Emergency Medicine Flashcards

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1
Q

Aspects of A-E assessment

A

Identify a problem and deal with it as going along…
Airway - patent? look, listen and feel –> head tilt + chin lift, jaw thrust, airway adjunct
Breathing - RR, O2 Sats (>94% - scale 1, 88-92% - scale 2 if COPD), resp exam, ABG –> Oxygen (15L/min O2 non-rebreather mask)
Circulation - HR, BP, CRT, cardio exam –> IV fluids
Disability - BM, pupils (PEARL - pupils equal and reactive to light), GCS/AVPU, abdo/neuro exam
Exposure - calf tenderness, bleeding, bruising, rashes etc.

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2
Q

COPD breathing problem Ix? Mx?

A

Ix: ABG, ECG, CXR, FBC, U&E

Infective exacerbation of COPD Oon CXR: emphysematous changes, opacity, flattened diaphragm + hyperexpanded chest

Acute Mx:

  • 15L/min O2 non-rebreather mask (despite COPD)
  • Salbutamol NEB - back to back
  • IpB NEB - 6 hourly

On discharge:

  • Pred for 7 days
  • PO Abx (e.g. co-amox)

Reassess:

  • If O2 sats increasing, RR decreasing and HR decreasing
  • Continue abx/steroids, wean off nebs + O2
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3
Q

PaO2 (Partial Pressure of Oxygen) normal range?

A

Normal: ≥10 on room air

On Oxygen: PaO2 (kPa) should be 10 less than FiO2 (level of oxygen they are on %)

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4
Q

Reading an ABG?

A

Low O2 = T1RF

Low O2 + High CO2 = T2RF

Low pH + high CO2 = Respiratory acidosis (low CO2 = metabolic)

High pH + low CO2 = Respiratory alkalosis (high CO2 = metabolic)

NOTE: if bicarb is high in RA = chronic RA (compensation by bicarb is slow) –> this determines if should be on scale 1/2 O2 (scale 2 = 88-92%)

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5
Q

When to do ABG vs VBG?

A

ABG (radial artery) - acute breathing problem

VBG (venous) - check lactate, glucose, elctrolytes FAST

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6
Q

Oxygen therapy principles

A

Oxygen from wall = 100%

Peak inspiratory flow - the maximum rate of drawing in O2 normally is 20L/min (not normally measured unless ITU)

O2 therapy goal is increasing conc grad between alveoli and blood - done by increasing FiO2 (fraction of inspired O2)

Devices types: 1) variable (can’t guarantee FiO2, depends on PIF) - nasal cannula, hudson mask, non-rebreather mask 2) fixed - venturi mask (useful if COPD as need to know exactly how much O2 giving)

NOTE: If PIF increases (breathing harder) –> FiO2 decreases so more device O2 is required

High-flow nasal oxygen therapy - humidifies + warms O2 = well-tolerated –> very high flow rate can be achieved - finely controlled FiO2

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7
Q

O2 therapy vs ventilation

A

O2 therapy - increase FiO2 so bigger conc gradient between alveoli and bloodstream (of part of the lung that is working)

Ventilation - pressure increases SA of lungs available for gas exchange e.g. if part of the lung is blocked off (e.g. mucus, collapse)

SO COMBO IS NORMALLY USED

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8
Q

AKI - key things to do?

A

1) Check trend
2) Check drug chart (any nephrotoxic?) –> remove/replace
* Common: Metformin (increases risk of lactic acidosis), ACEi (reduces renal perfusion pressure), NSAIDs, diuretics (unless congestive heart failure - may have AKI from fluid overload)
3) Check fluids (pre-renal - dehydration) –> give fluids

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9
Q

Case 1 Learning points

A
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10
Q

Bibasal crackles indicates what? Ix? Mx?

A

Fluid overloaded with pulmonary oedema = acute heart failure

HF = pumping of blood by heart isn’t meeting body demands

Ix:

  • Bedside - ECG
  • Bloods - ABG, troponin, BNP
  • Imaging - CXR, Echo (further down the line)

Acute HF Initial Mx:

  • Immediate: sit patient up, O2 15L/min NRM
  • Medical: IV furosemide (higher dose if on LT Tx), GTN, Morphine IV
  • If no improvement: repeat furosemide (after 15mins) –> consider CPAP
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11
Q

Types of Non-Invasive Ventilation

A

CPAP = fixed IPAP and EPAP

  • Holds open/splints airways –> for T1RF –> increase O2

BiPAP = IPAP higher than EPAP

  • Gradient allows exhalation more easily –> for T2RF –> excrete CO2

(- If had high CO2 on ABG –> increase IPAP –> more excreted CO2)

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12
Q

CXR for HF

A

Bilateral opacification

Cardiomegaly

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13
Q

CXR for Infective Exacerbation of COPD (IECOPD)

A

Emphysematous changes

Opacity

Flattened diaphragm + hyperexpanded chest

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14
Q

ECG Important Considerations

A
  • Make sure to compare to a previous ECG = dynamic changes (acute)
  • Coronary infarcts commonly present as T-wave inversion/RBBB/LBBB, not always with ST-elevation/depression
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15
Q

NSTEMI Mx? Scoring? Ix?

