesment when assessing a head injury?
- Assess events (retrogate and anterograde amnesia)
- CNS examination
- Early involvement of anaesthetics and ITU
90
What are the 5 criteria for immediate CT head?
- GCS <13 or <15 2 hours post-injury
- Suspected skull fracture
- Post-traumatic seizure
- Focal neurological deficit
- >1 vomit
91
Recall 4 signs of skull fracture
Haemotypanum
'Panda eyes'
CSF rhinorrhoea/ otorrrhoea
Battle sign (mastoid ecchymosis)
92
Recall 4 criteria for soon (within 8 hours) CT head following trauma
ABCD
- Age >65
- Bleeding/ clotting disorders (including current anticoagulation)
- (Re)Collection of events before missing (retrograde amnesia)
- Dangerous mechanism of action (eg involving a motor vehicle, or fall from >1m/ 5 stairs)
93
Recall 4 criteria for an immediate CT spine
- GCS <13 on initial assesment
- Patient intubated
- Ruling out needed (eg for surgery)
- Clinical suspicion and age >65/ focal neurology/ high-impact injury/ limb paraesthesia
94
What would the expected pupil size and light response be in 3rd nerve compression secondary to tentorial herniation?
Unilateral dilated pupil
| Light response sluggish or fixed
95
What would the expected pupil size and light response be in BL 3rd nerve palsy/ poor CNS perfusion?
BL dilated pupils with sluggish/fixed light response
96
What would the expected pupil size and light response be in optic nerve injury?
Unilaterally dilated/ equal and cross-reactive light response
97
What is a normal ICP?
<15mmHg
98
If a headache is described as 'worse when leaning forward' what is this typical of?
Raised ICP
99
What is Cheyne-Stokes respiration and what is it a sign of?
Sign of raised ICP
| Periods of gradual hypopnoea and hyperpnoea interspersed by periods of apnoea
100
What can be done in ventilated patients to help bring ICP down?
Hyperventilate --> cerebral vasoconstriction --> reduced ICP
101
What are the 3 subtypes of cauda equina syndrome, and what are their symptoms?
CES-S: CES-suspected = BL sciatica, perianal sensory issues + sphincter issues
CES-I: CES-incomplete = voluntary control of micturition, objective signs/evidence of CES
CES-R: CES-retention/complete = complete urinary retention, overflow incontinence
102
At what spinal level does the cauda equina begin?
L2
103
Recall 2 'white flags' for cauda equina
White flags = too late
Urinary retention
Urinary/faecal incontinence
104
Recall 3 red flags for cauda equina
Red flag = ACT NOW, before it is too late
BL sciatica
Saddle anaesthesia
Lower limb weakness
105
Recall and justify some useful investigations in suspected cauda equina syndrome
Lower limb neuro exam (will be abnormal in CE compression)
Saddle anaesthesia (will be reduced sensation in CE compression)
DRE (reduced anal tone in CE compression)
Bladder scan (will show urinary retention in CES as lose sensation of fullness)
MRI as 2nd line to visualise cause
106
Recall 2 options for cauda equina management
If metasatic disease --> PO dexamethosone whilst awaiting MRI resluts
If within 48 hours of bladder dysfunction --> decompressive laminectomy
107
Which 3 types of cancer are most likely to cause spinal cord compression?
Lung, breast and prostate
108
What 2 things typically make back pain worse in spinal cord compression?
Lying down
| Coughing
109
What is the difference in symptoms between a spinal cord compression above vs below L1?
Above L1: UMN signs and sensory level
| Below L1: LMN signs and peripheral numbness
110
How should suspected spinal cord compression be investigated
Whole spine MRI within 24 hours
111
How should spinal cord compression be managed?
Dexamethosone +/- radiotherapy (if frail, or multiple lesions) or surgery (if not frail, and there are fewer lesions)
112
What investigations are important in DKA?
To establish DKA: BM, ketones, pH
Any needed to find cause (eg infection/ surgery/ chemo depending on BG)
Assess the damage (CRP, ECG, CXR, BC)
113
At what level of ketones would you consider transfer to ITU/HDU?
>6
114
Recall 4 possible complications of DKA
VTE
Aspiration pneumonia
Cerebral oedema
Electrolyte imbalances (low K+/Mg2+/PO4,3-)
115
How much KCL should you add per litre of saline in hypokalaemia (during DKA)?
40mmol
| If K+ <3.5, contact HDU/ITU for higher doses
116
In hypoglycaemia, when would you give IM/IV treatment rather than PO treatment?
BM <4 and unconscious/ no swallow
117
Recall how to manage hypoglycaemia based on the BM
BM >4: long acting CHO (eg bread)
BM <4: if able to swallow - glucotabs
if unable to swallow - IM glucagon or IV glucose 20%
118
How should myxoedema coma be managed?
```
IV T3 (5-20mcg/12 hours)
IV hydrocortisone (100mg/8 hours)
```
119
How should thyroid storm be immediately managed?
1st - propranolol (or digoxin if beta blockers CI)
2nd - carbimazole
3rd - hydrocortisone or dexamethosone
4th - treat cause
120
What is the ongoing management for thyroid storm?
- 4 hours after first dose of carbimazole --> Lugol's iodine for 10 days
- after 5 days of carbimazole treatment, reduce carbimazole from 20mg to 15mg, TDS, PO
- After 10 days, stop propranolol and iodine; adjust carbimazole
121
What is the mechanism of action of carbimazole?
Inhibits TPO
122
What are the 2 main symptoms of an Addisonian crisis?
