Emergency med Flashcards
how should you oxygenate a patient with poor respiratory effort?
mechanical ventilation with bag and valve mask
which form of shock has warm peripheries
distributive e.g. sepsis
due to systemic vascular resistance decrease rather than fall in cardiac output
skin manifestation of carbon monoxide poisoning
cherry red skin
rare
when is an initial fluid bolus of 500ml appropriate
severe dehydration where systolic BP <90
ECG changes in posterior MI
ST depression, broad R waves, and upright T waves in leads V1-3
key features of HHS [4]
severe hyperglycaemia
hypotension
hyperosmolality without significant ketosis or acidosis.
treatment of aspirin overdose
IV sodium bicarbonate for urinary alkalinisation
haemodialysis if severe
treatment for paracetamol overdose ingestion less than 1 hour ago + dose >150mg/kg
activated charcoal
treatment for paracetamol overdose <4 hours ago
Wait until 4 hours to take a level and treat with N-acetylcysteine based on level
treatment for paracetamol overdose ingestion within 4-8 hours + dose >150mg/kg:
Start N-acetylcysteine immediately if there is going to be a delay of ≥8 hours in obtaining the paracetamol level
treatment for paracetamol overdose ingestion within 8-24 hours + dose >150mg/kg
Start N-acetylcysteine immediately
treatment for paracetamol overdose ingestion >24 hours ago
Start N-acetylcysteine immediately if the patient has jaundice, right upper quadrant tenderness, elevated ALT, INR >1.3 or the paracetamol concentration is detectable
treatment for staggered dose paracetamol overdose
Start N-acetylcysteine immediately
Criteria used to predict mortality from paracetamol overdose and to identify those patients who would potentially benefit from liver transplantation
Kings College Criteria
what arterial PH is an indication for liver transplant in paracetamol overdose
Arterial pH Less than 7.3
features of myxoedema coma [6]
hypothermic
hypotensive
bradycardia
slow mental function
lethargy
loss of consciousness
initial adenosine dose in SVT
6mg IV
initial step of management of tension pneumothorax
needle decompression followed by chest tube
signs on ECG for PE [4]
sinus tachycardia
RAD
RVHS
S1Q3T3
What does massive PE mean?
a PE with haemodynamic instability
how is massive PE treated?
IV alteplase i.e. thrombolysis
at what point are adrenaline and amiodarone given IV in ALS
which drug is a one off and which one is repeated
both are after 3rd shock for a shockable rhythm
amiadarone is a one off
adrenaline is given every other cycle from the 3rd
note: amiodarone only used for shockable rhythms
how is PEA or asystole managed? [2]
CPR
IV adrenaline in the first cycle and every other cycle
dosage of adrenaline and amiodarone used in ALS
amiodarone 300mg IV
adrenaline 1mg IV
contraindication to thrombolysis in management of MI [7]
- Aortic Dissection
- GI bleed
- Allergic reaction
- Iatrogenic: recent surgery, anticoagulation
- Neurological disease: recent stroke (within 3 months), malignancy
- Severe HTN (>200/120)
- Trauma, including recent CPR
timeframe for considering PCI from onset of symptoms and medical contact
12 hours from onset of symptoms and within 2 hours of presentation
Patients who present within 12 hours of symptom onset but after 2 hours of medical contact for MI receive…
thrombolysis
If patients present more than 12 hours of MI symptom onset
treatment approach
pharmacotherapy
Patients found to be at a high risk of death with NSTEMI require…
re-vascularization within 12-24 hours
management of acute pulmonary oedema [5]
Positioning the patient upright
Administering oxygen
Establishing IV access
Administering IV Furosemide
Considering non-invasive ventilation such as Continuous Positive Airway Pressure (CPAP) if initial medical therapy fails,
management of haemodynamically stable torsade de pointes
2mg IV magnesium sulphate over 1-2 minutes
haemodynamically unstable–> DC cardiovert
feature on ECG for torsade de pointes [2]
- polymorphic VT on the background of prolonged QT
