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Year 5 Core Conditions > Emergency Conditions > Flashcards

Emergency Conditions Flashcards

1
Q

What amount of paracetamol results in a risk of severe liver damage being unlikely when considering paracetamol toxicity?

A

<150ml/kg

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2
Q

When is risk of severe liver damage likely in paracetamol poisoning - what amount per kg?

A

> 250mg/kg

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3
Q

When is judged on LFTs to be severe liver damage?

A

A peak ALT more than 1000IU/L

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4
Q

In an A-E assessment, what are the airway noises that may be present, and what can they represent? (4)

A
  1. Normal e.g. talking = airway patent
  2. Stridor = upper airway obstruction
  3. Gurgling/stridor = not maintaining own airway
  4. See-sawing of chest = breathing against an obstructed airway
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5
Q

In terms of B for the A-E assessment, what needs to be done? (7)

A
  1. Inspection
  2. Palpation - central trachea?
  3. Auscultation - air entry equal? wheeze?
  4. Respiratory rate
  5. Sp02
  6. ABG if <94% or have COPD
  7. CXR if resp. symptoms
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6
Q

In the circulation aspect of an A-E assessment, what needs to be done? (11)

A
  1. Inspection - grey? mottled?
  2. Palpation - peripheries
  3. Pulses
  4. Cap refill time - central
  5. End organ perfusion - conscious state/urine output
  6. Pedal or sacral oedema?
  7. Heart rate
  8. Blood pressure
  9. IV access, send bloods, VBG, blood cultures etc.
  10. Fluids?
  11. ECG is chest pain or tachy/brady
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7
Q

What details in a history are important to establish when assessing someones hydration status? (10)

A
  1. Bleeding - from any source
  2. Vomiting - frequency, amount, blood
  3. Stools - frequency, amount, blood
  4. Fever and diaphoresis
  5. Urine output - colour and amount
  6. Lightheaded at rest or on standing
  7. Thirst?
  8. Eating and drinking status
  9. Symptoms of fluid overload? - SOB, orthopnoea, leg swelling
  10. Is the patient on a fluid restriction for a medical condition e.g. heart failure
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8
Q

What data in the bedside charts is important for assessing a patients hydration status? (7)

A
  1. Vital signs - HR, BP, RR
  2. Fluid balance chart - input/output
  3. Daily weight
  4. Stool chart
  5. Medication chart - diuretics?
  6. Fluid prescription chart
  7. Surgical documentation - estimated blood loss, transfusions
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9
Q

What elements of hydration status can be assessed on the hands/arms? (5)

A
  1. Peripheral temperature
  2. Peripheral cap refill
  3. Radial pulse
  4. BP
  5. Skin turgor
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10
Q

What elements of hydration status can be assessed on the face and neck? (4)

A
  1. Mucous membranes
  2. Sunken eyes
  3. Conjunctival pallor
  4. JVP
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11
Q

What elements of hydration status can be assessed on the chest, abdomen and legs? (7)

A
  1. RR
  2. Central cap refill
  3. Four heart valves - S3 gallop rhythm can be a sign of fluid overload
  4. Auscultate the lungs for coarse crackles - pulmonary oedema
  5. Assess for sacral oedema
  6. Ascites
  7. Pedal oedema
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12
Q

What outputs can be checked when assessing hydration status? (3)

A
  1. Urine outputs - quantity, volume, colour
  2. Drain outputs - quantity and type
  3. Wounds - fluid losses and type e.g. blood, pus
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13
Q

In the disability part of the A-E, what needs to be assessed? (6)

A
  1. GCS
  2. AMTS
  3. Glucose - CBG
  4. Pupils - PEARL?
  5. Moving all limbs?
  6. Temperature
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14
Q

In the exposure part of A-E, what needs to be assessed? (5)

A
  1. Abdominal exam
  2. DVT?
  3. Bruises/rashes
  4. Clues - drug charts, collateral history
  5. Establish working diagnosis and give treatment
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15
Q

List all of the possible A-E assessments that can present? (17)

A
  1. Anaphylaxis
  2. Pneumothorax
  3. Acute asthma
  4. Exacerbation of COPD
  5. Acute pulmonary oedema
  6. PE/DVT
  7. Sepsis
  8. MI
  9. Upper GI bleed
  10. Blood transfusions
  11. Tachyarrhythmias
  12. Bradyarrhythmias
  13. Seizures
  14. DKA
  15. Hypoglycaemia
  16. Opiate overdose
  17. Hyperkalaemia
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16
Q

What is the management for anaphylaxis?

