Emergency Medicine Flashcards by Eilidh Middleton

Tinnitus is a characteristic feature of which type of overdose?

Aspirin

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What would the ABG show in an aspirin overdose

Initially respiratory alkalosis (caused by activation of respiratory centres in the brain)

Later metabolic acidosis (causes by wasting of bicarbonate ions due to the ingested acid load)

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Respiratory depression, reduced consciousness and bilaterally constricted (pinpoint) pupils are characteristic features of an overdose of what medication?

Opioid overdose

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Respiratory depression, confusion and cerebellar symptoms such as nystagmus and ataxia are features of an overdose of what medication?

Benzodiazepine such as diazepam

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What is the first step in the management of suspected choking?

Encourage the patient to cough

If the cough is effective, they are encouraged to continue coughing.

If ineffective, five back blows are delivered followed by five abdominal thrusts, and this is repeated

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Cherry red skin and confusion is pathognomonic for which condition

Carbon Monoxide poisoning

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How is Carbon Monoxide poisoning managed

100% oxygen via face mask

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How is a clinical diagnosis of meningococcal infection made

Blood or CSF culture

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How is heroin withdrawal managed

NICE specifically advises against prescribing opiates in withdrawal, favouring either lofexidine (an alpha 2 receptor agonist) or symptomatic management with medications such as benzodiazepines for agitation and anti-emetics/loperamide for GI symptoms.

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What is the mainstay of treatment for ventricular fibrillation

Defibrillation and CPR

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If ventricular fibrillation is not resolving with Defibrillation and CPR what can be given after the 3rd shock

Amiodarone 300mg IV and Adrenaline 1mg IV (1:10,000)
Amiodarone is given as a one-off dose. However Adrenaline may be repeated every other cycle following a shock (i.e. cycles 3, 5, 7 etc.)

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What is the mainstay of treatment for pulseless electrical activity

Defibrillation and CPR

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What is the first step in managing DKA

IV fluids as the acute issue in these patients is severe dehydration which needs to be treated with IV fluids.

The patient should only be started on a fixed rate insulin infusion at a rate of 0.1 units/kg/hr once the first bag of fluids is complete

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What features indicate that a PE is massive

Hypotension (systolic < 90 mmHg or a drop in systolic blood pressure of ≥ 40 mmHg for ≥ 15 minutes)

Signs of shock

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What side does the tracheal deviation in relation to the side of the pneumothorax

Tracheal deviation AWAY from the pneumothorax

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How is a tension pneumothorax managed

Immediate needle decompression with a large-bore needle inserted into the 2nd intercostal space in the midclavicular line
This should be followed by chest drain insertion to reduce the risk of an immediate recurrence of the tension pneumothorax.

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What scoring system is used to predicts mortality in upper GI bleeds

Rockall score
OR
Glasgow-Blatchford Score (only for pre-endoscopy)

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In what scenario’s would you immediately give N-acetylcysteine in a paracetamol overdose

Ingested >15 hours ago
OR
Staggered overdose

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In what scenario’s would you immediately give activated charcoal in a paracetamol overdose

If ingested within the last hour

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In what scenario’s would you have to wait until 4 hours post-ingestion in a paracetamol overdose

If pt is presenting with ingestion < 4 hours ago

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Paracetamol overdose can be life-threatening.

What can it cause?

Hepatocellular necrosis
Renal tubular necrosis
Hepatic encephalopathy
Death

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What is the most appropriate emergency treatment for anaphylaxis

500 micrograms of 1:1000 adrenaline IM injected into middle third of anterolateral thigh

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What is the first line management of severe hypoglycaemia eg. Seizures, Unconscious

150ml IV 10% dextrose STAT

Provides a rapid increase in plasma glucose levels

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Pancreatic pseudocyst are a recognised complication of acute pancreatitis.

Those that are not symptomatic and non-communicating are managed conservatively.

How are those that are symptomatic and communicate managed?