- QRS “twists” around the isoelectric lines
definition of hypotension in shock
systolic blood pressure < 90 mmHg or a drop in systolic blood pressure of ≥ 40 mmHg for ≥ 15 minutes
what is the sign someone is in Addisonian crisis when hypotensive
IV fluids don’t improve the BP
they need IV hydrocortisone definitively
management of Addisonian crisis
Fluid resuscitation for hypotension
Administration of IV hydrocortisone 100mg (Stat and then given regularly)
IV glucose if hypoglycaemic
Transition back to oral steroids after 3 days
Consideration of fludrocortisone if there is adrenal disease present
what is flumanezil used for? [2]
why can’t it be used for mixed overdoses
Benzo overdose or reversal in benzo naive patients who have been dosed highly
can’t be used in mixed overdoses as there is a risk of seizure
5 signs of fluid overload
Bilateral reduced air entry
Inspiratory crepitations
Raised JVP
S3 gallop
Peripheral oedema
How often are adrenaline doses repeated in anaphylaxis
repeated every five minutes, several times if necessary
clinical signs on examination in aortic dissection [3]
Radio-radial delay
Radio-femoral delay
Blood pressure differential between arms
biochemistry in Addisonian crisis
hyponatraemia (most classically), hyperkalaemia, hypoglycaemia and hypercalcaemia
Diagnostic investigations of Addison’s disease
short Synacthen test
4 signs of hypopituitary coma
hypothermia
hypotension
septic signs without fever
short stature, loss of hair, gonadal atrophy
management of hypopituitary coma
hydrocortisone and T3
surgery if apoplexy is the cause
3 things to investigate in an unconscious person suspected of poisoning
glucose
paracetomol
salicylate
contraindications for activated charcoal [2]
alcohol
metal salts like lithium
reversal agent for TCA overdose
sodium bicarbonate
reversal agent for beta blocker overdose
atropine
reversal agent for ethylene glycol (antifreeze) poisoning
fomepizole
reversal agent for cyanide poisoning
100 oxygen and sodium nitrate/thiosulphate
reversal agent for organophosphate toxicity
atropine
reversal agent for digoxin toxicity
digifab (digoxin-specific antibody)
reversal agent for iron toxicity
desferrioxamine
when should an adult burn case be referred to a specialist burns unit
> = 10% TBSA
signs of severe hypothermia
temp <=35 deg (rectal) with no shivering
2 investigations for hypothermia
temperature (oral/axillary/PR) and ECG
management of hypothermia [6]
warm, humidified O2
removal of wet clothing
rewarm slowly at 0.5 deg/hour
blankets
warm IV infusion
cardiac monitoring
carboxyhemoglobin levels in CO poisoning
what is severe
10-30%
> 30% is severe
investigation in CO poisoning
ABG/VBG
pulse oximetry will be falsely high
management of CO poisoning [2]
100% high flow oxygen NRB
hyperbaric oxygen
which causes of shock cause low cardiac output [2]
hypovolaemia
pump failure
which causes of shock cause low SVR [5]
sepsis
anaphylaxis
neurogenic
endocrine failure e.g. Addison
drugs
treatment of cardiogenic shock [2]
dobutamine
dopamine
treatment of septic shock
noradrenaline
treatment of hypovolaemic shock
blood
adrenaline dose in anaphylaxis in adults
500mcg
treatment of bradycardia [3]
atropine, up to a maximum of 3mg
transcutaneous pacing
isoprenaline/adrenaline infusion titrated to response
treatment of haemodynamically unstable PE
continuous infusion of UFH + thrombolysis
treatment of thyrotoxic storm
symptom control: IV propanolol (IV digoxin if CI)
IV PTU
IV hydrocortisone
lugol (potassium iodide)
initial fluid type given in trauma
crystalloid
airway manoeuvre that can be used in cervical spine injury
jaw thrust
TRALI vs fluid overload
TRALI will not raise JVP and presents with hypotension and fever
causes of torsade de points
T (=Terfenadine)
H (=Haloperidol)
E (=Erythromycin)
M (=Methadone)
A (=Amiodarone)
S (=Sotalol)
C (=Chloroquine)
O (=Ondansetron)
T (=Tricyclic Antidepressants)
S (=Serotonin Reuptake Inhibitors).
x-ray sign of epiglottis
thumb sign
