Emergency Conditions

Question 1

Anaphylaxis (criteria)

Answer 1

Any one of the following two criteria are fulfilled:
Criteria 1
Acute onset with simultaneous involvement of skin, mucosal and at least one of following:
a. Respiratory compromise
b. Reduced blood pressure
c. Severe gastrointestinal symptoms
Criteria 2
Acute onset of hypotension or bronchospasm of laryngeal involvement after exposure to a known or highly probably
allergen ( even in absence of typical skin or mucosal involvement )

Question 2

Anaphylaxis (treatment)

Answer 2

Cardiac arrest = ALS algorithm
No cardiac arrest
1. Adrenaline (1:1000) every 5 mins as needed - adult 0.5mL, children 0.01mL/kg
2. Cardiac monitoring, high flow O2, IV access
● Saline 1000mL adults, 20mL/kg children
*Refer to page 50 of GP study notes

Question 3

Working in the ED room of a remote hospital 500km away from the first tertiary hospital. 25M stung by an insect, BIB
friends. Looks unwell with swollen lips and gasping for air. SatO2 93%, HR 110, BP 86/50.Nil PHx.
(most likely diagnosis, 6 most important management steps)
Further information: After initiation of immediate management, pulse reduces to 100 but BP drops to 80/40. He is still
conscious. (What are your 3 management steps at this stage?)

Answer 3

What is the most likely diagnosis?
Anaphylactic shock
What are your 6 most important steps in his immediate management?
1. Adrenaline 0.5mg IM in anterolateral thigh
2. Call for assistance
50
3. Two large bore IV lines
4. Lay patient flat
5. Give high flow oxygen 8-10L via Hudson mask
6. Give IV normal saline 1L stat
7. Monitor vital signs
Further information: After initiation of immediate management, pulse reduces to 100 but BP drops to 80/40. He is still
conscious. What are your 3 management steps at this stage?
1. Repeat adrenaline 0.5mg IM every 3-5 mins
2. Call for air ambulance
3. Start IV adrenaline infusion
4. Continue rapid IV fluid resuscitation with normal saline

Question 4

Animal bites (evaluation and management)

Answer 4

Evaluation and management
1. Ensure patient is haemodynamically stable
2. Assess for injuries to adjacent structures
3. Evaluate for presence of foreign body
4. Neurovascular assessment
5. Treatment:
a. Deep tissue/systemic symptoms: Start IV amoxicillin + clavulanate
● Can use piperacillin + tazobactam if above not available
b. No deep tissue/systemic symptoms: amoxicillin + clavulanate PO for 5 days
● Can use metronidazole 400 mg + doxycycline if above not suitable

Question 5

Emergency room of a remote town. 67F, Aboriginal, drops in on the way to a funeral with a cat bite 24 hours ago.
Ongoing significant pain and swelling with fever. Hx obesity, T2DM (diet controlled). Smoker, social drinker. IUTD.
O/E: cat bites on hand, hand oedematous, red and hot to touch. BP 130/80.
(5 examination findings needing transfer to ED, initial mx before transfer, refusing to go - approach)

Answer 5

List 5 examination findings that would prompt you to admit Casey to hospital for further management?
● Evidence of deep infection (persistent or progressive pain, pain with passive movement)
● Presence of deeply embedded foreign body
● Vascular involvement
● Tendon damage
● Nerve damage
● Joint involvement
You decided to transfer Casey to a tertiary hospital unit. List 4 initial management steps you would take prior to
transfer.
● Administer tetanus booster
● Commence IV antibiotics - amoxicillin + clavulanate
● Administer analgesia - 2.5mg morphine IV
● Irrigate wound with normal saline
● Dress wounds
Casey refuses to go to the tertiary hospital. How would you manage this situation? List 4 management steps.
● Explore the reasons that Casey does not want to go to hospital
● Explain the reasons why you would like to transfer Casey including serious consequences
● Discuss her case with the emergency specialist for further treatment advice
● Involve an Aboriginal health care worker

Question 6

Chest pain (differentials, history, red flags, management)

