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)
- 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
Encapsulated yeast on india ink staining of CSF?
Cryptococcal meningitis (in HIV)
TCA overdose - features? Ix? Mx?
Features:
- Anticholinergic - dry mouth, blurred vision, dilated pupils
- Cardiac - sinus tachy, arrhythmia, vasodilation
- CNS -reduced GCS, seizures, delirium
Ix: ECG, blood gas
Mx: A-E approach
- Sodium bicarbonate 8.4% - arrythmias & QTc prolongation
- No features/Ix findings after 6hrs = discharge
Reduced GCS, pupillary changes, resp depression - Dx?
Sedative toxidrome - opiates, barbituates, benzos, baclofen, clonidine
Confusion, autonomic dysfunction, neuromuscular hyperactivity - Dx?
Serotonin syndrome
Adult with head injury what imaging to do? Signs of basal skull fracture?
7th (& 3rd) CN palsy following head injury indicates what?
Basal skull fracture
Depressed skull fracture (open head injury) - Mx?
IV abx + tetanus booster
Headaches + poor concentration after head injury
Post-concussion syndrome
Mannitol/hypertonic saline is used for what neurologically?
Osmotic diuretic used to acutely lower ICP
Unilateral ptosis + down & out eye + fixed dilated pupil indicates what?
3rd nerve palsy
Inability to abduct eye after head injury?
6th nerve palsy - false localising sign w/ raised ICP
Status epilepticus - def? Triggers in epilepsy? Mx?
Tonic-clonic seizure ≥ 5 mins or ≥ 2 seizures without complete neurological recovery between
- Refractory = continued despite using ≥2 antiepileptic drugs (AEDs) incl benzo.
Triggers in epilepsy:
- drug withdrawal, dose change, non-compliance
- Intercurrent illness, metabolic derangement
- Drugs lowering seizure threshold:
- abx (penicillin, cephalosporins, metro, isoniazid, imipenem)
- TCA, Aminophyline
- Cyclosporin, Tramadol
Alcohol withdrawal seizures - when?
12-24hrs after last drink - CIWA score
Acute paralysis + dysarthria following Tx for hyponatremia?
Osmotic demyelination syndrome
Focal weakness following seizure?
Todd’s paralysis
Absent p-waves, tall tented T-waves, broad QRS complexes?
Hyperkalaemia
Sharp chest pain relieved by leaning forward, saddle-shaped ST-segment on ECG?
Pericarditis (secondary to uraemia)
Polyarthropathy, fractures & calcific skin lesions on a background of CKD?
Renal osteodystrophy
How do you treat ph<7 on blood gas in DKA?
Ask for senior support –> they would give dilute 1.26% bicarbonate to bring pH up to 7 but no higher
After this improvement will occur spontaneously
DO NOT USE 8.4% BICARBONATE
What is the lethal triad of trauma? Mx?
- Hypothermia (reduced circulating volume)
- Acidosis (LA)
- Coagulopathy (coag factor consumption and reduced operation from hypothermia)
NOTE: normally happens in severe trauma with sign. blood loss
Mx: trauma laparotomy
Fluids:
- Normal maintenance requirements for the patient if NBM (H20, Na, K, UO)?
- Maintenance fluids
- Resus fluids
Normal requirements if NBM:
- H20 - 25-30ml/kg/day (cardiac disease is 20-25)
- Na - 1-2mmol/kg/day
- K - 0.5-1mmol/kg/day
- Glucose - 50-100g/day (prevent ketosis)
- UO should be >0.5ml/kg/hr
Maintenance fluids - traditional fluid regimen of ‘1 salty + 2 sweet’
- 1L saline 0.9% + 20mmol KCl (over 8hrs)
- 1L dextrose 5% + 20mmol KCl (over 8hrs)
- 1L dextrose 5% + 20mmol KCl (over 8hrs)
- NOTE: surgeons often prescribe Hartmann’s instead of NaCl as isotonic –> less likely to cause hyponatremia (above regimen provides too much H2O & too much Na)
Resus fluids - 500ml fluid bolus 0.9% NaCl over 15-20 minutes (250ml if HF)
How to Tx asystole?
IV adrenaline
Which airway device provides protection for the lungs from regurgitated stomach contents?
Which airway device is often used in cardiac arrest?
Tracheal tube - seal off airway = protection from aspiration
i-gel (supraglottic) airway = easier to place (than tracheal tube)
confusion, coarse tremor, jerking leg movements + bipolar disorder - Dx?
