Emergency Medicine Flashcards
1
Q
Definition of Acute dystonia?
A
It’s a movement disorder characterized by involuntary painful muscle contractions and abnormal postures that involves the face, neck and trunk.
Torticolis (head rotated in an odd angle).
2
Q
Causes of a acute dystonia?
A
Medications, namely:
•Antipsychotics:
-Haloperidol
-Chlorpromazine
-Risperidone
•Antiemetics:
- Metoclopramide
3
Q
Time onset for acute dystonia?
A
Quick onset after initiation of the medication to 5 days after the initiation of the causative medication.
4
Q
Treatment of acute dystonia?
A
First line:
-Procyclidine (IV or IM it’s anticholinergic)
2nd line:
-Diazepam IV (benzodiazepine)
5
Q
What is the management of acute exacerbation of COPD?
A
1.Brochodilators
- Salbutamol (B2 agonist) nebulized 5mg
- (Consider) Nebulized ipratropium bromide 0.5mg (anticholinergic).
2.Corticosteroids
- Prednisolone 30 mg STAT (continue 30mg PO/day for 1-2 weeks)
OR
- Hydrocortisone 100mg IV;
3.Aminophylline
- In cases refractory to the treatment with bronchodilators;
4.Antibiotics if:
- Purulent sputum;
- Fever;
- ↑CPR;
- Signs of pneumonia.
5.O2 therapy
- Initiate with venturi mask with FiO2 of 24-28%;
- The goal is SPO2 in between 88-92%;
- SPO2 <80% will lead to anaerobic metabolism and metabolic acidosis;
- SPO2 >92% will lead to retention of CO2 and respiratory acidosis (inhibition of respiratory drive; the respiratory drive is “driven” by CO₂).
➜ In a patient with COPD, they become desensitised to higher levels of CO2 in the blood, and so they need a higher level of CO2 to generate enough respiratory drive to breathe properly.
6.NIV use when:
- ↓PH (<7.35) + ↑PCO2 (which will lead to resp. acidosis) in spite of adequate O2 therapy offering;
7.Invasive ventilation if:
- Failure of NIV: ↓↓PH (<7.26) + ↑↑PCO2 in spite of NIV;
- Contraindications of NIV: resp. arrest; ↓consciousness level; High aspiration risk.
8.Scenarios
- ↓PH + ↑PCO2 ➜ NIV or Invasive (depends of the case);
- Normal PH + ↑PCO2 ➜ Venturi mask
- Normal PH + Normal/↓PCO2 +↓PO2 (hypoxemia) ➜ Titrate O2 to achieve target 88-92%.
6
Q
Define Anaphylaxis.
A
It’s an acute allergic reaction, with rapid onset of symptoms that can lead to death.
7
Q
What are the causes of Anaphylaxis?
A
- Food
- Insects bites/venom
- Medications
8
Q
Symptoms of anaphylaxis?
A
Skin
• Erythema
• Pruritus
• Urticaria
• Angiodema
Oral
• Lips, tongue and uvula oedema.
Respiratory
• Oedema of pharynx, epiglottis and larynx;
•Dyspnoea;
•Chest thightness;
•Cough;
• Wheeze
• Congestion, rhinorrhoea, sneezing.
Cardiovascular
- Hypotension/Shock due to peripheral vasodilation and increased vascular permeability leading to leakage of plasma from the circulation.
- Dizziness
- Syncope
- Tachycardia
Ocular
- Periorbital oedema.
9
Q
Anaphylaxis management?
A
1- ABCD
2- Epinephrine IM (middle 3rd of the anterolateral thigh)
• <6 years: 150mcg IM (0,15 ml 1 in 1000)
• 6-12 years: 300 mcg IM (0,3ml 1 in 1000)
• >12 years: 500 mcg IM (0,5ml 1 in 1000)
• Chlorphneramine should be given after Epi.
3- High flow O2
4- (If) Hypotension: IV fluids.