Answer 6

Differential (Murtagh)
- Probable: MSK, psychogenic, angina
- Serious: CVD, cancer, infection, pneumothorax, oesophageal rupture
- Pitfalls: valvular issues, GORD, oesophageal spasm, herpes, rib #
- Masquerade: drug use, depression, anaemia
Key questions
1. Radiation
2. Other/associated symptoms e.g. syncope, inspiration, back pain
3. Pleuritic/reproducible
4. Haemoptysis
5. Injury/trauma to chest or back
6. Family history - significant if in any relative <55 years of age

Red flags

1. Dizziness/syncope
2. Pain in the arm/jaw
3. Thoracic back pain
4. Sweating
5. Palpitations
6. Haemoptysis
7. Dyspnoea
8. Pain on inspiration

Immediate management for acute myocardial infarction
1. Organise urgent ambulance transfer to the nearest emergency department
2. Aspirin 300 mg PO STAT dose chewed or crushed
3. GTN spray 400-800 microg sublingually, repeat every 5 minutes (up to 3 doses total if tolerated) - if
haemodynamically stable
4. IV morphine 2.5-5mg IV or fentanyl 25-50 microg IV - if persistent pain
5. Insert 2x 18G cannulas
6. 500-1000mL IV fluids STAT - if BP low
7. Oxygen supplementation if <94%
8. Repeat ECG/continuous cardiac monitoring

Question 7

Diabetes ketoacidosis (diagnostic criteria, causes, investigations, management hospital vs. GP)

Answer 7

Diagnostic criteria:
● BSL > 11
● Venous pH <7.3
● Ketonaemia >3 or urine ketone >2 on standard urinalysis

Common causes: noncompliance, inappropriate adjustment, or cessation of insulin, new-onset diabetes, AMI

Investigations:
● Serum glucose
● Urinalysis and urine ketones
● Serum electrolytes
● BUN and creatinine
● Plasma osmolality
● Venous blood gas
● ECG

Aim of management:
● Correction of fluid loss with aggressive IV fluid replacement
● Correction of hyperglycaemic and suppressive ketone production with insulin
● Correction of electrolyte disturbances (especially potassium)
● Thorough investigation for and management of concurrent infection or other precipitating conditions/factors

GP management:
● Urgent specialist input and transfer to hospital
● Support patient with emergency maintenance
● Establish IV access for fluids
● Monitor cardiac rhythm

Hospital management:
● Measure BSL (serum) hourly
● Give IV 0.9% sodium chloride STAT to patients with signs of shock
● Measure serum K+ - do not give insulin to patients if initial K+ is 3.3, replace K+ first

Question 8

Foreign body - airway

Answer 8

Management: Prone position with blows to the back. Heimlich manoeuver not recommended.

** Refer to page 165 of GP Study Notes

Question 9

2M, BIB mother, 3/52 persistent cough. CXR was normal. Had seen another GP and completed 2x courses of ABx.
Cough was dry but now it is more productive. O/E: T 37.9, slightly reduced AE on R) lower lung with minimal wheeze.

1. What is the most important diagnosis for the patient’s presentation?
2. What investigation would be most helpful at this stage?
3. Your investigations and assessment are suggestive of the most important differential diagnosis. What is your most appropriate management option?

Answer 9

What is the most important diagnosis for the patient’s presentation?
● Inhaled foreign body
What investigation would be most helpful at this stage?
● Inspiratory and expiratory chest films
Your investigations and assessment are suggestive of the most important differential diagnosis. What is your most
appropriate management option?
● Urgent referral to hospital

Question 10

Working in ED of a district hospital located in a small remote town. 45M, carpenter, injury at work with nail gun. In
good health with childhood immunisations. O/E: no sign of significant neurovascular injury. Able to bend his finger at
all joints.

1. Apart from investigations, what are the 4 initial management steps that you may take?
2. You decide to remove the foreign body at the emergency room.What are the 3 most likely short and long term complications of this injury that you need to warn Daniel about?
3. Daniel comes back to see you in 4 months with a complaint about his finger. He describes it as locking finger in flexion at the DIP which requires passive extension to put it back in full extension. What is your diagnosis?

