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Fourth > Emergency med > Flashcards

Emergency med Flashcards

1
Q

What dose of lorazepam is used in the second stage of status epilepticus?

A

4mg IV over 2 mins

OR

0.1 mg/kg IO slow bolus

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2
Q

What dose of thiamine is given in patients with suspected alcohol induced status epilepticus?

A

250mg IV over 30mins

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3
Q

What dose of glucose is used in status epilepticus? What range is corrected?

A

If glucose < 3.5 mg - give Glucose 50ml 50% IV

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4
Q

what are the bloods to consider in status epilepticus?

A

FBC, U&E, LFT, CK, Ca2+, glucose, blood cultures and AED levels
Toxicology screen, Prolactin

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5
Q

what dose of diazepam and midazolam can be used for status?

A

diazepam 10mg PR

5-10mg buccal midazolam

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6
Q

Why is bicarbonate level low in DKA?

A

Insulin deficiency → ↑ lipolysis → ↑ free fatty acids → hepatic ketone production (ketogenesis) → ketosis → bicarbonate consumption (as a buffer) → anion gap metabolic acidosis

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7
Q

When do you consider HDU admission in DKA?

A
  • Heart or Renal failure
  • GCS <12, sats <92%
  • SBP <90
  • Young people, elderly, comordities or pregnant
  • Ketones > 6mmol/l , HCO3 < 5 mmol/l , pH <7.1
  • K+ <3.5 mmol, anion gap >16
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8
Q

What rate is insulin administered in DKA?

A

0.1 units/kg/hr

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9
Q

What is the treatment dose of glucose used in hypoglycaemia?

A

10% at 200 ml/hr

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10
Q

What dose of naloxone is used in opioid poisoning

A

0.8 mg IV (Repeat in 2-3 mins if needed)

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11
Q

What is the adult dose of adrenaline used in anaphylaxis?

A

500 micrograms IM

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12
Q

What is the KDIGO classification for AKI stage 1?

A

Serum creatinine - Increase in >26 micromolar/ L in 48h OR increase in 1.5 * the baseline

UO - <0.5ml/kg/h for more than 6 hrs

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13
Q

What is the KDIGO classification for AKI stage 2?

A

increase of 2 - 2.9 * baseline in serum creatinine

<0.5 ml/kg/h of UO in more than 12 hrs

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14
Q

What is the KDIGO classification for AKI stage 3?

A

Increase of > 3* baseline

or

> 354 micro micromol

or

started on dialysis

< 0.3ml/kg for >24h or anuria for >12hrs

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15
Q

What are the indications for urgent haemodialysis?

A

A - metabolic ACIDOSIS severe (pH < 7.2 or BE < -10)

E - Electrolytes - Refractory hyperkalaemia (K > 6.5)

I - Intoxications

O - Overload with fluid refractory to diuresis

U - Uraemic pericarditis, uraemic encephalopathy

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16
Q

What are the signs of salicylate toxicity?

A

Early - nausea, vomiting, tinnitus, tachypnea and hyperpnoea

Late - hyperthermia, agitation, low GCS, seizures, low BP, non-cardiogenic pulmonary oedema

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17
Q

What is the ABG picture for salicylate poisoning?

A

Initially respiratory alkalosis as it causes direct stimulation of the central respiratory muscles and then develop metabolic acidosis.

Salicylates directly stimulate the respiratory center of the brain → CO2 washout → primary respiratory alkalosis. Salicylates are uncouplers of mitochondrial oxidative phosphorylation → inhibition of TCA cycle and ATP production → accumulation of lactic acid and ketones → increased anion gap metabolic acidosis. Because chloride is falsely elevated in the presence of salicylates, a high anion gap may not always be present.

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18
Q

What is the step by step tx of salicylate poisoning?

A

Correct dehydration

Keep patient on ECG monitoring

Give activated charcoal or slow release formations

Check urine pH, consider catheterisation to monitor urine output

Correct acidosis - if plasma salicylate levels are > 500mg/L or severe metabolic acidosis - give 1.5L 1.26%

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19
Q

What bloods would you think about if you are considering salicylate poisoning?