A

Immediate:

  • Aspirin PO stat AND Ticagrelor OR Clopidogrel PO stat
  • Fondaparinux SC

On discharge (give all despite BP/HR):

  • Aspirin for life
  • Ticagrelor OR Clopidogrel for 1 year (2 needed for 1 year as stent impregnated with Tacrolimus
  • Ramipril (ACEi) - titrate up to 10mg
  • Atorvastatin
  • Bisoprolol (B-blocker) - titrate up to 10mg

Scoring Risk: GRACE score

Ix if high risk: cathlab for angiogram (will be started on IV unfractionated heparin instead of fondaparinux as procedure is very thrombogenic) –> PCI (stent)

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16
Q

Anaemia Ix? Mx?

A

Ix: FBC, haematinics, B12/folate, endoscopy

Blood transfusion threshold: Hb <70 or <80 AND ACS

Other options: Fe infusion, ferrous fumarate

NOTE: anaemia can exacerbate chest pain/ACS

17
Q

Significance of Atorvastatin + Clarithromycin?

A

Drug-drug interaction –> risk of liver damage + rhabdomyolysis

Withhold atorvastatin

18
Q

Heart failure key consequences x2

A

1) Reduced CO (SV*HR) –> shock, tachycardia, AKI
2) Congestion –> pulmonary oedema + peripheral oedema

19
Q

How do you calculate ejection fraction? What are the different types of HF based on ejection fraction?

A

Ejection fraction = SV/End Diastolic Volume

HF w/ preserved EF: >50% - inadequate filling of stiff ventricles

  • Causes: volume overload (valve regurg), pressure overload (HTN), decreased distensibility (constrictive pericarditis)
  • No drugs w/ prognostic benefit, Mx Sx w/ diuretics

HF w/ reduced EF: <40% - inadequate emptying of ventricles from outflow obstruction or impaired contractility

  • Causes: MI, cardiomyopathy, arrhythmia
20
Q

Acute HF vs ACS

A
21
Q

Critical drugs - DO NOT EMIT when put on NBM in hospital

A
  1. Parkinson’s drugs (Levodopa, Carbidopa)
  2. Antiepileptics (Na Val, Carbamazepine, Lamotrigine, Levetiracetam)
  3. Antiretrovirals (-avir)
  4. Steroids (long-term)

Routes –> patches, IV, NG tube

22
Q

What area of the lungs does aspiration pneumonia normally affect? Mx?

A

The right bronchus is more vertical and so aspiration normally affects the right lung base = coarse crackles

Mx: O2, suction, abx, NBM until SALT review

23
Q

Irregularly irregular heart rhythm - Dx? Ix? Mx?

A

AF - II narrow complex tachycardia with no p-waves

Ix:

  • ECG, Echo (valve check)
  • Bloods - U&E, Mg (QT interval), Troponin (ischaemic), TFTs

Mx:

  • Haemodynamically unstable –> DC cardioversion
  • Rate control - Bisoprolol 2.5mg OD (max 10mg, can use rate-lim CCB)
  • Rhythm control - if clear reversible cause: <48hrs = DC/chemical cardioversion (flecanide/amiodarone); >48hrs = anticoag 3-4wks (clot may have formed)
  • Stroke risk Mx - CHADS-Vasc Vs HAS-BLED/ORBIT - Apixabab 5mg BD (DOAC, can use Warfarin)
24
Q

Virchow’s triad + anticoagulants vs antiplatelets

A

1) Stasis - coag factor activation–> venous clot (AF, DVT)
* Anticoags are most effective as coag factors cause clot
2) Vessel wall injury - plaque rupture - thrombogenic material release –> platelets activated –> arterial thrombosis (MI, stroke)
* Antiplatelets most effective as platelets cause clots
3) Hypercoagulability - does not change acutely

25
Q

Types of anticoagulant

A
  • Heparins
    • LMWH (SC) - VTE prophylaxis BUT bad for renal function
    • UFH (SC/IV) - GOOD for renal function as a rapid reversal BUT heparin-induced thrombocytopenia (hypercoag state) risk needs APTT ratio monitoring
  • DOACs - oral + no monitoring BUT bad for renal function e.g. Apixaban (BD), Rivaroxaban (OD)
  • Vit K antagonist = Warfarin if weight extremes, reduced renal function or AF w/ MS/mechanical heart valve BUT INR monitoring + drug interactions
26
Q

EtOH XS (alcohol excess) management?