Answer 10

Apart from investigations, what are the 4 initial management steps that you may take?
● Provide strong pain relief with subcutaneous morphine
● Tetanus immunisation
● Removal of foreign body under ring block
● Wound irrigation
You decide to remove the foreign body at the emergency room.What are the 3 most likely short and long term
complications of this injury that you need to warn Daniel about?
● Wound infection
● Loss of sensation due to damage to digital nerves
● Reduce flexion power at distal phalanx due to damage to tendon
● Joint stiffness due to damage to joint structure
● Bleeding
Daniel comes back to see you in 4 months with a complaint about his finger. He describes it as locking finger in
flexion at the DIP which requires passive extension to put it back in full extension. What is your diagnosis?
● Trigger finger

Question 11

Head injury - indications of Ix, treatment

Answer 11

Treatment based on severity:
Trivial
- No red flags on history or examination + GCS 15
-Discharge home with advice for analgesia and when to re-present for assessment
Mild/concussion
- GCS 13-15 with signs of mild head injury (headache, drowsiness, vomiting, LOC >5 secs, not acting normally)
- Observe in ED for up to 6 hours after trauma with 30 minutely neurological
observations.
- Discharge home if returns to baseline or further investigation if persisting.
Moderate
- GCS 9-12
- Consult senior doctor or neurosurgeon for advice

Investigations: Indications as below
● Sign of basal skull fracture on secondary survey
● Focal neurological deficit
● Suspicion of open or depressed skull fracture
● GCS <8
● GCS persistently <13
● Suspected non-accidental injury
● Seizure lasting for more than 2 mins after impact

Question 12

Illicit drugs - methamphetamines (type, mechanism, clinical course, other symptoms, management)

Answer 12

*** Symptoms and complications similar to cocaine but last longer.
Type: Stimulant
Mechanism: CNS excitation and peripheral sympathomimetic
Clinical course: Euphoria → apprehension, agitation, altered mental state, seizure, coma
Other symptoms: Tachypnoea, mydriasis, tremor, diaphoresis and hyperpyrexia +/- hallucinations
Management: DRSABCD → airway support → IV benzodiazepine, fluid resuscitation and treatment of hyperthermia

Question 13

Box jellyfish or sea wasp (Chironex fleckeri)

examination, prevention, treatment

Answer 13

Key points:
● Most dangerous
● Can cause sudden death (cardiopulmonary failure)
● In the coast of tropical areas
Examination: Frosted ladder appearance
Prevention: Avoid exposure to ‘jellyfish alert’ areas. Use a ‘stinger suit’.
Treatment: ** do not use pressure immobilisation bandaging
1. Remove victim from water to prevent drowning
2. Remove tentacles
3. Pour vinegar over sting site and surrounding areas
4. Use cold pack for small stings and ice massage for large areas
5. Check respiration and pulse
6. Commence CPR (if necessary)
7. Gain IV access
8. Give oxygen (if necessary)
9. Give box jellyfish antivenom IV for major stings (if in cardiovascular compromise)
10. Provide pain relief

Question 14

Bluebottle (Physalia) jellyfish

features, treatment

Answer 14

Key points:
● Common
● Mostly in NSW and Queensland
Clinical features:
● Intense local pain
● Linear red eruption
● Systemic effects in less than 2% of cases
Treatment: ** Use of vinegar not helpful and can cause more pain
● Wash sting site with sea water
● Remove any tentacles by hand or wash them off with sea water
● Immerse affected area in hot water (45 degrees) for 20 mins

Question 15

Tiny Box Jellyfish

presentation, management

Answer 15

Presentation: Mild sting with a delayed severe syndrome (~ after 30 mins)
● Severe generalised back, abdominal and muscle pain/cramps
● Chest pain, sweating and anxiety
● Restlessness, ‘impending doom’ feeling
● Headache, nausea, vomiting
● Tachycardia, hypertension
Management: No antivenom available. First aid as other jellyfish.

Question 16

Lead poisoning (key point, exposure, presentation)

Answer 16

Key point
● Should be considered in children with development delay, pica (e.g. chalk eating), or where there is history suggesting exposure

Exposure: environmental factors around mining towns or near smelters, occupational factors in mining and manufacturing industries.

