Emergency Medicine

Question 1

What type of shock should be given for ventricular tachycardia?

Answer 1

VT is a shockable rhythm so a 200J biphasic (unsynchronised) shock should be administered.

Question 2

List the causes of torsades de pointes?

Answer 2

Causes of a long QT interval which may predispose a patient to developing TDP include the following. This can be remembered by a useful mnemonic - TIMMES:

Toxins: drugs including anti-arrhythmics, anti-psychotics and tricyclic antidepressants

Inherited: congenital long QT syndromes such as Romano-Ward and Jervell and Lange-Nielson syndromes.
Ischaemia

Myocarditis

Mitral valve prolapse

Electrolyte abnormalities, such as hypokalaemia and hypocalcaemia and hypomagnesia.

Subarachnoid Haemorrhage

Question 3

List the causes of torsades de pointes?

Answer 3

Medication (antiarrhythmics, antibiotics such as erythromycin, tricyclics, antipsychotics, ketoconazole)
Myocardial infarction
Renal/liver failure
Hypothyroidism
AV block
Toxins
Electrolytes - hypomagnesia, hypocalcemia, hypokalemia.

Question 4

Emergency Management of Torsades de pointes?

Answer 4

In unstable patients with haemodynamic compromise, DC cardioversion can be done. In stable patients, the choice of treatment is IV Magnesium Sulphate 2g over 1 to 2 minutes.

Question 5

What is Torsades de pointes?

Answer 5

Torsades de pointes (TdP) is a form of polymorphic ventricular tachycardia caused by QT prolongation.

It can degenerate into VF, and it can cause significant haemodynamic compromise and death.

Question 6

Which electrolyte disturbances prelong the QT?

Answer 6

Hypokalaemia
Hypomagnesaemia
Hypocalcaemia

Question 7

Drugs that prolong QT:

Answer 7

Antiarrhythmics
Erythromycin
Tricyclics antidepressant
Antipsychotics
Ketoconazole

Question 8

1st step managing DKA

Answer 8

First initial treatment: ISOTONIC SALINE - 1L of 0.9% sodium chloride over 1 hour.

Question 9

Management of pulseless electrical activity and asystole:

Answer 9

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.).

Question 10

When do you give adrenaline in VFib / VTachy?

Answer 10

Give adrenaline after 3 shocks.
(1mg 1:10,000)

Question 11

How does N-acetylcysteine treat a paracetamol overdose?

Answer 11

N-acetylcysteine works by restoring the levels of glutathione, which conjugates and neutralises the toxins.

Question 12

Indications for thoracotomy:

Answer 12

Indications for thoracotomy in haemothorax include >1.5L blood initially or losses of >200ml per hour for >2 hours

Question 13

Amiodarone needs what bloods monitored?

Answer 13

TFT’s
Amiodarone can cause thyroid dysfunction: both hypothyroidism and hyperthyroidism.

Question 14

Hypercalcemia presents with what ECG abnormality?

Answer 14

Short QT

Question 15

Test for anaphylaxis

Answer 15

Anaphylaxis - serum tryptase levels rise following an acute episode

Question 16

PCI guidelines on time

Answer 16

PCI should be offered if the presentation is within 12 hours of the onset of symptoms and PCI can be delivered within 120 minutes of the time when fibrinolysis could have been given (i.e. consider fibrinolysis if there is a significant delay in being able to provide PCI).

Question 17

TB medication that turns tear and urine orange

Answer 17

Rifampicin

Question 18

Subtrochanteric fracture =

Answer 18

Intermedullary nail

Question 19

ALS - when to give adrenaline and amiodarone:

Answer 19

In VF/VT after the third shock, both amiodarone and adrenaline should be given intravenously. CPR should continue whilst this is being given. Amiodarone is given after the 3rd shock and again after the 5th shock. Adrenaline is given every 3-5 minutes, with the first dose being given after the 3rd shock in the shockable algorithm and straight away in the non-shockable algorithm.