Emergency Medicine Flashcards
Aspects of A-E assessment
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 - assess everything but not all at the same time –> calf tenderness, bleeding, bruising, rashes etc.
NOTE: if put in intervention say to examiner I would reassess previous steps e.g. A&B if gave IV fluids are there any changes
Anaemia Ix? Mx?
Ix: FBC, haematinics, B12/folate, OGD
Blood transfusion threshold: Hb <70 or <80 AND ACS
Other options: Fe infusion, ferrous fumarate
NOTE: anaemia can exacerbate chest pain/ACS
Significance of Atorvastatin + Clarithromycin?
Drug-drug interaction –> risk of liver damage + rhabdomyolysis
Withhold atorvastatin
Critical drugs - DO NOT EMIT when put on NBM in hospital
- Parkinson’s drugs (Levodopa, Carbidopa)
- Antiepileptics (Na Val, Carbamazepine, Lamotrigine, Levetiracetam)
- Antiretrovirals (-avir)
- Steroids (long-term)
Routes –> patches, IV, NG tube
Alcohol withdrawal management?
- Chlordiazepoxide (decreasing regimen + PRN) - prevent alcohol withdrawal Sx (anxiety, shakes etc.) + CIWA scoring (dose increased inf CIWA score increases)
- Pabrinex (thiamine, B1) - prevent Wernicke’s encephalopathy (ophthalmoplegia, ataxia, confusion)
- Bloods - coagulation (injury, bleeds), LFTs
Major hemorrhage GI Mx?
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)
When carrying out confusion assessment, what should you compare to?
Make sure to compare to baseline not what you would perceive as normal
Constipation in elderly patients:
- Common drugs causing constipation?
- How would you Ix constipation?
- How would you Ix urinary retention?
- How would you Mx urosepsis?
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)
Delirium definition? Common causes?
Delirium screen breakdown? Mx?
Def: Acute confusional state caused by a physical condition
Causes: U PINCHES ME
- Urinary retention
- Pain
- Infections
- Nutrition
- Constipation –> stool chart + PR exam
- 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
How to think about inf for abx? What are the best broad-spectrum abx? Abx for pseudomonas cover?
- 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
Opioids:
- Strength of different opioids
- Forms of oral morphine
- Guide to giving morphine
- When to give oxycodone
- Breakthrough analgesia
- Conversion between opioid doses
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:
- If can’t tolerate oral e.g. vomiting alot –> oral dose/2 = IV (& SC) dose
- Immediate-release PRN (max 4-hourly) –> see how much using
- 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
What should you always check for elderly patients?
- Polypharmacy
- Physical & cognitive baseline
- Bowels & bladder
Septic shock definition? Neutropenic sepsis criteria & abx Tx?
Septic shock = sepsis + haemodynamic instability
Neutropenic sepsis:
- Neutrophils <0.5
- Temp >38 degrees
- Tx = Tazocin
How to determine different causes of shock & Tx?
Emergency station common topics
If incomprehensible noises during acute station what do I do?
GCS measurement:
- Eyes (4)
- Voice (5)
- Movement (6)
Opiate overdose Tx? What if patient becomes unrousable again?
IV access –> STAT dose naloxone 400mcg - after 1-min of no improvement –> 800mcg
Stay by the bedside until improved resp rate
If the patient becomes unrousable again - Naloxone has a short half-life so may still be opioid toxic –> Naloxone infusion
Dx if haemodynamically unstable + melaena? What would you do? What type of blood is given?
What if you don’t know what caused the bleed?
Upper GI bleed
Activate major haemorrhage protocol -2222, call seniors, contact gastro reg on call
O ‘-ve’ blood initially then group-specific/cross-matched
If can’t get history assume variceal in nature –> IV abx broad-spectrum + Terlipressin (vasoconstriction - less blood loss)
How do you confirm anaphylaxis with blood test?
Anaphylaxis Mx (acute & chronic)
ABCDE
- Stop suspected cause
- Secure airway, give 100% oxygen, +/- intubate if respiratory obstruction imminent
- IM 0.5mg adrenaline (1:1000)
- IV 10mg chlorpheniramine
- IV 100mg hydrocortisone
- Treat bronchospasm – salbutamol +/- ipratropium
Going forward:
- Maintain fluids + monitor pulse oximetry, ECG and BP
- If still hypotensive, may need transfer to ICU and an IVI of adrenaline +/- aminophylline (bronchodilator) and nebulised salbutamol
After acute episode:
- Admit to ward and monitor ECG, monitor for 6hrs for biphasic reaction
- Measure mast cell tryptase 1-6 hours after = confirm anaphylaxis
- Continue chlorpheniramine
- Suggest MedicAlert bracelet with name of culprit allergen
- Teach about self-injected adrenaline & give auto-injector
- Skin prick tests showing specific IgE to help identify allergens to avoid
Sepsis definition? Septic shock def?
Life-threatening organ dysfunction caused by dysreg host response to infection
Septic shock = persistent hypotension (<90/MAP <65) or lactate >2 despite fluid resus (30ml/kg)
What is qSOFA score?
qSOFA = risk of ITU admission/death at the point of presentation with sepsis
- Hypotensive, altered mental status, tachypnoea (>22)
What is sepsis 6?
3 in, 3 out
All within 1hr
Metformin use, impaired renal function + acidosis - what is going on?
Metformin induced lactic acidosis
Elderly, T2DM, hyperglycaemia, hypernatremia - what is going on?
HHS (hyperosmolar hyperglycaemic state)
What is a T1 hypersensitivity reaction? (anaphylaxis)
IgE mediated mast cell degranulation & histamine release
Anaphylaxis to penicillins - cross-reactivity?
3% to 3rd-gen cephalosporins - so ideally avoid
Fever, rash, lymphadenopathy, deranged LFTs, eosinophilia - Dx?
Drug reaction with eosinophilia and Systemic Sx (DRESS)
Contact of a patient with meningococcal meningitis - do what?
Cipro 500mg STAT dose (2g IM Ceftriaxone if pregnant)
G-ve diplococci on CSF gram stain?
Neisseria meningitides