Presentation:
Acute
- CNS toxicity
● Fatigue, weakness, headache
● Encephalopathy (altered conscious state and
seizures)
● Cerebral oedema, coma
- GI effects - abdo pain, N&V, constipation
- Other - haemolytic anaemia, hepatitis

Chronic
- CNS effects - poor concentration, headache, impaired coordination, aggressive behaviour, intellectual impairment
- GI effects - abdo pain, anorexia, constipation, weight loss
- Kidney and CV effects - HTN, gout, nephropathy,
Fanconi syndrome
- Other - chronic anaemia, arthralgia, myalgia, reduced
fertility, dental caries

Question 17

Near drowning (rules to remember, key management issues)

Answer 17

Rules to remember:
● Victims can response to resuscitation up to 30 mins of immersion
● Mouth to mouth should always be attempted
● All symptomatic patients should receive high flow oxygen
● Artificial surfactant via ETT can be given in children (no evidence for adults yet)
● No difference in outcome between salt-water and fresh-water drowning
Key management issues:
● Ventilation and oxygenation are the initial priorities
● Resuscitation should follow standard advanced life support protocols
● Prolonged resuscitation efforts are indicated

Question 18

Paracetamol poisoning

Answer 18

Toxic doses:

• 10g (or 200mg/kg in patient under 50kg) over 24 hour period
• 20g (or 300mg/kg in patients under 40kg) over 48 hour period

Management: Urgent referral to ED for acetylcysteine.

Question 19

Snake bite (complications, first aid, principles of management)

Answer 19

Complications:
● Coagulopathy (** most important and common major effect)
● Neurotoxicity - progressive descending flaccid paralysis
● Myotoxicity - rhabdomyolysis
● Acute kidney injury
First aid: Pressure bandage over the bite side and whole affected limb and completely immobilise the patient.
Pressure bandage should only be removed if (1) antivenom therapy has started, (2) clinical and laboratory
assessment confirms there is no evidence of systemic envenoming.
Principles of hospital management:
● Adequate antivenom
● 24 hour onsite laboratory that can perform coagulation studies
● Critical care facilities where antivenom can be safely administered and anaphylaxis can be treated

Question 20

Snake bite - antivenom therapy

Answer 20

Contact positions information centre 13 11 26 (if considering).

Indication: systemic envenoming.

Timing: within 2 hours of the bite. ** There is no role if after 12 hours

Type:
- Monovalent: Antibodies from one group (e.g. tiger snake, brown
snake)
- Polyvalent: Antibodies to five snake groups (black snake, taipan,
death adder, tiger snack and brown snake)

Question 21

Spider bite - key points

Answer 21

● Big black spider bites must be managed as suspected funnel-web spider bites
● Red-back spider bites do not cause life-threatening effects but can cause significant pain/systemic effects
● All other Australian spider bites only require symptomatic relief

Question 22

Red-back spider bite (key words, features, treatment)

Answer 22

Key words: dark and dry places outdoors (e.g. shoes, helmets)
Clinical features: radiating pain from the bite site to the draining lymph nodes and proximal limb, regional sweating
Treatment: ** do not use pressure bandage
1. Ensure tetanus up to date
2. Analgesia
3. Observe patient until they are asymptomatic or their pain is adequately controlled
Note: Pain can last up to 5 days

Question 23

Funnel-web spider bite (key points, presentation, management, post-treatment)

Answer 23

Key points:
● Most dangerous
● Can cause sever, life-threatening envenoming

Presentation:
● Localised pain and bleeding
● Localised neuromuscular toxicity (paraesthesia, numbness, muscle fasciculations)
● Severe envenoming (rare)

Management:
1. Pressure bandage over bite site and whole affected limb
● Broad (15cm) bandage to be used
2. Complete immobilisation of the affected limb and patient
3. Rapid transportation to hospital that has funnel-web spider antivenom
4. Resuscitation (if required)
5. Antivenom (if required)
6. Ensure tetanus up to date

Post-treatment:
● All patients treated with antivenom require admission
● Monitor for 12-24 hours until symptoms have resolved
Note: Patient with suspected funnel-web spider bite should be monitored for at least 4 hours after bite and at least 2 hours after the removal of the pressure bandage.