Emergency Med Flashcards
What GCS or below do we worry about airway compromise?
8 or below
What is the toxic dose of paracetamol?
75mg/kg
What bloods should be done at 4 hours post ingestion in paracetamol OD?
VBG INR U&Es LFTs FBC Paracetamol level
How long is the standard course of NAC?
21 hours
What 3 criteria do the bloods need to meet post NAC?
INR is 1.3 or less AND
ALT is less than two times the upper limit of normal AND
ALT is not more than double the admission measurement
What to do if a pt on warfarin is actively bleeding?
Stop warfarin
Give 5mg IV Vit K
IV prothrombin complex concentrate (octaplex)
What does Geriatric Admission Profile (GAPS) include?
U&E, FBC, LFT, glucose, CRP, calcium, B12 & folate, ferritin, iron and transferrin, TFT, vitamin D
Bamford stroke classification for TACS?
Unilateral weakness (and/or sensory deficit) of the face, arm and leg Homonymous hemianopia Higher cerebral dysfunction (dysphasia, visuospatial disorder)
Bamford stroke classification for PACS?
2 of 3 symptoms:
Unilateral weakness (and/or sensory deficit) of the face, arm and leg
Homonymous hemianopia
Higher cerebral dysfunction (dysphasia, visuospatial disorder)
What is a lacunar stroke?
Purely motor or sensory?
Mx of HTN in in the acute management of ischaemic stroke?
Avoid tx unless any of the following: hypertensive encephalopathy hypertensive nephropathy hypertensive cardiac failure/myocardial infarction aortic dissection pre-eclampsia/eclampsia
Causes of VF arrests?
Electrolyte abnormalities (hyperkalaemia, hypokalaemia, hypocalcaemia)
Toxins (particularly TCA od)
Hypothermia
Less commonly the other causes of cardiac arrest
What rhythm is seen in cardiac arrest?
PEA
What should be administered in cardiac arrest with non-shockable rhythm?
IV adrenaline
5Ds of Charcot’s foot?
Density change (areas of lucency and sclerosis) Destruction Debris (loose bodies and bone fragments) Distension (joint effusion) Dislocation (e.g. metacarpophalangeal joints)
Gas gangrene abx?
Tazocin + clindamycin
Tx for orthostatic hypotension?
Fludrocortisone
Midodrine
What temp increase should we aim for in hypothermia?
1 degree rise per hour
What formula should be used for burns victims fluid requirement in first 24 hrs?
Parkland Formula
Fluid required in 1st 24 hr = 4ml x patients weight in kg x % burn
Half should be given in first 8 hours and remainder over 16 hours
When to catheterise burns patient?
Patients with burns >20% TBSA or intubated
Patients with perineal burns or 15-19% TBSA catheterisation should be considered
When to refer to burns unit?
Burns > 10 % TBSA in an Adult
Burns > 5 % TBSA in a Child
Full thickness burns > 5% TBSA
Burns of face, hands, feet, perineum, genitalia, and major joints
Circumferential burns
Chemical or electrical burns
Burns in the presence of major trauma or significant co-morbidity
Burns in the very young patient, or the elderly patient
Burns in a pregnant patient
Suspicion of Non-Accidental Injury
First aid for minor burns?
Hold under cool running water for 20mins
Wrap in cling film
What layers do superficial, partial and full thickness burns affect?
Superficial - epidermis
Partial thickness - dermis
Full thickness - underlying subcutaneous tissue
What should you do with blistered areas of a burn?
De-roof, dress with non-adherent dressing and review in 48 hours
Which types of anaesthesia can cause malignant hyperthermia?
Volatile anaesthetic agents
Suxamethonium
CIs to lidocaine Tx?
SAN disease and all forms of AV block
How long does lidocaine take to work and wear off?
Few mins
Lasts 1-2 hours
MOA of lidocaine?
Local anaesthetics act on the smaller C fibres, which transmit pain and temperature sensation, before the larger A fibres, which transmit touch and power
Causes of prolonged QTc? (TIMMES)
Toxins: drugs including anti-arrhythmics, anti-psychotics, TCAs, macrolides
Inherited: congenital long QT syndromes such as Romano-Ward and Jervell and Lange-Nielson syndromes.