Endoscopic or surgical intervention due to the risks of infection, haemorrhage or rupture of the cyst

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Which interleukins are important in the mediating the underlying inflammatory response in bacterial infections

IL1, 4, 6, 10 and 13 Activates B and T lymphocytes and promotes inflammation

What is the four components of the Systemic inflammatory response syndrome (SIRS)

≥ 2 of: - 38°C or < 36°C - Heart rate > 90 - Respiratory rate > 20 - Raised WBC

Define sepsis

Systemic inflammatory response syndrome (SIRS) (i.e. at least two of the following: fever, high HR, high RR, raised WBC) AND Presumed or confirmed infection

Define septic shock

Severe sepsis with either: Hypotension despite adequate fluid resuscitation OR Lactic acidosis

Name the 6 components of sepsis 6

1) Take bloods (FBC, U&E, LFT, CRP, lactate) 2) Take blood cultures 3) Administer oxygen if required 4) Administer IV antibiotics 5) Administer IV fluid resuscitation 6) Monitor urine output

What is IV adenosine used in ILS

In the treatment of supra-ventricular tachycardias (SVT) second line after vagal manoeuvres

What is the first line pharmaceutical management of bradycardia associated with haemodynamic compromise

IV atropine

What is the second line pharmaceutical management of bradycardia associated with haemodynamic compromise if IV atropine has not helped or countraindicated

IV adrenaline

What is the first line pharmacotherapy given in suspected opioid overdose

Naloxone

Characteristic Hx of acute pericarditis is pleuritic chest pain and low-grade fever. What ECG pattern would you have in acute pericarditis

PR depression and global saddle-shaped ST elevation

How is acute pericarditis managed

Analgesia (NSAIDs such as aspirin or ibuprofen) and bed rest If underlying cause is known - treat it Colchicine and steroids may also be used

What are the two serious complications of pericarditis

1) Cardiac tamponade 2) Chronic constrictive pericarditis

Spinal cord compression needs urgent neurosurgical review. What medication should be given whilst awaiting specialist advice

Loading dose of dexamethasone

What is the most common cause of spontaneous intracerebral haemorrhage.

Hypertensive vasculopathy Hypertension leads to the formation, and subsequent rupture, of Charcot-Bouchard aneurysms in the small penetrating blood vessels of the brain

How are extra-dural haematoma that is less than 30cm in volume, less than 15mm thick and causing less than 5mm midline shift managed

Conservative management

How are extra-dural haematoma that is greater than 30cm in volume managed

Surgical evacution e.g. burr holes regardless of their GCS

Likely bleeding site? Lucid interval after an initial loss of conciousness, which may then be followed by rapid deterioration

Extra-dural haematoma

What type of haematoma is this?

Extradural haematoma Extradural = Egg shaped

Beck's triad is a triad of signs of cardiac tamponade. What are the 3 components of the triad?

Raised JVP Hypotension Muffled heart sounds

Nothing

Preceding viral infection with pleuritic chest pain worsening on lying down and relieved on sitting forward is the classic presentations what condition

Acute pericarditis

Likely Dx: Child with fever with SoB and signs of respiratory distress e.g. stridor, increase WoB, use of accessory muscles Unvaccinated

Acute epiglottitis. This is a serious, but now rare due to the introduction of Haemophilus influenzae type B (HibB) vaccinate as the infection is most commonly caused by Haemophilus influenzae type B

How should child with acute epiglottitis be managed

Endotracheal intubation by an anaesthetist These patients should not be examined, treated or cannulated, but left alone. Any upset or distress may lead to total airway obstruction

What is the gold standard investigation for diagnosis of suspected cauda equina syndrome or cord compression

Urgent whole spine MRI

Which one of these is a life-threatening complication of sepsis? Disseminated intravascular coagulation (DIC) Immune thrombocytopenic purpura (ITP)

Disseminated intravascular coagulation (DIC) Over-activation of the coagulation pathway leading to increased risk of thrombosis and subsequent risk of bleeding due to depletion of clotting factors and platelets Characterised by raised PT, APTT and D-Dimer, and low platelet count and fibrinogen level

How is Disseminated intravascular coagulation (DIC) managed

Supportive with blood products and treatment of the underlying cause

What medication is used to manage the symptoms of thyrotoxic storm

IV propanolol

What is the first line medication used to treat thyrotoxic storm

Propylthiouracil (PTU)

What is the first line medication used to treat thyrotoxic storm in first trimester of pregnancy

Propylthiouracil (PTU)

What is the first line medication used to treat thyrotoxic storm after the first trimester of pregnancy

Carbimazole

What are the 4 factors that indicates haemodynamic compromise (and therefore the need for treatment) in bradycardia

Shock Syncope Myocardial ischaemia Heart failure

How is cardiac tamponade managed?