A
  1. Call for help
  2. Give 15L high flow oxygen
  3. Raise legs 45 degrees
  4. Adrenaline 500mcg 1:1000 IM
  5. Chlorphenamine 10mg IV
  6. Hydrocortisone 200mg IV
  7. NaCl 500ml 15 minutes
  8. NEBs salbutamol/ipratopium bromide
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17
Q

Who is at risk of a tension pneumothorax? (4)

A

Patients who experience:

  1. Trauma
  2. Ventilated patients
  3. Post-CPR
  4. Cardiothoracic surgery
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18
Q

What are the clinical signs of a tension pneumothorax? (5)

A
  1. Deviated trachea
  2. Cyanosis
  3. Absent breath sounds
  4. Resonant to percuss
  5. Hypotension (obstructive shock)
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19
Q

What is the management for tension pneumothorax? (4)

A
  1. 15 L high flow oxygen
  2. CALL FOR HELP (risk of cardiac arrest)
  3. Cannula (2nd intercostal space midclavicular line OR 5th intercostal space midaxillary line)
  4. Definitive = chest drain
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20
Q

What constitutes a secondary pneumothorax?

A

Age >50 with significant smoking history or evidence of underlying disease

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21
Q

What is the size of a spontaneous pneumothorax that warrants action?

A

> 2cm

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22
Q

What are the parameters that constitute a life-threatening asthma? (only need one)

A 
33, 92 CHEST
PEFR <33% of predicted
02 sats <92%
Cyanosis
Hypotension
Exhaustion/LOC
Silent chest
Tachycardia
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23
Q

What are the parameters that constitute an acute severe asthma attack? (4)

A
  1. PEF 33-50% best or predicted
  2. RR >25/min
  3. HR >110/min
  4. Inability to complete sentences in one breath
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24
Q

When is a life-threatening asthma attack near fatal?

A

Raising pCO2 and/or needing ICU

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25
Q

What is the mnemonic for management of an asthma attack?

A 
O SHIT ME
-ABG first if O2 <92% and CXR, PEFR
- Oxygen
- Salbutamol NEBS 5mg
- Hydrocortisone 100mg IV OR Prednisolone 40mg PO
- Ipratropium bromide 500mcg QDS
CALL FOR HELP
- Magnesium sulphate IV 2g 
- IV aminophylline/theophylline
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26
Q

What needs to be assessed in someone presenting with an exacerbation of COPD? (7)

A
  1. Ask them about previous NIV, ICU admissions, home NEBs, LTOT
  2. No. of admissions in the last 12 months
  3. ABG straight away - ideally on air
  4. CXR
  5. ECG
  6. Bloods - theophylline level if on it regularly
  7. Sputum culture +/- blood cultures
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27
Q

When is NIV e.g. BiPAP indicated for someone with an exacerbation of COPD?

A

Refractory type 2 respiratory failure despite one hour of maximal medical therapy

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28
Q

What is the difference in management for someone with an acute exacerbation of COPD as opposed to life-threatening asthma? (5)

A 
1. Oxygen: 
asthma = 15L O2 NRBM   
COPD = 24-28% venturi, adjust to ABGs, target 88-92%
2. Salbutamol
asthma = 5mg driven with 6L O2
COPD = 5mg through air
3. Steroids 
asthma = 40mg Pred PO
COPD = 30mg Pred PO 
4. Ipratropium 
asthma = 500mcg driven with 6L O2
COPD = 500mcg air 
5. Escalation
asthma = intubate and ventilate
COPD = NIV after 1 hour if type 2 respiratory failure on ABG
(theophylline and mag sulphate for seniors)
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29
Q

What are the causes of acute pulmonary oedema?

A
  1. Stenotic valves
  2. Fluid overload
  3. Heart failure
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30
Q

What will be found on assessment for someone with pulmonary oedema?