Ischaemia
Myocarditis
Mitral valve prolapse
Electrolyte abnormalities, such as hypokalaemia and hypocalcaemia
Subarachnoid Haemorrhage
Mx of DKA in hour 1 in adults?
A to E
1L 0.9% saline over 1 hour (if SBP <90 add STAT bolus 500ml in 15 mins)
Fixed rate insulin infusion (0.1 units/kg/hr) AFTER commencing fluid
What needs to be checked hourly in DKA?
Blood/capillary glucose
Blood/capillary ketones
Observations including GCS
AND continuous ECG
Fluid resuscitation in DKA in hours 2-12?
If K+ <5.5mmol/L add KCl
1L 0.9% saline + 40mmol KCl over 2 hours then
1L 0.9% saline + 40mmol KCl over 2 hours again then
1L 0.9% saline + 40mmol KCl over 4 hours then
1L 0.9% saline + 40mmol KCl over 4 hours again then
1L 0.9% saline + 40mmol KCl over 6 hours
Until when do you continue fixed rate insulin in DKA?
Blood ketones <0.3mmol/L AND
pH >7.3 AND
Bicarbonate >18mmol/L
Mx of DKA in hours 12-24?
Aim to have normal biochemical parameters
If patient unable to eat and drink then start sliding scale insulin
If able to eat and drink then restart subcutaneous insulin regimen - this will need some crossover with IV insulin.
Mx of HHS?
Fluid resuscitation
Insulin at 0.05 units/kg/hour
VTE prophylaxis
Fluid resuscitation in HHS?
Fluid of choice is 0.9% saline: 1L over 1-2 hours 1L (+KCl) over 2-4 hours 1L (+KCl) over 4-6 hours 1L (+KCl) over 6-8 hours 1L (+KCl) over 8-10 hours
What score is used prior to endoscopy in patients with an upper GI bleed?
Glasgow-Blatchford score
Any score >0 suggests medical intervention needed
What score is used after endoscopy in patients with an upper GI bleed?
What is it used to estimate?
Rockall score
Used to estimate the risk of re-bleeding and the risk of mortality
Define AKI
increase in serum creatinine of 26 μmol/L within 48 hours
increase in serum creatinine ≥1.5 times above baseline value within 1 week
urine output of <0.5 ml/kg/hr for > 6 consecutive hours
antidote for anti-freeze?
Fomepizole
Damage to which vessels causes extradural haemorrhage?
Middle meningeal vessels
Damage to which vessels causes subdural haemorrhage?
Bridging veins
drug-induced pancreatitis causes? FATSHEEP
Furosemide Azathioprine/Asparaginase Thiazides/Tetracycline Statins/Sulfonamides/Sodium Valproate Hydrochlorothiazide Estrogens Ethanol Protease inhibitors and NRTIs
Contraindications to thrombolysis in MI? AGAINST
Aortic Dissection GI bleed Allergic reaction Iatrogenic: recent surgery Neurological disease: recent stroke (within 3 months), malignancy Severe HTN (>200/120) Trauma, including recent CPR
What common SE can doxycycline cause?
Oesophagitis
4 adverse signs of tachycardia?
Shock
Sycope
Heart failure
Myocardial ischaemia
When can you immediately safely cardiovert in AF?
No adverse signs
Onset <48 hours
How long do patients need anticoagulation before and after cardioversion in AF?
3 weeks before
4 weeks after
Which meds are CI in WPW?
Digoxin
Verapamil
What carboxyhaemoglobin concentration is diagnostic of carbon monoxide poisoning?
> 20%
Beck’s triad of cardiac tamponade?
Raised JVP
Hypotension
Muffled heart sounds
What is Kussmaul’s sign?
Rise in JVP with inspiration
What is pulsus paradoxus?
Drop in SBP of about 15mmHg with inspiration
Aspirin od blood gas findings?