A
  1. Pabrinex (thiamine, B1) - prevent Wernicke’s encephalopathy (ophthalmoplegia, ataxia, confusion)
  2. Chlordiazepoxide (decreasing regimen + PRN) - prevent alcohol withdrawal Sx (anxiety, shakes etc.) + CIWA scoring (dose increased inf CIWA score increases)
  3. Bloods - coagulation (injury, bleeds), LFTs
27
Q

What are the markets of liver synthetic dysfunction?

A

Bilirubin

Albumin

Coagulation screen (APTT, PT, INR)

28
Q

Management of decompensated chronic liver disease?

A

Ascites

  • Dx:
    • Serum Ascites Albumin Gradient (SAAG) - serum albumin conc vs ascites conc - 11.1g/L
      • <11.1g/L = exudative cause - infection/inflammation (albumin leaking into ascites) OR nephrotic syndrome (pee out albumin so low serum albumin)
      • Otherwise = transudative cause from portal HTN
    • >250 neutrophils = spontaneous bacterial peritonitis (SBP) –> Tazocin/3rd gen cephalosporin
  • Mx:
    • Paracentesis –> post-paracentesis circulatory dysfunction SO if >5L drained give human albumin solution (HAS) 8g/L drained
    • Spironolactone (2nd line - Furosemide) - prevent reaccumulation

Hepatic encephalopathy (liver not dealing with toxins) - give Lactulose + Rifaximin to prevent

Coagulopathy - OGD (check for varices) + vit K (needed for clotting)

29
Q

Major hemorrhage GI Mx?

A

High risk of variceal bleed:

  • MASSIVE –> balloon tamponade
  • Assess - A-E approach:
    • Circulation –> blood transfusion (Hb <70) but if haemodynamically unstable and waiting give IV fluids
    • Drugs
      • IV Terlipressin(/Somatostatin) - blanked vascoconstriction
      • Ceftriaxone/Norfloxacin (apparently helps outcomes)
    • Intervention - endoscopic band ligation​​

F1 essentials: 2x large bore cannula, VBG, G&S + X-Match, bleep the bleed registrar (arrange endoscopy)

30
Q

How does lactic acidosis appear on VBG? Lactate physiology/pathology?

A

Acute metabolic acidosis - low pH, low cHCO3/low BE, high lactate

Physiology:

  • Glucose –> Pyruvate –O2–> mitochondria –> ATP
  • Glucose –> Pyruvate –NO O2–> Lactate (+ small ATP) –> excreted by kidney or liver/muscle –gluconeogenesis –> glucose

Pathology:

  • Hypoxia
    • Reduced oxygen delivery - from reduced circulating volume (bleed), vascular compromise (clot)
    • Reduced oxygen carriage - reduced gas exchange, anemia
  • Mitochondrial toxicity - mitochondria can’t aerobically produce ATP
    • Drugs - metformin, propofol, cyanide
    • Inherited - MELAS
  • Reduced metabolism (of lactate) - liver/renal impairment, muscle compromise
  • Increased glycolysis (more pyruvate) - both paths increase
    • Increased glucose uptake from adrenergic stimulation e.g. salbutamol use
    • Increased energy demand of cells - exercise
31
Q

When carrying out confusion assessment, what should you compare to?

A

Make sure to compare to baseline not what you would perceive as normal

32
Q

Constipation in elderly patients:

  • Common drugs causing constipation?
  • How would you Ix constipation?
  • How would you Ix urinary retention?
  • How would you Mx urosepsis?
A

Drugs causing constipation:

  • Opioids e.g. codeine
  • CCBs e.g. amlodipine
  • Fe supplements
  • Anticholinergics e.g. atropine
  • Bisphosphonates e.g. alendronate
  • Parkinson’s drugs e.g. L-dopa

Ix:

  • Constipation - stool chart + PR exam
  • Urinary retention - bladder scan, catheterise, urine dip + MC&S

Mx Urosepsis:

  • Sepsis 6 - 3 in (O2, IV fluids, abx), 3 out (BC, VBG, UO)
33
Q

Delirium definition? Common causes?

Delirium screen breakdown? Mx?