A
  1. B - bibasal crepitations, reduced air entry, stony dullness to percuss. (CXR)
  2. C - ECG - MI? Murmur S3 - heart failure?
  3. E - pedal or sacral oedema
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31
Q

What is the management for acute pulmonary oedema?

A

OMFG

  1. Sit them up and stop fluids
  2. Oxygen - 15L NRBM
  3. Morphine - 2mg IV
  4. Furosemide 40-80mg IV
  5. GTN - 2 puffs every 5 minutes

(CPAP if no better)

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32
Q

When should a PE be suspected?

A

There should be a high index of suspicion for these… anyone with:

  1. New hypoxia
  2. Type 1 respiratory failure
  3. Pleuritic chest pain, breathlessness, haemoptysis
  4. ECG - sinus tachycardia most common (S1Q3T3)
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33
Q

What are the risk factors for a PE?

A
  1. DVT
  2. Immobility
  3. Previous VTE
  4. Haemoptysis
  5. Malignancy
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34
Q

What is the pathway for investigations for PE?

A 
Suspected PE
Is the patient unstable (right heart strain/hypotension)
if yes --> thromboylsis
if no --> WELLS score 
Wells 4 or more = CTPA (V/Q if preg) 
Wells <4 = D dimer check
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35
Q

What are the causes of a positive D dimer? (6)

A
  1. PE
  2. Recent surgery
  3. Malignancy
  4. Pregnancy
  5. Liver failure
  6. Infection
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36
Q

What is the management for PE? (4)

A
  1. LMWH
  2. Switch to long-term NOAC or warfarin
    - this is where bridging happens giving both LMWH and warfarin
    (NEVER GIVE NOAC AND LMWH at the same time)
  3. Provoked = 3 months, unprovoked = 6 months
  4. Follow up ECHO to look for pulmonary hypertension
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37
Q

In terms of sepsis recognition, what are the parameters for diagnosing SIRS? (4)

A

Two from these four…

  1. HR > 90bpm
  2. RR > 20
  3. Temp < 36 or >38
  4. WCC <4 or >12
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38
Q

What are the parameters for qSOFA? (3)

A

Two from these three…

  1. Hypotension
  2. Altered mental status
  3. Tachypnoea
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39
Q

What 3 things are needed generally for a diagnosis of STEMI?

A

ECG changes
Myocardial injury markers - troponin
Clinical symptoms

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40
Q

What may be seen on ECG for an NSTEMI?

A
  1. T wave inversion

2. ST depression

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41
Q

Which type of MI may lead to arrhythmias?

A

Inferior - right coronary artery supplies the SAN and AVN

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42
Q

What are the causes of raised troponins?

A
  1. Acute MI (type I and 2 - thrombosis and ischaemia)
  2. Aortic dissection
  3. Myocarditis
  4. PE
  5. Sepsis
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43
Q

What is the early management for MI?

A

MONAC

  1. Morphine + metoclopramide
  2. Oxygen (only if low O2%)
  3. Nitrates 2 puffs GTN
  4. Aspirin 300mg
  5. Clopidogrel 300mg/Ticagrelor 180mg
44
Q

What is the gold standard treatment for STEMI?

A

PCI

45
Q

What is the management for NSTEMI?

A
  1. MONAC
  2. GRACE/TIMI scores
    …if high risk = glycoprotein 2b3a inhibitors - abciximab
  3. PCI within 96 hours
46
Q

What is the medical management for secondary prevention of ACS?

A 
MONACBASH full therapy
B - bisoprolol
A - ace inhibitors 
S - statins - atorvastatin 80mg 
H - heparins - fondaparinux unless for PCI  then unfractionated heparin
47
Q

Causes of upper GI bleeds? (5)

A
  1. Oesphageal varices
  2. Peptic ulcers
  3. Oesphagitis
  4. Cancer
  5. Mallory-weiss tears
48
Q

Causes of lower GI bleeds? (5)

A
  1. Diverticulae
  2. UC
  3. Mesenteric ischaemia
  4. Infectious - dysentery e.g. Shigella
  5. Cancer
49
Q

What is the management in the A-E assessment for someone with an upper GI bleed? (A-C)

A

Airway - bowl, suction
Breathing - 15L NRMB as critically unwell, but realistically may be nasal cannulae due to vomit/blood
Circulation - 2X 16G canulae ACF - bloods = FBC, U&Es, LFTs, clotting, cross match,
1 litre Hartmanns/0.9% NaCl
SENIOR HELP - activate massive transfusion protocol

50
Q

What type of blood is given in A&E resus/delivery suite?