Lithium toxicity
Fat emboli presentation? DDx?
Trauma –> multiple fractures
- Followed by early-onset (within 24 hours) hypoxia, dyspnea, and tachypnea
- Followed by Neuro findings - acute confusional state/altered GCS/seizures/focal deficits
- Finally petechial rash (1/3 cases)
DDx: PE (but no neuro Sx)
Drugs for cardiac arrest?
DC shock (150J biphasic)
Adrenaline 1mg IV (10ml 1:10,000)
Amiodarone 300mg IV (if shockable rhythm)
Trauma patient initial Mx?
Airway and cervical spine
Next - CT-head + CXR
Common tumour markers - hormones, enzymes, tumour antigens, monoclonal abs?
Hormones:
- Calcitonin - medullary thyroid carcinoma
- ACTH, ADH - small cell bronchial carcinoma (paraneoplastic)
- beta-HCG - testicular germ-cell tumours, choriocarcinoma
Enzymes:
- NSE (neurone specific enolase) - small cell lung cancer (70% of untreated patients)
- ALP - paget disease of bone, mets to bone/liver
- LDH - detects necrosis e.g. in ovarian cancer, testicular germ cell tumours, lymphomas, Ewing’s sarcoma
Tumour antigens:
- AFP - hepatocellular carcinoma, teratoma
- PSA - prostatic carcinoma (or BPH/prostatitis)
- CEA (carcinoembryonic antigen) - post-op colorectal carcinoma; lacks the specifity or sensitivity to establish a diagnosis of cancer
Monoclonal abs:
- CA 19-9 - pancreatic, gastric, hepatobiliary carcinoma
- CA 15-3 - breast carcinoma
- CA 125 - ovarian carcinoma
Most accurate way to assess burns area?
Lund and Browder chart
Emergency focused Hx?
A – Allergies
M – Medications
P – Past Pertinent medical history
L – Last Oral Intake
E – Events Leading Up To Present Illness / Injury
Post-op process? Peri-operative RFs? Post-op complications?
Process:
- A-E
- Focused Hx
- Input (fluid, food) –> Output (urine, drain, stool)
- Review prev admission Hx + operation note
- Review Ix e.g. blood, scan, histology
- Escalation plan (ITU, ward-based care), DNAR status
RFs:
- Patient - obesity, IS, malnutrition, steroids, DM
- Operation - contamination/soiling, foreign body, prosthesis, duration
Complications:
- Immediate <24hrs: haemorrhage, anaesthetic (anaphylactic, hypotension, agitation)
- Early (3-4 days):
- Pyrexia - Chest, Catheter, Cut, Cannula, Central venous line, Calf (DVT)
- Anastomotic leak, collection, paralytic ileus, prosthesis inf
- Late:
- Anaemia
- Malnutrition
- Dumping syndrome (if vagus nerve severed –> stomach dumps food into duodenum without digestion –> very tired after eating)
- Reoccurrence
- Incisional hernia
- Chronic pain
Blood transfusion reactions - Immediate? Delayed?
Immediate (<24hrs):
- Immune:
- Acute haemolytic transfusion reaction (ABO incompatibility)
- Anti-A/B abs activating complement pathway –> inflammatory cytokine release
- Features:
- Early - fever, low BP, anxiety, red urine
- Late - low BP, widespread haemorrhage secondary to DIC
- Transfusion-related acute lung injury (TRALI)
- Donor abs against recipient HLA antigens (neutrophil, leukocyte)
- Within 6hrs - sudden dyspnoea, severe hypoxemia, low BP, fever
- Resolves with supportive care within 2-4 days
- Anaphylaxis - allergic to protein components in donor transfusion
- Itchy rash, angioedema, SoB, vomiting, lightheaded, low BP
- Acute haemolytic transfusion reaction (ABO incompatibility)
- Non-immune:
- Bacterial infection
- Transfusion-associated circulatory overload (TACO)
- Acute/worsening resp compromise/pul oedema up to 12hrs post-transfusion
Delayed (>24hrs):
- Immune:
- Delayed haemolytic transfusion reaction (DHTR)
- Abs to antigens e.g. Rhesus/Kidd
- 3-13 days post-transfusion
- Sudden drop in Hb, fever, jaundice, haemoglobinuria
- Febrile non-haemolytic transfusion reaction (FNHTR)
- Abs against donor leukocytes/HLA antigens
- Fever during transfusion, no haemolysis
- Normally if received multiple transfusions/women with multiple pregnancies
- Post-transfusion purpura (PTP)
- Adverse reaction to blood/platelet transfusion when body produces allo-abs to introduced platelets’ antigens –> destroy patient’s platelets –> thrombocytopenia
- 5-12 days post-transfusion
- Graft versus host disease (GvHD)
- After receiving transplanted tissue from a genetically different person
- WBCs in donated tissue (graft) recognise recipient as foreign –> attack host cells
- Can also occur in blood transfusion if blood has not been irradiated/treated with approved pathogen reduction system
- Delayed haemolytic transfusion reaction (DHTR)
- Non-immune:
- Viral infection
- Malaria
- Prions
Types of airway management? Airway management procedure?