A

Paracetamol and salicylate levels
FBC, U&E, LFT, INR, Hco3

salicylate level may need to be repeated after 2h

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20
Q

What are things to do in resus of upper Gi bleed

A
  1. LFT, U&E (urea high), clotting, Group and save and crossmatch
  2. Think about active haemorrhage protocol - if SBP <90
  3. transfuse RBC if hb<70
  4. Correct clotting abnormalities
  5. keep patient NBM
    and examine their abdomen for signs of liver injury - telangiectasia, purpura, jaundice and DRE - melena
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21
Q

What dose of iv terlipressin is given in suspected varices causing bleed?

A

IV terlipressin 1-2mg over 6hrs for less then or 3 days

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22
Q

What are the features of critical limb ischameia?

A 
Pain
Pallor
Paraesthesia 
Perishgly cold
pulselessness
paralysis
23
Q

What are the non-shockable rhythms? and what is the management?

A

Pulseless electrical activity
Asystole

Continue CPR - until pulse is felt and then shock
Adrenaline 1mg IV is given in the first cycle, and, should a non-shockable rhythm persist, every other cycle (i.e. cycles 1, 3, 5 etc.)

24
Q

What are the shockable rhythms? what is the management?

A

Ventricular Fibrillation and Pulseless Ventricular Tachycardia

25
Q

What are some of the renotoxic drugs to stop in AKI?

A
  1. ACE-I/ARBs
  2. Spironolactone
  3. Diuretics
  4. Gentamicin - may need dose adjustment if necessary for treatment
  5. NSAIDs
26
Q

What are the risk factors for acute angle closure glaucoma?

A

Asian, female and drugs with anti-muscarinic properties - such as amitriptyline

27
Q

What is the first line management for acute angle closure glaucoma?

A

Iv acetazolamide and topical beta blockers such as timolol
Muscarinic agonists such as pilocarpine eye

definitive mx: iridotomy

28
Q

What is the first hour management of DKA?

A

1L 0.9% saline over 1 hour (give STAT fluid challenge if Bp<90)
Fixed rate insulin infusion (0.1 units/kg/hr)

continue any long acting insulin that the patient is on

initiate hourly:

  1. Blood cap glucose
  2. Blood cap ketones
  3. Obs including GCS
29
Q

what is the management of DKA in the 2-12hrs?

A

Fluid resuscitation
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

Ensure ketones are falling at 0.5mmol/hr

30
Q

What is the mx of acute exacerbation of COPD?

A
  1. oxygen therapy - situp, 24% via venturi mask
  2. Nebulised bronchodilators - salbutamol - 5mg/4h and ipratropium 500mcg/6h
  3. Steroids - IV hydrocortisone 200mg and oral prednisolone 40mg for 7-14days
  4. Antibiotics - if signs of infection - PO
31
Q

When would you consider a COPD exacerbation for NIV?

A

If Resp rate> 30

OR

pH<7.35 (respiratory acidosis)

or PCO2 keeps rising despite medical treatment

32
Q

When would you consider intubation in exacerbation of COPD?

A

pH< 7.6

33
Q

what are the contraindications for NIV?

A 
Vomiting/excess secretions (aspiration risk)
Confusion/agitation*
Impaired consciousness*
Bowel obstruction*
Facial burns/trauma
Recent facial/upper gastrointestinal/upper airway surgery*
Inability to protect airway*
Pneumothorax (undrained)*
34
Q

what are the negatives of invasive ventilation?

A
  1. Difficult to wean patients off ventilatory support
  2. Risk of ventilator associated pneumonia and pnemothoraces

Speak to patient before they rapidly deteriorate to understand their wishes

Consider comorbidities, FEV1, functional status, whether the patient requires home oxygen and have they been admitted o ICU before and weaned off invasive ventilation

35
Q

What are the lab tests that would indicate towards adrenal insufficiency?

A
  1. Electrolytes - low Na and high K due to the mineralocorticoid deficiency
  2. Glucose - low glucose due to the glucocorticoid deficiency
  3. Short synacthen test - measure serum cortisol 30min after ACTH administration
36
Q

What is the treatment of addisonian crisis?