A

O-negative

51
Q

What is the difference between the glasgow blatchford score and the rockall score?

A

GB score is the need for endoscopy

Rockall predicts mortality

52
Q

What is the management after A-C for an upper GI bleed? (6)

A
  1. Antiemetic
  2. If varices - terlipressin, prophylactic antibiotics
  3. Sengstaken-Blakemore/Minnesota tube - pass like NG tube, inflate balloon in the stomach and then put tension on it to tamponade bleeding varices
  4. Call gastro - endoscopy –> variceal banding –> thermal coagulation of ulcer
  5. TIPPS - transvenous intrahepatic Porto-Systemic Shunt to reduce risk of rebleeding
  6. H. pylori test and treat
53
Q

What are the causes of seizures? (7)

A
  1. Epilepsy
  2. Electrolyte abnormalities e.g. hyponatraemia, hypercalcaemia
  3. Intracranial haemorrhage
  4. Low CBG
  5. Recreational drugs
  6. Local anaesthetic toxicity
  7. Lithium toxicity
54
Q

In terms of seizures and timelines, what is the management?

A

0-5 minutes = O2 and monitor
5-30 minutes = IV lorazepam 4mg OR buccal midazolam 5mg OR rectal diazepam 10mg
30-60 minutes = phenytoin infusion 18mg/kg IV
60 minutes = escalate to ICU –> thiopentone rapid sequence induction

55
Q

What are the common triggers for DKA? (5)

A
  1. First presentation of T1DM
  2. Missed insulin
  3. Infection
  4. Pregnancy
  5. Gliflozins e.g. empagliflozin for T2DM can cause DKA with normal blood sugar
56
Q

What are the three parameteres that need to be met for DKA to be confirmed?

A

D - glucose >11mmol/L
K - ketones >3mmol/L capillary or ++ in urine
A - VBG pH<7.3 or bicarb <15mmol/L

57
Q

On assessment for someone with DKA, what signs/vitals would indicate someone requires HDU/contact critical care outreach? (5)

A
  1. Ketones >6mmol/L
  2. pH <7.0
  3. Hypokalaemia <3.5mmol/L
  4. GCS <12
  5. BP <90 systolic/ HR >100bpm
58
Q

What is the immediate management for someone with confirmed DKA? (3)

A
  1. IV access - bloods for FBC, U&Es, LFTs, VBG/venous glucose
  2. One litre 0.9% NaCl over 1 hour (unless hypotensive = 500ml bolus)
    • then go get trust guidelines..
      (insulin 0.1%/kg/hour)
      (50 units actrapid in 49.5ml 0.9% NaCl)
59
Q

Which scale is used to determine symptoms of hypoglycaemia?

A

Edinburgh hypoglycaemia scale - divided into autonomic, neuroglycopenic, malaise

60
Q

What are the clinical features of hypoglycaemia? (10)

A
  1. Sweating
  2. Palpitations
  3. Shaking
  4. Hunger
  5. Confusion
  6. Aggression
  7. Drowsiness
  8. Slurred speech
  9. Headache
  10. Nausea
61
Q

In adults with a CBG <4, who are conscious and can swallow safely, what is the management?

A

15-20g quick acting carbohydrate e.g. 5-7 Dextrosol tablets or 4-5 Glucotabs
OR
150-200ml pure fruit juice/lucozade
**after 15 minutes repeat CBG and give more carbs if necessary. Repeat up to 3 times if necessary, if still hypo, give IV 10% glucose at 100ml/hr

62
Q

If a patient with a CBG <4 is able to swallow, conscious but disorientated or aggressive what is the management?

A

If capable, treat as per mild hypo, but otherwise consider 1.5-2 tubes of 40% glucose gel (squeezed into mouth between teeth and gums). If ineffective, use 1mg glucagon IM

63
Q

If someone with hypoglycaemia is fitting/unconscious or NBM (nil by mouth), what’s the management?