Artificial airway types:
- Oropharyngeal airway (OPA) - prevent tongue blocking the airway/upper airway muscle relaxation in unresponsive individual (no cough/gag reflex)
- Nasopharyngeal airway (NPA) - used in responsive individuals/jaw clenched (more risk of soft tissue damage)
- Endotracheal airway (ETA) with intubation - if can’t breath on their own (need mech ventilation)/planned surgery requiring general anaesthetic, protects the airway from aspiration
- Supraglottic airway devices - step prior to intubation (elective procedures, cardiac arrests, prehospital airway Mx)
- Laryngeal mask airway (LMA) - temporary open airway during anaesthesia or life-saving measure during difficult airway intubation (≥ 3 attempts of 10mins each)
- iGel - as above but prevent aspiration & has port for NG tube insertion
Airway management:
- Basic (non-invasive):
- Head tilt & chin lift
- Jaw thrust
- Bag-valve mask
- Advanced (invasive/specialised):
- OPA/NPA
- Laryngeal mask airway (LMA)/iGel
- ETA with intubation
- Rapid sequence induction (RSI) of anaesthesia & intubation
- Cricothyroidotomy (emergency procedure - between thyroid & cricoid cartilage)
- Tracheostomy (2nd/3rd tracheal rings - surgical procedure for temp/permanent intubation)
Management of poisoning <1hr since ingestion, conscious, protected airway?
oral activated charcoal within 1hr
Treatment of high INR? Target?
- Any bleeding: stop Warfarin AND IV vit K slowly
- If major bleed = ADD dried PCC/FFP
- INR @24hrs –> continue Tx if INR high, continue Warfarin when INR <5
- INR >8: stop Warfarin AND oral Vit K
- INR @24hrs –> continue Tx if INR high, continue Warfarin when INR <5
- INR 5-8: miss dose of Warfarin –> reduce maintenance dose
Target: 2.5 (2-3 range)
Drugs for cardiac arrest?
DC shock (150J biphasic)
Adrenaline 1mg IV (10ml 1:10,000)
Amiodarone 300mg IV (if shockable rhythm)
Drugs for anaphylaxis?
Adrenaline 0.5mg IM (0.5ml 1:1000)
Hydrocortisone 200mg IV
Chlorphenamine 10mg IV
Seizure drugs?
Lorazepam 4mg IV (diazepam 10mg PR if no IV access)
Hypoglycaemia drugs?
20% glucose 75ml IV (repeat as needed) over a time period up to 20 mins
- 2nd line - glucagon 1mg IM (if no IV access, not ideal if anticoagulated as IM + causes nausea/flushing
- NOTE: risk of aspiration of glucose gel in an unconscious patient
Hyperkalaemia drugs?
10% Ca gluconate 10ml IV over 5 mins
THEN
10 units Actrapid insulin added over 30 mins AND 100ml 20% glucose
Bradycardia drugs?
Atropine 500mcg IV (repeat every 3-5mins to max 3mg)
SVT drugs?
Adenosine 6mg IV (then 12mg then 12mg)
- Must be given as bolus + flushed quickly via large vein
VT drugs (without adverse signs)?
Amiodarone 300mg IV over 20-60mins
Rapid tranquillisation of agitated patient @risk to self/others - drugs?
Lorazepam 1-2mg PO/IM or Olanzapine 5-10mg PO/IM
- Give oral if possible, give half if elderly/renal impairment
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) - stopping abruptly –> Addisonian crisis
Routes –> patches, IV, NG tube
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
Torsade de Pointes (TdP) - Tx?
Broad-complex irregular tachycardia where the size and shape of the QRS varies complex to complex within any given lead (polymorphic)
- Increased QT interval increases the risk e.g. drugs (clari, amiodarone)
Magnesium sulfate IV 2g over 10 minutes
