Emergency medicine

Question 1

What are the symptoms and treatment of foreign body above the glottis?

Answer 1

Hoarseness of voice
Drooling
Gagging/ coughing
Inspiratory stridor

Tt: flexible nasal endoscopy

Question 2

What are the symptoms and treatment of foreign body below the glottis?

Answer 2

Unilateral expiratory wheeze

Tt: bronchoscopy (flexible for detecting, rigid for extracting)

Question 3

What are the symptoms of a basal skull fracture, and which bone is most likely affected?

Answer 3

Battle’s sign (mastoid ecchymosis)
CSF rhinorrhea (torn dura, risk of meningitis)
Seventh nerve palsy
Periorbital ecchymosis (racoon eyes)
Haemotympanum
Vertigo

This type of fracture most commonly affects the petrous portion of the temporal bone, the external auditory canal, and the eardrum.

Question 4

What is the difference of the pain experienced during an MI and an aortic dissection?

Answer 4

MI: pain occurs slowly and gains intensity with time, usually a few hours; dull and crushing pain.

AD: sharp, tearing or ripping pain, abrupt and at its maximum from the time of onset.

Question 4

What is the most appropriate action in a suspected TCA overdose, and why?

Answer 4

ECG monitoring.

Important ECG finding suggestive of TCA poisoning is QRS widening (>100 ms); broad complex tachycardias may occur which are life threatening.

Question 5

What is the suspected diagnosis and most appropriate initial investigation?

Severe epigastric pain, referred to the right shoulder;
Rigid abdomen;
History of rheumatoid arthritis

Answer 5

Dx: perforated peptic ulcer

Investigation: erect chest X-ray. Air under the diaphragm gives the diagnosis of a perforation

Question 6

What are the signs of heroin withdrawal?

Answer 6

Agitation, nervousness, abdominal cramp, sweating, shivering, arthralgia

Question 7

What is the most appropriate treatment for active bleeding in a patient with liver disease and a high INR?

Answer 7

Fresh frozen plasma, which contains clotting factors not produced in liver disease

Question 8

What are the findings of subdural haemorrhage?

Answer 8

Thunderclap headache;
Requires urgent CT of the brain;
Crescent-shaped hyperdensity

Question 9

What are the findings of extradural haemorrhage?

Answer 9

Usually follow trauma;
Biconvex or lens-shaped haemorrhage

Question 10

How to treat if a high amount of paracetamol has been consumed > 36 hours ago?

Answer 10

• Obtain paracetamol levels, INR, venous gas, renal profile, liver profile and FBC
• If jaundiced, start NAC immediately, don’t wait for blood results

Question 11

How to treat if a high amount if paracetamol has been consumed > 15 hours ago or if a staggered ingestion was taken > 24 hours ago?

Answer 11

Start NAC within 1 hour

Question 12

How to treat if a high amount of paracetamol was ingested and the timing is uncertain?

Answer 12

Start NAC within 1 hour

Question 13

How to treat if a high dose of paracetamol was ingested < 1 hour ago and the dose was > 150 mg/kg?

Answer 13

Give activated charcoal orally with IV antiemetic

Take blood sample 4 hours post-ingestion

If paracetamol levels are above treatment line, star NAC

Question 14

How to treat if a high dose of paracetamol was ingested < 4 hours ago?

Answer 14

Delay blood tests until 4 hours post-ingestion

If paracetamol levels are above treatment line, star NAC

Question 15

How to treat if a high dose of paracetamol was ingested > 4 hours ago and the results would be available within 8 hours of ingestion?

Answer 15

Obtain paracetamol levels, INR, venous gas, renal profile, liver profile and FBC

If paracetamol levels are above treatment line, star NAC

Question 16

How to treat if a high dose of paracetamol was ingested > 4 hours ago and the results would not be available within 8 hours of ingestion?

Answer 16

Prescribe NAC

Also do paracetamol levels and continue NAC if above treatment line

Question 17

What are the “sepsis 6”?

Answer 17

Take 3, give 3

Take 3
- blood cultures
- FBC, urea and electrolytes, coltting, lactate
- start monitoring urine output

Give 3
- high flow oxygen
- intravenous fluid challenge
- intravenous ATB

Question 18

What is the maximum daily paracetamol dose?