Pericardiocentesis where fluid is aspirated and subsequently drained from the pericardium

In shockable cardiac arrest, after the third shock a 300mg of IV amiodarone is given. When and at what dose will the next IV amiodarone be given?

Given after the 5th shock The further dose is half the initial i.e. 150mg

What is the management of amitriptyline overdose

Sodium bicarbonate

What scoring scale is used to assess the severity of alcohol withdrawal

Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised Takes into account the following features: Tremor Nausea and vomiting Anxiety

If a patient has been in asystole for more than how many minutes, in the absence of a reversible cause, it is reasonable grounds for stopping the CPR attempt

20 minutes

What medication is used in aspirin overdose to maintain good kidney function and to alkalise the urine in order to increase salicylate excretion

IV sodium bicarbonate

First line management of supraventricular tachycardia (SVT)

Vagal manoeuvres

What type of haematoma is this?

Subdural haematoma suB = Banana shaped

What is the definitive treatment of acute compartment syndrome

Fasciotomy

What is the gold standard diagnostic tool for encephalitis

Lumbar puncture with CSF analysis - microscopy, serology, cultures

What is the empirical treatment for suspected encephalitis

IV acyclovir and IV ceftriaxone

IV fluids with an insulin infusion is the initial treatment for DKA. What kind of rate is the insulin?

IV fluids and a fixed rate insulin infusion

Except bloods, which is the most important investigation in amitryptiline overdose

Electrocardiogram (ECG) Classic progression from sinus tachycardia, to widened QRS and then ventricular arrhythmias

What is the first line management of a spontaneous primary pneumothorax: Pt has SoB OR/AND Pneumothorax is > 2cm

Needle aspiration with 16-18G cannula followed by a period of observation

What is the first line management of a spontaneous primary pneumothorax: No SoB AND Pneumothorax is < 2cm

Conservative management followed by outpatient review in 2-4 weeks

What is the first line management of a secondary pneumothorax: No SoB AND Pneumothorax is < 1cm

Admit for observation for 24 hours and administered oxygen as required Secondary meaning they have an underlying lung disease

What is the first line management of a secondary pneumothorax: No SoB AND Pneumothorax between 1-2 cm

Needle aspiration using a 16G cannula Secondary meaning they have an underlying lung disease

What is the first line management of a secondary pneumothorax: SoB OR/AND Pneumothorax > 2 cm

Insert a chest drain Secondary meaning they have an underlying lung disease

Overdose of what substance causes an initial respiratory alkalosis and later a metabolic acidosis

Aspirin

How is Torsades de Pointes managed in an unstable patients with haemodynamic compromise

Synchronised DC cardioversion Haemodynamic features include heart failure, ischaemia, syncope or hypotension

How is Torsades de Pointes managed in an stable patient

IV Magnesium Sulphate 2g over 1 to 2 minutes

What scoring system is used to assess the risk of patients who present with an upper GI bleed when the patient has yet to have an endoscopy

Glasgow-Blatchford score Rockall score is most appropriate post-endoscope

What scoring system is used are used to assess the risk of patients who present with an upper GI bleed when the patient has yet to have an endoscopy

Glasgow-Blatchford score Rockall score is most appropriate post-endoscope

What blood test is most specific for acute pancreatitis

Serum amylase Serum lipase as a similar sensitivity and specificity to serum amylase but hardly used in hospital

Name the triad of key features of Hyperosmolar Hyperglycaemic State

1) Hyperglycaemia 2) Hyperosmolality (serum osmolality >320 mmol/kg) 3) Volume depletion in the absence of ketoacidosis (pH >7.3, HCO3 >15 mmol/l)

How long should direct oral anticoagulant be continued in an unprovoked pulmonary embolism

6 months

How long should direct oral anticoagulant be continued in a provoked pulmonary embolism

3 months

What are the three main sites for intraosseous access

Proximal tibia Distal tibia Proximal humerus

IV atropine 500 micrograms is used to treat bradycardia with adverse features. Atropine should only be used up to what dose?

3mg i.e. 6 doses 500 micrograms

What is the first line management of wound abscess

Wound exploration and washout

Most common causative agent in glandular fever

Epstein-Barr virus (EBV)