A
  1. fluid resuscitate if hypotensive
  2. IV hydrocortisone 100mg
  3. IV glucose if hypoglycaemic
  4. swap back to oral steroids after 3 days
    consider fludrocortisone if there is adrenal disease
37
Q

What are signs of severe asthma?

A

unable to complete sentence in one breath
RR >25/min
Pulse rate > 110
PEF 33-50% of predicted

38
Q

What are signs of a life theatening asthma attack?

A
  1. PEF <33%
  2. silent chest, cyanosis , feeble respiratory effort
  3. Arrhythmia or hypotension
  4. exhaustion, confusion and coma
  5. ABG - normal PCO2 and low paO2
39
Q

What are signs of a life theatening asthma attack?

A
  1. PEF <33%
  2. silent chest, cyanosis , feeble respiratory effort
  3. Arrhythmia or hypotension
  4. exhaustion, confusion and coma
  5. ABG - normal PCO2 and low paO2
40
Q

What is the criteria used for critical care referral in patients with acute exacerbation of asthma

A

Requiring ventilatory support

With acute severe or life-threatening asthma who is failing to respond to therapy, as evidenced by:

Deteriorating peak flow reading

Persisting or worsening hypoxia

Hypercapnia

Exhaustion, feeble respiration

Respiratory arrest

41
Q

what is the immediate mangement of acute exacerbation of severe asthma?

A

Sit-up
100% O2 via non-rebreathe mask (aim for 94-98%)
Nebulised salbutamol (5mg) and ipratropium (0.5mg)
Hydrocortisone 100mg IV or prednisolone 50mg PO

42
Q

what is the immediate management of acute exacerbation of life threatening asthma?

A

Inform the intensive care team
Mangesium sulphate 2g IV over 20 minutes
Nebulised salbutamol every 15min

43
Q

What is the treatment of myxoedema coma?

A 
ITU/HDU care
IV T3/T4
50-100mg IV hydrocortisone
Mechanical ventilation and oxygen - if hypoventilation
IV fluid - to correct hypovolaemia
Correct hypothermia
Correct hypoglycaemia
Treat any heart failure
44
Q

what are the signs of serotonin syndrome?

A 
neuromuscular excitation (e.g. hyperreflexia, myoclonus, rigidity)
autonomic nervous system excitation (e.g. hyperthermia)
altered mental state
45
Q

what can be used in severe serotonin syndrome?

A

Cyproheptadine

46
Q

What is the tx for torsades de pointes?

A

IV magnesium sulphate - 2g over 1- 2 mins

47
Q

What is the ECG sign of pericarditis?

A

PR depression and T wave changes

48
Q

What is the first steps of management of STEMI?

A
  • Morphine
  • Metoclopramide
  • Oxygen (if sats <94%)
  • Nitrates (GTN spray)
  • Aspirin 300 mg
  • Clopidogrel 300 mg (Although, in practice, other similar drugs such as Ticagrelor are increasingly being used)
49
Q

What is the ECG findings of PE?

A

right heart strain (RBBB, right axis deviation, T wave inversion and ST segment changes)

the rare S1Q3T3 feature (S wave in lead I, Q wave and T wave inversion in lead III)

50
Q

What are things to think about in patient with patients with adverse signs and bradycardia?

A

Think ahead, if you need an anaesthetist to sedate the patient for transcutaneous pacing
- Give atropine 500mcg IV

51
Q

What is the step by step management of bradycardia?

A

If adverse signs present

  1. Give atropine 500mcg IV
  2. If not responding - another dose of atropine 500 mg IV every 3-5 mins (upto 3mg)
  3. Transcutaenous pacing - need to call anaesthetist for sedation
  4. if that cant be done now - isoprenaline infusion
52
Q

what are the risk factors of asystole that warrant treatment?

A
  • Recent asystole
  • mobitz II AV block
  • complete heart block with broad QRS
  • Ventricular pause > 3s
53
Q

What is the tx of HHS?

A 
Fluid resuscitation 
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

Insulin at 0.05 units/kg/hour
Only if ketones >1mmol/L or glucose fails to fall
Continue any long acting insulin

VTE prophylaxis - these patients are high risk due to dehydration

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