Answer 18

4g in adults

ie: 2x 500mg tablets four times a day

Question 19

What is the percentage of body surface burned that requires fluid replacement in children?

Answer 19

10%

Question 20

What are the symptoms and most commonly affected bone in an orbital blowout fracture?

Answer 20

Periorbital ecchymosis, enophthalmos and diplopia on upward gaze

Most common: maxilla (orbital floor)

followed by ethmoid (medial wall)

Question 21

What is the consequence for rapid correction of hypernatraemia?

Answer 21

Cerebral oedema

“high to low your brain will blow”

Question 22

What is the consequence for rapid correction of hyponatremia?

Answer 22

Central pontine myelinolysis

“low to high your pons will die”

Question 23

Why should diabetic patients, who take insulin, take carbohydrates before going to bed if drinking alcohol?

Answer 23

Because during alcohol intoxication, the liver is too busy to break down glycogen, so glucagon is ineffective

Question 24

What is the percentage of stage 1 blood loss?

Answer 24

10 - 15%

Question 25

What is the percentage and symptoms of stage 2 blood loss?

Answer 25

15 - 30%

Postural hypotension
Slight tachycardia > 100 bpm
Increased RR > 20 ipm
Slightly restless mental status
Urine output 20-30 ml/hour

Question 26

What is the percentage and symptoms of stage 3 blood loss?

Answer 26

30 - 40%

Hypotension
Tachycardia > 120 bpm
Tachypnoea > 30 ipm
Confused mental status
Urine output less than 20 ml/hour

Question 27

What is the percentage and symptoms of stage 4 blood loss?

Answer 27

Over 40%

Marked hypotension
Extreme tachycardia < 140 bpm
Extreme tachypnoea
Decreased consciousness, lethargy or coma
No urine output

Question 28

What solution should be prescribed for correction of hyperkalaemia with ECG changes for a patient with normal blood glucose?

Answer 28

10 units of short-acting (Actrapid) insulin with 50 ml dextrose 50% given over 5-15 minutes

Followed by 500ml dextrose 10% over 12 hours

Question 29

What solution should be prescribed for correction of hyperkalaemia with ECG changes for a patient with high blood glucose (more than 11.1)?

Answer 29

10 units of short-acting (Actrapid) insulin with 50 ml sodium chloride 0.9% given over 5-15 minutes

Only once glucose levels normalise, give 500ml dextrose 10% over 12 hours

Question 30

How to manage > 5% and > 10% burns in children?

Answer 30

> 5% refer to burn unit
10% start IV + refer

Question 31

How to manage > 5% and > 10% burns in adults?

Answer 31

> 10% refer to burn unit
15% start IV + refer

Question 32

What are the symptoms of heroin withdrawal?

Answer 32

Flu like syndrome: muscle cramps, watering eyes, runny nose

Oter symptoms like agitation, sweating and insomnia

Question 33

How to proceed with a clinically stable patient with a trauma associated fracture?

Answer 33

Splint it

Hip - Thomas’ splint

Question 34

What is the normal lab value for glucose?

Answer 34

3.5 to 5.5

Question 35

What are the appropriate tests to determine the severity of asthma exacerbation in urgent care, and in A&E?

Answer 35

Urgent care: peak flow meter
- moderate: PEFR 50 to 75% best or predicted
- acute: PEFR 33 to 50% best or predicted ( admit if any features of severe asthma remain after initial management)
- life-threatening: PEFR < 33% best or predicted (admit immediately)

A&E: arterial blood gas

Question 36

How to treat major bleeding in patients who are using warfarin?

Answer 36

• stop warfarin
• vitamin K
• PCC
• FFP

Question 37

How to differentiate between the 4 stages of shock?

Answer 37

Stage 1
- 10-15% blood loss
- normal BP
- normal HR

Stage 2
- 15-30% blood loss
- postural hypotension
- slight tachycardia > 100 bpm

Stage 3
- 30-40% blood loss
- hypotension
- tachycardia < 120 bpm

Stage 4
- > 40% blood loss
- marked hypotension
- severe tachycardia > 140 bpm