10
Q
Arterial blood gases
Is the patient hypoxic?
A
- PAO2 = 80-100 mmHg / 10.7-13.3 kPa
- Type 1 respiratory failure: ↓PO2 + Normal/low PCO2
- Type 2 respiratory failure: ↓PO2 + ↑PCO2
11
Q
Acid-base balance
Is the patient acidotic or alkalotic?
A
- PH <7.35: Acidosis
- PH >7.45: Alkalosis
12
Q
Acid-base balance
PH↓ + ↑PCO2
Whats’s the cause of this acid-base disorder?
A
Respiratory acidosis
* CO2 makes the blood acidotic ➜ Patient retains CO2 acutely;
HCO3 = 24-30 mmol/L
* It is produced by the kidneys to act as a buffer to neutralize the acid in order to maintain normal levels of PH;
* It is a slow process, it takes time so:
1. Acute resp. acidosis: normal HCO3 (it cannot be produced fast enough to compensate for the ↑ of CO2);
2. Chronic resp. acidosis: ↑HCO3 is indicative of a chronic retention of CO2 (e.g.: COPD).
- In an acute episode of COPD, the patient cannot compensate fast enough so it becomes acidotic even though it has an elevated levels of HCO3.
13
Q
Whats’s the cause of this acid-base disorder?
↑PH + ↓PCO2
A
Respiratory alkalosis
* An increase in RR will get rid of CO2.
1. Hyperventilation: ↑PH ↓PCO2 ↑PO2
2. Pulmonary embolism: ↑PH ↓PCO2 ↓PO2 (hypoxemia)
14
Q
Whats’s the cause of this acid-base disorder?
↓PH + ↓HCO3
A
Metabolic Acidosis
* ↑Lactate : -Raised in anaerobic metabolism, indicative of tissue hypoxia.
* ↑Ketones: -Diabetic ketoacidosis
* ↑H+ ions : - Renal failure; - Type 1 renal tubular acidosis; - Rhambomyolysis;
* ↓HCO3: -Diarrhoea; - Renal failure; -Type 2 renal tubular acidosis.
15
Q
Whats’s the cause of this acid-base disorder?
↑PH + ↑HCO3
A
Metabolic alkalosis
* There’s loss of H+ ions due to:
* Vomiting: stomach produces hydrochloric acid ➜ loss of H+ ions;
* Kidneys loss of H+ ions by the kidneys can be due to: ↑Aldosterone ➜ will lead to excretion of H+ ions.
↑Aldosterone can be due to:
- Conn’s syndrome (1ry aldosteronism);
- Liver cirrhosis;
- Heart failure;
- Use of loops/thiazide diuretics.
16
Q
Acid-base balance
Base excess
A
BE=±2
* BE >+2 = Metabolic alkalosis OR Compensated resp. acidosis
* BE < -2= Metabolic acidosis OR compensated resp alkalosis
17
Q
In ADULTS
What is the management of acute exacerbation of Asthma in adults?
A
-
Initial immediate treatment
* O2 administration if SPO2<92% (goal is SPO2= 94-98%)
* Bronchodilators: -Salbutamol nebulized 5mg OR Terbutaline nebulized 10mg
* Corticosteroids: - Prednisolone 40-50mg PO OR Hydrocortisone 100mg IV
2.If life threatening features present :
* O2 administration;
* Nebulized salbutamol: -5 mg every 15 min OR 10mg continuous nebulization; - Add Ipratopium bromide 0.5mg to the salbutamol nebulizations.
* MgSO4 IV 1.2-2g (single dose) over 20 min.
* If symptoms are refractory to the treatment: - Salbutamol IV or Aminophylline IV.
3.If improvement of symptoms in 15-30min:
* Salbutamol nebulizations every 4h;
* Prednisolone 40-50mg PO for 5-7 days.