A

Check ABC, stop IV insulin, contact doctor urgently.
Give IV glucose over 15 minutes as:
75ml 20% glucose or
150ml 10% glucose

Recheck glucose after 10 minutes and if still less than 4, repeat treatment.

64
Q

After an episode of hypoglycaemia, with a CBG now restored above 4mmol/L, what should you do?

A

If they have a safe swallow; give 20g long acting carbohydrate e.g. two biscuits/slice of bread/200-300ml milk
OR
If NBM, give 10% glucose infusion at 100ml/hour until reviewed by doctor

65
Q

If someone has a narrow complex tachycardia, what is it most likely?

A

SVT

66
Q

What is the treatment for SVT if they are stable? i.e. no hypotension, syncope or heart failure?

A
  1. Vagal manoeuvres - carotid massage, face into cold water, blow into a syringe (REVERT trial)
  2. Adenosine IV 6mg, 12mg, 12mg
67
Q

What is important to determine in someone with a broad complex tachycardia?

A

Do they have a pulse??!?!

68
Q

What is given to a patient with a bradycardia and adverse features?

A

Atropine 500mcg IV (repeat up to 3mg)

69
Q

What is seen on ECG for 1st degree heart block?

A

Prolonged PR interval 3-5 small squares

70
Q

What is seen on ECG for 2nd degree Mobitz type 1 AKA Wenckebach heart block?

A

PR interval gets longer and longer then drops a QRS

71
Q

What happens on the ECG in 2nd degree heart block Mobitz type 2?

A

Dropping QRS complexes regularly and in a pattern e.g. 2:1 or 3:1

72
Q

What happens in third degree heart block AKA complete heart block?

A

No association between atria and ventricles

73
Q

What is the triad of clinical features for an opiate overdose?

A
  1. Pinpoint pupils
  2. Reduced conscious levels
  3. Low respiratory rate
74
Q

What is important to remember when considering an opidate overdose? (4)

A
  1. Nothing else gives you a low RR
  2. Anyone with a new reduced GCS - think glucose, think opiates, think hypoactive delirium
  3. Beware patches and iatrogenic opiate overdose
  4. Beware new AKI - opiates excreted renally - new AKI will increase risk of accumulation
75
Q

What is the management for opiate overdose in terms of A-E assessment? (4)

A

Airway -

  1. O2 15L NRBM - may need bag mask and crash call
  2. ABG
  3. If RR<10 or persistent low GCS, give naloxone 400mcg IV
  4. If IVDU or no access give naloxone IM
76
Q

Naloxone is one of the few drugs you may have to give yourself. Nurses often refuse. How is it administered?

A

Up to 400mcg can be given IV, and generally it is given 1ml at a time.
Flush the cannula first, then give 1ml, then flush the cannula again. Give small doses as the patient may get aggressive or can be in pain.

77
Q

What is the best opiate to give for a patient with a low eGFR?

A

Oxycodone

78
Q

When should hyperkalaemia be suspected? (7)

A
  1. AKI
  2. Patients on Sando-K/IV potassium
  3. Potassium-sparing diuretics e.g. Spironolactone
  4. ACE inhibitors/ARB (co-trimoxazole can also cause it)
  5. CKD
  6. DKA
  7. Addisonian crisis
79
Q

What are the findings on ECG for hyperkalaemia? (3)

A
  1. Broad QRS
  2. Absent P waves
  3. Tall tented T waves
80
Q

What is the treatment for hyperkalaemia?

A
  1. 30ml 10% (or 10mls) calcium gluconate IV
  2. Insulin - actrapid 10 units in 50ml 50% dextrose (prescribe insulin/dextrose on IV fluid chart)
  3. 10mg salbutamol NEBs
81
Q

What is the calcium gluconate for in the treatment of hyperkalaemia?

A

Stabilises the myocardium

82
Q

What does the insulin do in the treatment of hyperkalaemia?

A

Pushes potassium intracellularly for 4-6 hours

83
Q

When performing CPR and shocks on a patient in VF, what is given and when to in terms of drugs?

A

Adrenaline 1mg IV or IO
Amiodarone 300mg IV
- to be administered following the third shock, and then administered after alternate shocks thereafter (approx. every 3-5 minutes)

84
Q

What is agonal breathing?

