Emergency Medicine Flashcards

1
Q

Supraventricular Tachycardia (SVT) is any ____ complex tachycardia characterised by a heart rate of more than 100 bpm and a QRS width of less than ____ ms on an ECG.

Atrial Fibrillation (AF), AV Re-entry Tachycardia (AVRT) and AV Nodal Re-entry Tachycardia (AVNRT) are examples of SVTs.

Patients with adverse features should be given _____ .

These features can be remembered by the mnemonic HISS, which stands for:

______

A

narrow

120

synchronised DC shock Heart failure Ischaemia Shock Syncope
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2
Q

Management of SVT in Stable patients with no adverse features.

  1. Determine if rhythm is regular or irregular.

Regular:

Irregular:

A

Regular Rhythm
1. Vagal Manouevres - Carotid sinus massage / Valsava manouervre
2. IV Adenosine (6mg) - (blocks conduction through av node)

Prior to administering Adenosine, patients must be warned that they might experience difficulty breathing, chest tightness and flushing.

It should then be given rapidly over 1-3 seconds, followed by a 20 ml IV Normal Saline bolus**.

If this fails, a second dose of Adenosine 12mg can be administered, followed by another 18mg.

If this fails also -** Beta blocker or Verapamil **

Irregular rhythm
Manage according to AF algorithm:

Rate control with Beta-blocker
Rhythm control: Digoxin / Amiodarone (if Heart failure)
If in AF>48hrs - Anticoagulate

https://www.resus.org.uk/sites/default/files/2021-04/Tachycardia%20Algorithm%202021.pdf

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3
Q

Drugs that potentiate the effect of adenosine and thus contraindicate the use of adenosine.

A

Dipyridamole (antiplatelet)
Carbamazepine

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4
Q

Adenosine cannot be given to ____ and thus ____ is used instead.

A

Asthmatics
Verapamil

Adenosine is known to regulate myocardial and coronary circulatory functions. Adenosine not only dilates coronary vessels, but attenuates beta-adrenergic receptor-mediated increases in myocardial contractility and depresses both sinoatrial and atrioventricular node activities.

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5
Q

Complications of SVT can include:

A

Syncope
Deep vein thrombosis
Embolism
Cardiac tamponade
Congestive cardiac failure
Myocardial infarction
Death

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6
Q

Which drug is most appropriate to prescribe in aspirin overdose?

A

Sodium bicarbonate and fluid resuscitation (helps to eliminate the salicylate)

Sodium bicarbonate increases plasma bicarbonate and buffers excess hydrogen ions, alkalinising the blood and urine and enhancing the elimination of aspirin.

Glucose is also important to treat hypoglycaemia.

** Haemofiltration ± mechanical ventilation should be considered in severe toxicity **

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7
Q

Clinical features of serotonin syndrome can be split into neurological and autonomic.

Neurological features:

Autonomic features:

A

Neurological:

  1. Altered mental state
  2. Tremor
  3. Ataxia
  4. Hyperreflexia.

Autonomic:

  1. Tachycardia
  2. Hypertension
  3. Diarrhoea
  4. Hyperthermia

NB - Distinct from *Neuroleptic malignant syndrome *which is caused by anti-psychotics or sudden reduction in dopaminergics (i.e parkinson’s).

Predominant neurological feature of NMS is also** rigidity **

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8
Q

Which antibiotic can cause prolongation of the QT interval, which can lead to a polymorphic VT, otherwise known as torsades de points?

A

Clarithromycin

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9
Q

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 - TIIMMES:

A

Toxins: drugs including clarithromycin, 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

Subarachnoid Haemorrhage

TORSADES DE POINTES (VT) - PROLONGED QT INTERVAL

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10
Q

Management of Torsades de Pointes

A

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.

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11
Q

Management of tension pneumothorax?

A

This is with a large bore cannula/needle in the 2nd intercostal space, midclavicular line on the same side as the pneumothorax

This should be followed by chest drain insertion to reduce the risk of an immediate recurrence of the tension pneumothorax.

A tension pneumothorax occurs when air enters the pleural cavity through a one-way valve and cannot escape

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12
Q

Definition of Horners Syndrome and causes.

A

Horner’s syndrome is characterised by ptosis, meiosis with or without anhydrosis.

It is due to an interruption of the sympathetic nerve supply to the eye and can be classified into pre-ganglion causes, post ganglionic causes and central causes.

Causes:

Pancoast tumour (affecting sympathetic nerve supply)

Stroke

Carotid artery dissection (Red flag: neck pain)

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13
Q

Adult dose and route of adrenaline in anaphylaxis?

