Emergency Medicine Flashcards

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 - 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

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2
Q

Alcohol withdrawal management?

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

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4
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
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5
Q

Anaphylaxis Mx (acute & chronic)

A

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
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6
Q

Sepsis definition? Septic shock def?

A

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)

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7
Q

What is qSOFA score?

A

qSOFA = risk of ITU admission/death at the point of presentation with sepsis

  • Hypotensive, altered mental status, tachypnoea (>22)
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8
Q

What is sepsis 6?

A

3 in, 3 out

All within 1hr

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9
Q

Status epilepticus - def? Triggers in epilepsy? Mx?

A

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
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10
Q

What is the lethal triad of trauma? Mx?

A
  • 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

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11
Q

Drugs for cardiac arrest?

A

DC shock (150J biphasic)

Adrenaline 1mg IV (10ml 1:10,000)

Amiodarone 300mg IV (if shockable rhythm)

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12
Q

Trauma patient initial Mx?

A

Airway and cervical spine

Next - CT-head & neck + CXR

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13
Q

Emergency focused Hx?

A

A – Allergies

M – Medications

P – Past Pertinent medical history

L – Last Oral Intake

E – Events Leading Up To Present Illness / Injury

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14
Q

Post-op process? Peri-operative RFs? Post-op complications?

A

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
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15
Q

Blood transfusion reactions - Immediate? Delayed?

A

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
  • 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
  • Non-immune:
    • Viral infection
    • Malaria
    • Prions
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16
Q

Types of airway management? Airway management procedure?

A

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)
17
Q

Management of poisoning <1hr since ingestion, conscious, protected airway?

A

oral activated charcoal within 1hr

18
Q

Treatment of high INR? Target?

A
  • 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)

19
Q

Drugs for cardiac arrest?

A

DC shock (150J biphasic)

Adrenaline 1mg IV (10ml 1:10,000)

Amiodarone 300mg IV (if shockable rhythm)

20
Q

Drugs for anaphylaxis?

A

Adrenaline 0.5mg IM (0.5ml 1:1000)

Hydrocortisone 200mg IV

Chlorphenamine 10mg IV

21
Q

Seizure drugs?

A

Lorazepam 4mg IV (diazepam 10mg PR if no IV access)

22
Q

Hypoglycaemia drugs?

A

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
24
Q

Torsade de Pointes (TdP) - Tx?

A

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