Initially respiratory alkalosis
Later metabolic acidosis
Features of unstable angina
Chest pain at rest or minimal exertion lasting >15 minutes
ECG changes (new ST-depression or T wave inversion)
NO rise in troponin: no myocardial necrosis
Features of NSTEMI
Chest pain at rest or minimal exertion lasting >15 minutes
ECG changes (new ST-depression of T wave inversion)
Rise in troponin: myocardial necrosis
Features of STEMI
Chest pain at rest or minimal exertion, lasting >15 minutes
ECG changes (new ST-elevation or left bundle branch block)
Rise in troponin: myocardial necrosis
Tx of bradycardia with HISS?
Atropine 500mcg IV Can repeat up to max of 3mg Isoprenaline 5mcg/min IV Adrenaline 2-10mcg/min IV or transcutaneous pacing
RFs for acute closed angle glaucoma?
Female
Asian
Use of antimuscarinics
Tx of acute closed angle glaucoma?
IV Acetazolamide and a topical beta-blocker such as Timolol
Causes of VT?
Electrolyte abnormalities such as hypokalaemia and hypomagnesaemia
Structural heart disease including Myocardial infarction and HOCM
Drugs that cause QT prolongation e.g. clarithromycin, erythromycin
Inherited channelopathies e.g. Romano-Ward syndrome, Brugada syndrome
Occlusion of the LAD puts you at increased risk of what?
Rupture of interventricular septum
What times should mast cell tryptase be measured?
Initially
4hrs
12hrs
What would you expect to find with an optic neuritis?
RAPD
A relatively dilated pupil on the affected side when a torch light is swung towards it
Clinical features of central retinal vein occlusion?
sudden painless loss of vision
stormy sunset on fundoscopy
Clinical features of central retinal artery occlusion?
sudden painless loss of vision over a few seconds
pale retina and cherry red spot at macula on fundoscopy
Clinical features of Ischaemic optic neuropathy?
sudden onset monocular vision loss and colour blindness
RAPD o/e
fundoscopy - optic disc swelling in the acute phase or a pale optic disc in the chronic phase that suggests optic atrophy
Clinical features of Retinal detachment?
floaters and flashes followed by a ‘curtain falling over’ their vision
pale-grey area of retina ballooning forward on fundoscopy
Clinical features of Vitreous haemorrhage?
If minor, patients complain of floaters, if severe, patients complain of painless loss of vision
Common in diabetics
Retina hard to view on fundoscopy
Clinical features of optic neuritis?
Painful loss of vision over hours to days
Pain on moving eyes
‘red desaturation’
Common in MS
What to do if a pt has an anaphylactoid reaction to NAC?
Stop infusion
Give 10mg IV Chlorphenamine
universal donor of fresh frozen plasma?
AB RhD negative blood
When to discharge in anaphylaxis after symptom resolution?
Minimum 2 hours:
1 dose of adrenaline
Minimum 6 hours:
2 doses adrenaline
Previous biphasic response
Minimum 12 hours: >2 doses adrenaline severe asthma ongoing reaction possible patient presents late at night when A&E access difficult
What to give in potential tetanus exposure and unclear vaccine hx?
booster vaccine + immunoglobulin
King’s College Hospital criteria for liver transplantation (paracetamol liver failure)?
Arterial pH < 7.3, 24 hours after ingestion
or all of the following:
prothrombin time > 100 seconds
creatinine > 300 µmol/l
grade III or IV encephalopathy
Indications for thoracotomy in haemothorax?
> 1.5L blood initially or losses of >200ml per hour for >2 hours
3 things usually given in acute variceal bleed?
Blood products
Terlipressin
Empirical abx: Ceftriaxone
When to offer platelet transfusions?
platelet count of <30 x 10^9 with clinically significant bleeding
platelet count < 100 x 10^9 with severe bleeding or bleeding at critical sites, such as CNS
Mx of epistaxis?
- Pinch the cartilaginous (soft) area of the nose firmly for 20mins
- Cautery if bleeding point visible
- Packing (rapid rhino)
- Sphenopalatine ligation in theatre
Flail chest mx?
Analgesia
Respiratory support - consider PPV