A

500ug MICROGRAMS

IM

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14
Q

Investigations and Management of pulmonary oedema due to Left Ventricular Failure.

A

Investigations
Bedside observations
Arterial blood gas
ECG
Troponin if concerned about a new cardiac event
Serum BNP
Chest X-ray

Management - POUR SOD
- Take an ABCDE approach
- Sit the patient up
- Administer oxygen
- Ensure IV access
- IV Furosemide (40mg stat)

  • Consider non-invasive ventilation such as CPAP if failed medical therapy (usually in an intensive care setting)
  • Consider further therapies in the intensive care setting such as invasive ventilation and inotropic support if the above fails

https://www.nice.org.uk/guidance/cg187/chapter/1-Recommendations

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15
Q

When taken as an overdose, the metabolism of paracetamol results in a buildup of a toxic substance called _____.

A

NAPQI (N-acetyl-p-benzoquinone-imine).

NAPQI is inactivated by glutathione. In an overdose, glutathione stores are rapidly depleted, and NAPQI is left un-metabolised. It can cause liver and kidney damage.

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16
Q

Management of Paracetamol overdose:

A

If ingestion less than 1 hour ago + dose >150mg/kg: Activated charcoal

If ingestion <4 hours ago: Wait until 4 hours to take a level and treat with N-acetylcysteine based on level using** nomogram**

If ingestion 4-15 hours ago: Take immediate level and treat based on level

If staggered overdose ( which is defined as being an overdose taken over > 1 hour) or ingestion >15 hours ago: Start N-acetylcysteine immediately

Obtain following bloods:

FBC

Urea and Electrolytes

INR

Venous gas

If a patient presents after 16 hours, there is *uncertainty about timing * or has a staggered overdose then NAC should be started regardless of the nomogram.

NAC is associated with anaphylactoid reactions. These are not true anaphylactic reactions and can usually be managed by stopping the infusion temporarily and then restarting at a lower rate.

Consider need for transfer to liver unit if blood tests are worsening

Management Flow chart:

https://emj.bmj.com/content/19/3/202

17
Q

Emergency management of DKA?

A

Treating DKA (FIG-PICK)
Follow local protocols carefully.

**F **– Fluids – IV fluid resuscitation with normal saline.

If patient is alert, not significantly dehydrated and able to tolerate oral intake without vomiting –> encourage oral intake and give subcutaneous insulin injection.

If patient is vomiting, confused, or significantly dehydrated –> give IV fluids (initial bolus of 10ml/kg 0.9% NaCl then discuss with a senior) and insulin infusion at 0.1 units/kg/hour 1hr after starting IV fluids.

If there is evidence of shock, the initial bolus should be 20ml/kg.

If patient is shocked or comatose –> ABCDE approach for emergency resuscitation

Do not stop intravenous insulin infusion until 1 hour after subcutaneous insulin has been given.

**I **– Insulin – Add an insulin infusion (e.g. Actrapid at 0.1 Unit/kg/hour)
*G - Glucose – Closely monitor blood glucose and add a dextrose infusion if below a certain level (e.g. 14 mmol/l)
P – Potassium – Closely monitor serum potassium (e.g. 4 hourly) and correct as required - Aim for a reduction in blood ketones of 0.5 mmol/L/hour
** I ** - Infection – Treat underlying triggers such as infection
** C ** - Chart fluid balance
K - Ketones – Monitor blood ketones (or bicarbonate if ketone monitoring is unavailable)

Establish the patient on their normal subcutaneous insulin regime prior to stopping the insulin and fluid infusion.

Remember as a general rule **potassium should not be infused at a rate of more than 10 mmol per hour.

18
Q

Diabetic ketoacidosis (DKA) is a medical emergency that is characterised by ____ , _____ and _____ .

Specific cut off for these markers that indicates DKA ____.

A

hyperglycaemia

acidosis

ketonaemia

Specific values to make the diagnosis:

  • Ketonaemia: 3mmol/L and over
  • Blood glucose over 11mmol/L
  • Bicarbonate below 15mmol/L or venous pH less than 7.3

**NB: ** - Hyperglycaemia may not always be present.

19
Q

Emergency Management of PE:

Massive PE and HD unstable - ______

Acute PE and stable - _____

Recurrent PE or Anticoagulation resistant - _____

A

Unstable: Thrombolysis - (Streptokinase/Alteplase - seek senior input)

Stable: LMWH or UFH infusion (5 days - and INR >2 on 2 consecutive days) -** bridge with NOAC or Warfarin **

NB - Provoked PE - 3 months DOAC and check INR. Unprovoked PE - 6 months DOAC and check INR

(Side note: remember warfarin takes time to titrate INR but also can be reversed quickly with Vit.K)

Recurrent or treatment resistant: Inferior Vena Cava Filter

NICE visual summary:
https://www.nice.org.uk/guidance/ng158/resources/visual-summary-pdf-11193380893

20
Q

What reaction/side effect needs to be considered in the use of NAC?