A

It is occasional gasps, slow, laboured or noisy breathing in an unconscious and unresponsive patient. It is not normal breathing and is common in early stages of cardiac arrest and CPR should be started.

85
Q

In a cardiac arrest with a non-shockable rhythm, when should adrenaline be given?

A

As soon as IV access is established and CPR has started - give 1mg adrenaline IV and further doses every 3-5 minutes

86
Q

What are the reversible causes of cardiac arrest?

A 
4 H's, 4 T's
Hypoxia
Hypothermia
Hyperkalaemia
Hypovolaemia
Toxins
Tamponade
Tension pneumothorax
Thrombosis - coronary or pulmonary
87
Q

What % of cardiac arrests are VF or pulseless VT?

A

20%

88
Q

In a cardiac arrest with a non-shockable rhythm, when should adrenaline be given?

A

As soon as IV access is established and CPR has started - give 1mg adrenaline IV and further doses every 3-5 minutes

89
Q

A mixed metabolic and respiratory acidosis is seen in which drug poisoning/toxicity?

A

Aspirin

90
Q

What are the symptoms of an aspirin overdose? (5)

A
  1. Hyperventilation
  2. Tinnitus
  3. Deafness
  4. Vasodilatation
  5. Sweating
91
Q

What is the most useful blood to do for a prognostic marker of paracetamol overdose?

A

Prothrombin time

92
Q

A 15 year old girl presents to ED having taken an OD of an unidentified tablet. She is feeling SOB and dizzy, and her ABG shows pH 7.49, PaO2 16 and PaCO2 3. What is the likely drug overdose?

A

Aspirin - respiratory alkalosis

93
Q

What happens in aspirin overdose in terms of alkalosis and acidosis?

A

Initially there will be a respiratory alkalosis due to stimulation of the brainstem medullary respiration centre. This is later followed by metabolic acidosis, due to the uncoupling of oxidative phosphorylation.

94
Q

What are the early features of a tricyclic antidepressant overdose? (5)

A
  1. Dry mouth
  2. Dilated pupils
  3. Agitation
  4. Sinus tachycardia
  5. Blurred vision
95
Q

What features would indicate a severe poisoning of tricyclics? (4)

A
  1. Arrhythmias
  2. Seizures
  3. Metabolic acidosis
  4. Coma
96
Q

What ECG changes are seen with tricyclic antidepressant overdose?

A
  1. Sinus tachycardia
  2. Widening of QRS
  3. Prolongation of QT interval
97
Q

What is the first line management for tricyclic overdose?

A
  1. IV bicarbonate is first line for hypotension or arrhythmias
    OR
    other drugs for ventricular arrhythmias
  2. IV lipid emulsion is increasingly used to bind free drug and reduce toxicity
98
Q

What is the single most important factor in the criteria for liver transplantation? - which blood reading?

A

Arterial pH

99
Q

If an aspirin overdose has been taken, what investigations need to be done?

A
  1. Plasma salicylate (these will rise over several hours)
  2. pH
  3. U&Es - electrolytes
100
Q

What is the management of an aspirin overdose if it is mild-moderate?

A
  1. Activated charcoal (within 1 hour if more than 125mg/kg ingested)
  2. Replace fluid losses
  3. IV sodium bicarbonate
101
Q

What needs to be checked before giving sodium bicarbonate to treat aspirin overdose?

A

Plasma-potassium concentration - because hypokalaemia may complicate alkalisation of the urine (the urine should be between pH 7.5-8.5)

102
Q

What is the treatment for severe (>700mg/litre) aspirin/salicylate poisoning?

A

Haemodialysis

103
Q

What are the features of opioid poisoning?

A
  1. Coma
  2. Respiratory depression
  3. Pinpoint pupils
104
Q

When is naloxone indicated for opioid overdose?

A

If there is coma or bradypnoea

105
Q

Which opioid in particular will only be partially reversed with naloxone?

A

Buprenorphine

106
Q

What features could indicate hepatic necrosis in someone with paracetamol poisoning?

A

Right subcostal pain and tenderness

107
Q

When is acetylcysteine most effective in the treatment of paracetamol - up to what time point?

A

Up to 8 hours post-ingestion it is most effective

Year 5 Core Conditions (25 decks)

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