18
Q
ATLS: Blood loss / Hypovolemia
Describe the 4 different classes
A
-
Class 1:
* Blood loss: <750ml / <15%
* HR: 60-100 bpm
2.Class 2:
* Blood loss: 750 - 1500ml / 15 - 30%
* HR: 101-120 bpm
3.Class 3:
* Blood loss: 1500 - 2000ml / 30 - 40%
* HR: 120 - 140 bpm
4.Class 4:
* Blood loss: >2000ml / >40%
* HR: >140 bpm
19
Q
BURNS
ATLS formula for fluid requirements?
A
2ml x TBSA% x Weight in Kg
20
Q
BURNS
Parkland formula for fluid requirements?
A
4ml x TBSA% x Weight in Kg
21
Q
BURNS
After calculating the fluid requirements, how to administer the fluids?
A
- Hartmamnn’s solution used
- 1/2 of the total fluid requirements to be administered in the first 8h (from the time of burn injury and not arrival to the hospital);
- 2nd 1/2 of the total fluid requirements to be administered over the next 16h.
Calculate the fluid requirements using the ATLS or Parkland formulas.
22
Q
BURNS
Describe the Wallace Rule of 9’s
Percentage of burned area
A
- Head and neck (front & back) : 9% (4.5% each side);
- Upper limbs (front & back each): 9% each (total 18% for both limbs);
- Thorax and Abdomen (front): 18%
- Thorax and Abdomen (back): 18%
- Lower limbs (front & back each): 9% each (total 18% for both limbs);
- Perineum: 1%
23
Q
BURNS
When to administer the fluids
Burn percentage to start fluids
A
- Children: 10% of TBSA burned.
- Adults: 15% of TBSA burned.
24
Q
BURNS
When to refer to burns facilities?
A
-
Children: >2% TBSA burned;
Adults: >3% TBSA burned;
2.Burns involving these areas:
- Face
- Hands
- Feet
- Genitalia
- Perineum
- Major joints
3.All deep dermal and full thickness burns;
4.All electrical and chemical burns;
5.All inhalation burns;
6.All non-accidental injury burns;
7.All burns not healed within 2 weeks.
25
# **BURNS**
What is the management of *full thickness **circumfential burns*** affecting a **limb** or the **torso**?
**Escharotomy**
1. **Limbs**: full thickness circumfential burns can cause compartment syndrome ➜ urgent escharotomy.
2. **Torso**: full thickness circumfential burns can impede respiration.
## Footnote
Compartment syndrome: severe pain + paraesthesia + ↓ or absent pulses.
26
What are the causes of Carbon monoxide poisoning?
* Car exhausts
* Fire
* Faulty gas heaters
* Paint remover (stripper)
* Industrial solvent.
27
What is the mechanism of action of Carbon monoxide poisoning?
* It bonds to haemoglobin forming carboxyhaemoglobin (COHg).
* It reduces the capacity of the blood to carry oxygen.
* Oxygen delivery to the tissues will be decreased resulting in tissue hypoxia.
28
What are the symptoms of Carbon monoxide poisoning?
- Headache
- Nausea and vomiting
- Vertigo
- Confusion
► **Severe toxicity**
- Pink skin and mucosae (cherry skin)
- Hyperventilation
- Arrhythmias
- Fever
- Coma
- Death
29
What is the management of Carbon monoxide poisoning?
- Clear the airway;
- Give 100% O2:
1. If patient is conscious put a tight fitted mask with O2 reservoir;
2. If patient is unconscious intubate and ventilate in IPPV on 100% O2.
➨ The elimination half-life of CO is:
- 4h in breathing air;
- 1h on 100% O2
- 23 min on O2 at 3 atmosphere pressure.
30
What is the investigation / test in CO poisoning?
Sphectophotometry
| It's the COHgB levels in blood.
31
In CO poisoning, when to consider hyperbaric O2 treatment?
**Controversial type of treatment**
* >20% of COHb levels;
* Pregnacy
* Myocardial ischaemia
* Neurological signs other than headache.
