Emergency Medicine Flashcards
Tinnitus is a characteristic feature of which type of overdose?
Aspirin
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)
Respiratory depression, reduced consciousness and bilaterally constricted (pinpoint) pupils are characteristic features of an overdose of what medication?
Opioid overdose
Respiratory depression, confusion and cerebellar symptoms such as nystagmus and ataxia are features of an overdose of what medication?
Benzodiazepine such as diazepam
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
Cherry red skin and confusion is pathognomonic for which condition
Carbon Monoxide poisoning
How is Carbon Monoxide poisoning managed
100% oxygen via face mask
How is a clinical diagnosis of meningococcal infection made
Blood or CSF culture
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.
What is the mainstay of treatment for ventricular fibrillation
Defibrillation and CPR
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.)
What is the mainstay of treatment for pulseless electrical activity
Defibrillation and CPR
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
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
What side does the tracheal deviation in relation to the side of the pneumothorax
Tracheal deviation AWAY from the pneumothorax
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.
What scoring system is used to predicts mortality in upper GI bleeds
Rockall score
OR
Glasgow-Blatchford Score (only for pre-endoscopy)
In what scenario’s would you immediately give N-acetylcysteine in a paracetamol overdose
Ingested >15 hours ago
OR
Staggered overdose
In what scenario’s would you immediately give activated charcoal in a paracetamol overdose
If ingested within the last hour
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
Paracetamol overdose can be life-threatening.
What can it cause?
Hepatocellular necrosis
Renal tubular necrosis
Hepatic encephalopathy
Death
What is the most appropriate emergency treatment for anaphylaxis
500 micrograms of 1:1000 adrenaline IM injected into middle third of anterolateral thigh
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
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
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
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)