A

Anaphalactoid

Stop infusion (temporarily - start IV chlorphenamine or other antihistamine - resume NAC infusion but at a slower rate)

Normal rate of infusion - 300mg/kg 21 hr infusion -

https://www.toxbase.org/Chemical-incidents/Management-Pages/Acetylcysteine-Doses—Adults/

21
Q

TCA’s are _ and _ inhibitors.

Signs of a TCA overdose include:

Investigations

Management

A

Tricyclic antidepressants are noradrenaline and serotonin re-uptake inhibitors, and can be fatal in overdose.

They can cause drowsiness, coma, seizures and cardiac dysrhythmia.

Clinical Features
Signs of a TCA overdose include:

Neurological and cardiovascular!

Drowsiness
Confusion
Arrhythmias
Seizures
Vomiting
Headache
Flushing
Dilated pupils (not pinpoint as in opiate toxicity)

Investigations

Bloods: FBC, UE, CRP, LFTs, Venous Blood gas (look for evidence of acidosis)

**ECG **may show evidence of QT interval prolongation which can precipitate a cardiac arrhythmia.

Management
Overall management is supportive and dictated by the patient’s symptoms (sodium bicarbonate can be used).

Patients should be reviewed by intensive care if any concerns about their airway (particularly in drowsy patients) or severe metabolic acidosis that might require renal replacement therapy.

Activated charcoal can be considered within 2-4 hours of the overdose

22
Q

How does NAC work in paracetamol overdose?

A

NAC replenishes the store of glutathione which binds with the hepatotoxic metabolite of paracetamol, which is then excreted

23
Q

What is the best prognostic marker of acute liver failure in acetaminophen overdose?

A

Prothrombin time (INR)

The King’s College Criteria (of which INR is a component) can be used in patients with acute liver failure due to acetaminophen in order to assess their prognosis and facilitate assessment for consideration of a hepatic transplant.

24
Q

Organophosphates (found in pesticides) cause over-activity of the cholinergic system giving the symptoms _____

A

Organophosphate (blocks acetylcholinesterase enzymes increasing ACh) - SLUD

Salivation
Lacrimation
Urination
Diarrhoea

Small pupils
Fasciculations
Bradycardia

25
Q

ECG interpretation method

A

Details - patient/time/previous ECG’s

Rate - Rhythm strip X 6

Rhythm - count boxes between each QRS wave (use ruler and dots if neccessary)

P wave - Present before every QRS? Yes - sinus NO? - AF etc.

PR interval - <200ms or 5 boxes (each box 40ms or 0.04 secs). NO? - heart block. Primary secondary etc.

QRS wave - < 3 boxes or 120ms/0.12 seconds. NO? - Bundle Branch BLock (BBB). - William Marrow (V1 and V6)

ST segments - Compare with isoelectric line after the complex.

(ST elevation is caused by a lack of blood supply to the muscle. The potassium channels responsible for depolarization are ATP dependent and thus cannot open when there is a lack of blood)

T waves - inverted or flattened more than twice in each segment?

Axis - look at leads 1 and 3

If lead 3 is greater in amplitude than lead 1 - consider axis deviation

If leads arriving - right axis deviation
If leads leaving - left axis deviation

Everything else is normal.

Other stuff - QT/QTc Interval / P wave morphology / Ventricular hypertrophy / Strain (amplitude of QRS - can be nromal in a skinny person)

26
Q

Hallmark 2 treatments of cocaine induced NTEMI (vasospasm)

A

Benzodiazepine (diazepam)
Labetalol (beta and alpha blocker)

27
Q

Hallmark 2 treatments of cocaine induced NTEMI (vasospasm)

A

Benzodiazepine (diazepam)
Labetalol (beta and alpha blocker)

28
Q

Antidote to benzodiazepine overdose?