Hypoglycaemia
| Shock
123
Recall the management of Addisonian crisis
IM hydrocortisone 100mg STAT then ongoing
| IV fluid bolus +/- glucose then ongoing fluid mx
124
What is the most useful investigation for phaeochromocytoma?
Urinary catecholamines
125
What is the management of phaeochromocytoma?
1st - short acting alpha blockade --> long-acting alpha blockade
2nd --> beta blockade
3rd (delayed a few weeks) --> surgery
126
What 3 investigations should be ordered in ALL suspected poisonings?
Glucose
Paracetamol
Salicylate
127
Recall 5 drugs in which haemodialysis may be indicated in OD?
```
BLAST
Barbiturates
Lithium
Alcohol
Salicylates
Theophylline
```
128
Recall the reversing agent for BDZs
Flumenazil
129
Recall the reversing agent for opiates
Naloxone
130
Recall the reversing agent for paracetamol
N-acetylcysteine
131
Recall the reversing agent for aspirin
sodium bicarbonate
132
Recall the reversing agent for TCAs
sodium bicarbonate
133
Recall the reversing agent for beta blockers
Atropine
134
Recall the reversing agent for ethylene glycol (anti-freeze)
Fomepizole
135
What is the most common side effect of NAC?
Rash (non-IgE mediated allergic reaction)
136
Recall the management of paracetamol OD
If <2 hours: activated charchoal followed by paracetamol levels >4 hours after ingestion --> NAC if indicated
If 2-8 hours: do a paracetamol level >4 hours post-ingestion --> NAC if indicated
If >8 hours, and ingested amount >75mg/kg --> NAC then paracetamol level
If ingestion time unknown or staggered OD (taken over 1 or more hours) --> NAC
137
When do AST and ALT peak post paracetamol OD ingestion?
72 hours
138
What LFT result will likely be normal in paracetamol OD?
ALP
139
When is transplantation indicated in paracetamol OD?
If PT>180s on day 4
140
Recall 3 specific symptoms of salicylate OD
Tinnitus
Hyperventilation
Vertigo
141
Within what time window can you give activated charcoal for salicylate overdose?
<1 hour
142
How do you choose between sodium bicarbonate and haemodialysis in salicylate OD?
Severe metabolic acidosis --> IV NaHCO3
| Organ dysfunction/seizures --> haemodialysis
143
What % of TBSA burned is an indication for fluid resuscitation?
10% (children)
| 15% (adults)
144
What is the gold-standard assesment tool for calculating TBSA affected in burns?
Lund and Browder chart
145
What 2 prognostic parameters are affected by burn depth?
Healing time
| Scarring
146
How should burns be temporarily cooled?
Saline/paraffin gauze and clingfilm
147
What is the definitive management for partial thickness burns?
Silver sulfadiazine cream +/- cerium nitrate
148
What is the Parkland formula?
4 x weight(kg) x %burn = mL Hartmann's in first 24 hours (give 50% in first 8 hours)
149
What is escharotomy?
Removal of tough, leathery eschar following burn rehydration - if it is left it can --> impaired circulation and compartment syndrome
150
Roughly recall Wallace's rule of 9s
18% of TBSA = back, chest, each leg
9& TBSA = head, each arm
1% = perineum
151
Describe the appearance of each different thickness of burn
Superficial epidermal = red and painful
Superficial dermal = pale pink, painful, blistered
Deep dermal = white with patches of non-blanching erythema, reduced sensation
Full thickness = white/brown/black in colour, no blisters or pain
152
What temperature counts as 'hypothermia'?
Rectal temp <35C
153
How can you tell if hypothermia is mild or severe?
```
Mild = shivering
Severe = no shivering
```
154
What ecg finding is pathognemonic of hypothermia?
J waves (Osborne waves)
155
How quickly should you rewarm someone who is hypothermic?
0.5C/hour
156
What must be remembered about CPR attempts in hypothermia?
Must be continued until core temp >33C as rarely successful when temp <30C
157
What are the 3 most common symptoms of carbon monoxide poisoning?
Headache
Nausea and vomiting
Vertigo
158
What investigations should be done in suspected CO poisoning?
Pulse oximetry will be falsely high --> do VBG/ABG
| Need to check carboxyhaemaglobin levels
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How high will carboxyhaemoglobin levels be in CO poisoning?
10-30%
160
How should CO poisoning be managed?
100% high-flow oxygen through nrb mask
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What are the signs and symptoms of hypoactive vs hyperactive delirium?
Hypoactive: lethargy, bradykinesia, excessive somnolence, inattention
Hyperactive: agitation, hallucinations/ delusions, wandering, aggression
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How should delirium be investigated?
Confusion assesment method/ AMTS
Bedside: exam, obs, urine dip, cap blood glucose
Bloods: baseline (FBC, U&Es), LFTs, B12, folate, TFTs, glucose, clotting, bone profile, blood culture
Imaging: CXR, CT head
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How should delirium be managed?
1. Treat cause, modify RFs, well-lit room with familiar people
2. PO haloperidol
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Recall 3 drug classes that can precipitate delirium
BDzs
Anti-cholinergics
Opioids
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How should tetanus-prone injuries be managed?
If they've had full course of tetanus vaccines with the last dose <10y --> nothing
If they've had the full course of tetanus vaccines with the last dose >10y --> reinforcing vaccine, and if a very high risk wound --> tetanus IV Ig
If they have an incomplete or unknown vaccine history --> reinforcing dose of vaccine + tetanus immunoglobin