A

Def: Acute confusional state caused by a physical condition

Causes: U PINCHES ME

  • Urinary retention
  • Pain
  • Infections
  • Nutrition
  • Constipation
  • Hydration
  • Endo & electrolytes
  • Stroke
  • Medications & alcohol
  • Environmental

Delirium screen:

  • FBC, U&E, LFT, glucose, BC, Ca, TFTs, B12/folate
  • Urine dip + MC&S
  • CXR, possibly CT-head

Management: Tx cause

  • Conservative: lighting, clocks, 1:1 nursing, adequate hydration, laxatives, involve family/carers
  • SOS (risk to themselves/others):
    • Lorazepam (PO/IM/IV)
    • Haloperidol (PO/IM) - be careful if Parkinson’s –> worsens Sx
34
Q

How to think about inf for abx? What are the best broad-spectrum abx? Abx for pseudomonas cover?

A
  • where is the infection? e.g. resp, skin, cardio etc.
  • what are the common organisms that cause these infections? mainly G+ve or -ve?

G+ve: staph, strep, C. diff –> pneumonia, skin inf, colitis, sepsis

  • B-lactams:
    • Penicillins (peptidoglycan cell wall) - amox, co-amox, fluclox, tazocin
    • Cephalosporins (cover -ve’s as well) - ceftriaxone, cefuroxime, cefalexin
    • Carbapenems (holy grail) - meropenem
    • NOTE: ESBL (extended spectrum b-lactamase) - bacteria that are not sensitive to Pen + Cephalosporins
    • NOTE: Carbapenemase - resistant to carbapenems as well
  • Macrolides - for pen allergic = Clari, erythromycin
  • Glycopeptides - vancomycin, teicoplanin (good if pen allergic)
  • Oxazolidinones - linezolid (rarely used)

G-ve: E.coli, P. aeruginosa, K. pneumo, salmonella –> UTI, pneumonia, GI inf

  • Aminoglycosides (nephrotoxic –> monitoring) - gent, amikacin
  • Fluoroquinolones - cipro/levo/moxifloxacin
  • NOTE: broad spectrum so some +ve cover

Other antibiotic types:

  • Tetracyclines - doxy
    • Broad-spectrum intracellular pathogens (chlamydia, mycoplasma) –> STIs, pneumonia
  • Nitroimidazoles - metro
    • Anaerobes (c. diff, bacterial vaginosis) –> aspiration pneumo, abscesses
    • NOTE: nitrofurantoin (related compound) - concentrates in bladder –> UTI

Best broad-spectrum abx:

  • Co-amox: most G-ve AND +ve AND anaerobes
    • Does not cover pseudomonas + Neisseria spp.
  • Tazocin: as above AND pseudomonas
    • Does not cover Neisseria gonorrhoea
  • Meropenem: EVERYTHING (bar carbapenemase bacteria)

Abx for pseudomonas cover: gentamicin, amikacin, ciprofloxacin, ceftazidime

35
Q

Opioids:

  1. Strength of different opioids
  2. Forms of oral morphine
  3. Guide to giving morphine
  4. When to give oxycodone
  5. Breakthrough analgesia
  6. Conversion between opioid doses
A

Strength:

  • Weak - codeine, dihydrocodeine
  • Moderate - tramadol (surgeons love)
  • Strong - morphine, oxycodone, buprenorphine, fentanyl

Oral morphine has 2 forms:

  • Oral morphine has 2 forms:
    • Immediate-release (e.g. oromorph) - max 4-hourly
    • Modified-release (e.g. MST Continus/Zomorph/Morphgesic SR) - 12-hourly (BD) OR 24-hourly (OD)

Guide to morphine:

  1. If can’t tolerate oral e.g. vomiting alot –> oral dose/2 = IV dose
  2. Immediate-release PRN (max 4-hourly) –> see how much using
  3. If using a huge amount –> convert to modified-release (12/24-hourly):
    • Add up total daily PRN dose = X
    • 24-hourly = X (OD); 12-hourly = X/2 (BD)

​When to give oxycodone: renal impairment (eGFR <30mL/min)

  • Immediate-release: oxycodone oral solution, oxynorm
  • Modified-release: oxycontin
  • NOTE: same logic as above

Breakthrough analgesia:

  • Oral morphine/oxycodone
  • 1/10-1/6 of total daily dose of modified-release morphine

Example: 60mg Oromorph –> 30mg MST BD + 6-10mg breakthrough dose

Conversion - 10mg oral morphine:

  • Oxycodone - 5mg oral (x/2), 2.5mg IV (x/4)
  • Tramadol/Codeine - 100mg oral/IV (x*10) - NOTE: codeine has no IV option
36
Q

What is the AKI checklist?

A

Check baseline creatinine

Check fluid status

Check drug chart

37
Q

What should you always check for elderly patients?

A
  • Polypharmacy
  • Physical & cognitive baseline
  • Bowels & bladder