A

Flumazenil

(a selective GABAA receptor antagonist)

Only given in rare life-threatening circumstances

29
Q

Acute Pulmonary Oedema Management

A

ABCDE - treat as appropriate

Remember **POUR SOD MAN **

Pour away IV fluids
Oxygen (high flow)
Diuretic (IV furosemide 40mg)

Morphine (venous system dilatory effect and reduces preload)
Anti-emetic (Metaclopramide 10mg IV)
Nitrates in severe pulmonary oedema (IV if systolic bp >110 2 sprays if systolic BP > 90)

Step up therapy if this is refractory:

Treat any other underlying cause (arrythmia/MIValvular dysfunction etc)
CPAP
Inotropes and Intra-aortic balloon therapy (ICU)

30
Q

Long Term Heart failure Treatments

A

Treat underlying cause if appropriate

Pharmacological therapy:

ABAL

ACEi/ARB
Beta-blocker
Diuretic if fluid overloaded

If this fails to control symptoms:
Aldosterone antagonist or Ivabradine

Non-Pharmacological:

Cardiac resynchronisation therapy if ORS > 0.12s/ 3 squares
ICD if risk of Ventricular arrythmia

*Ivabradine is a heart-rate-lowering agent that acts by selectively and specifically inhibiting the cardiac pacemaker current (If), a mixed sodium-potassium inward current that controls the spontaneous diastolic depolarization in the sinoatrial (SA) node and hence regulates the heart rate.

This is based on NICE guidelines 2018. See the full guidelines before implementing treatment.

Refer to specialist (NT-proBNP > 2,000 ng/litre warrants urgent referral)
Careful discussion and explanation of the condition
Medical management (see below)
Surgical treatment in severe aortic stenosis or mitral regurgitation
Heart failure specialist nurse input for advice and support
Additional management:

Yearly flu and pneumococcal vaccine
Stop smoking
Optimise treatment of co-morbidities
Exercise at tolerated

31
Q

Max potassium in level 1 care (As an F1)

Per 500ml bag ____

Per Litre bag ____

Max rate ____

A

20mmol

40 mmol

10mmol/hr

32
Q

Make sure to avoid metaclopramide in patients _____

A

Parkinsons
and
Bowel Obstruction

also avoid Prochlorperazine
and Promethazine in parkinsons because of their antidopimenergic effect ast D2 receptors

33
Q

Important St.Johns wort interactions to be aware of

A

Anti-depressants

Warfarin

Oestrogen and Progesterone

34
Q

Causes of Hyperkalaemia?

A

3 causes:

  1. Reduced excretion from kidneys
  2. Release from cells
  3. Acidosis
  4. Reduced excretion from kidneys:

AKI
and
Addison’s

DRUGs that reduce K+ excretion from the kidneys : **KBANK **:

K+ containing laxatives (movicol/fybogel)
Beta Blockers
ACE inhibitors
NSAIDs
Potassium Sparing Diuretics (i.e aldosterone antagonists - spironolactone/eplerenone etc.) but also diuretics in general

Heparin (which inhibits aldosterone release)

and

Ciclosporin/Tacrolimus (immunosuppressants)

  1. Cellular Release:

Rhabdomyolysis

Digoxin Toxicity (NB - Can be precipitated by hypokalemaia) - “Reverse tick sign” on ECG

Tumour Lysis Syndrome

Massive Haemolysis

  1. Acidosis:

DKA or any other metabolic acidosis

35
Q

Hyperkalaemia is a potentially life threatening electrolyte abnormality.

Treat K+ >___ mmol/L or any hyperkalaemia with ECG changes with the following;

Give 10ml of 10% _____ (or chloride) over 10 mins - this is cardioprotective

Intravenous ____ (10u soluble insulin) in 25g ____ (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemia

Nebulised salbutamol - also causes intracellular K+ shift

Treatment with sodium bicarbonate is controversial

Other aspects of management:

Check contributing drugs (e.g. ACE inhibitors, spironolactone)

Once initial measures completed, recheck urea and electrolytes and ECG and glucose

Urinary potassium

A

Hyperkalaemia is a potentially life threatening electrolyte abnormality.

Treat K+ >6.5mmol/L or any with ECG changes with the following;

Give 10ml of 10% calcium gluconate (or chloride) over 10 mins - this is cardioprotective

Intravenous insulin (10u soluble insulin) in 25g glucose (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemia

Nebulised salbutamol - also causes intracellular K+ shift

Treatment with sodium bicarbonate is controversial

Other aspects of management:

Check contributing drugs (e.g. ACE inhibitors, spironolactone)

Once initial measures completed, recheck urea and electrolytes and ECG and glucose

Urinary potassium

36
Q

Causes of Hyponatraemia?

A

Remember to classify into:

Hypovolaemic (In the elderly dehydration is a very common cause especially in patients with dementia)

Euvolaemic (SIADH / Hypothyroidism)

Hypervolaemic

and drugs:

Thiazide diuretics > Loop Diuretics > K+ sparing diuretics

37
Q

Hyponatraemia Management

A
38
Q

This question asks about the first-line medical management of ascites. The BNF recommends _____ for managing oedema and ascites secondary to liver cirrhosis. Furosemide is recommended as an adjunct.

A

spironolactone