32
# Intoxications
What are the symptoms of Paracetamol poisoning?
**Initial sypmtoms**
* Nausea
* Vomiting
* Pallor
**After 24h**
* ↑ levels of hepatic enzymes;
**After 48h**
* Jaundice
* RUQ pain
* Hepatomegaly
**Other symptoms**
* Hypoglycaemia
* Hypotension
* Encephalopathy
* Coagulopathy
* Coma
33
# **Intoxications**
Patients at ↑ risk of hepatotoxicity
| In a scenario of paracetamol poisoning
**Taking drugs that ↑ liver enzymes levels**
- Rimfamphicin
- Phenytoin
- Carbamazepine
- Chronic alcohol abuse
- St. John's Wort (flower that is used in the treatment of depression)
**Malnourished patients**
- HIV
- Hepatitis C
- Anorexia
- Bulimia
- Cystic fibrosis
- Alcoholism
**People who haven't eaten in a few days.**
34
# **Intoxications**
In a scenario of **paracetamol** poisoning, when to discharge home?
Ingestion of <150mg/Kg (child or adult), with no hepatic risk factors.
35
# **Intoxications**
In **paracetamol** poisoning, when to admit to the hospital?
* Patients presenting **within 8h** of ingestion of >150mg/Kg (24 tablets/12g) ;
* Unknown amount ingested.
36
# **Intoxications**
In **paracetamol** poisoning, when to measure paracetamol plasma concentration levels?
≥ 4h post ingestion of >150mg/Kg of paracetamol.
37
# **Intoxications**
In **paracetamol** poisoning, when to administer activated charcoal?
If the patient presents in <1h post ingestion of >150mg/Kg of paracetamol.
| **1g/Kg, máx 50g**
38
# **Intoxications**
When to administer N-acetylcysteine?
| In **paracetamol** poisoning
* If after 4h post ingestion, the plasma concentration of paracetamol is above the appropriate line (100mg/L);
* If 15h post consumption, the plasma paracetamol levels are above 15mg/L;
* If time of consumption is unknown, regardless of plasma concentration of paracetamol;
* If the patient presents late (>8h) post ingestion of >150mg/Kg of paracetamol;
* If there was a staggered overdose (not all the pills were not taken within 1h. e.g.: Consumption of 6g, 12 tablets of paracetamol everyday for 6 days. This is an overdose!)
* Jaundiced;
* Comatose.
39
What are the Kings's College criteria for Liver transplant?
| In **paracetamol** poisoning
**Arterial PH** <7.3 after 24h of ingestion
OR **ALL** of the following:
1. Prothrombin time > 100s (normal 11 - 13.5s)
2. Creatinine >300mmol/l
3. Grade 3 or 4 encephalophaty
40
What is the time of onset of TCA (Tricyclic antidepressants) Intoxication?
Rapidly time of onset, sometimes within 1h of ingestion.
41
What are the symptoms of TCA Intoxication?
**Dryness**
- Dry mouth
- Dry flushed skin
- Urinary retention
**Eyes**
- Dilated pupils
- Blurred vision
**ECG + cardiovascular**
- Sinus tachycardia
- Arrhytmias
- Hypotension
**Neurological**
- Agitation
- Drowsiness
- ↓ level of counsciness
- Seizures
- Severe sedation
- Coma
**Acid-base disorder**
- Metabolic acidosis
42
What are the ECG changes found on TCA intoxication?
- Sinus tachycardia
- Widening of the QRS complex >100ms (as toxicity worsens)
- Prolongation of the QT interval (as toxicity worsens)
- Widening of the PR segment (as toxicity worsens)
- Broad complex tachycardia
43
What is the Acid-base disorder found on TCA intoxication?
- Metabolic acidosis
44
What is the management for TCA intoxication?
- ABC
- Cardiac monitoring looking for widening of the QRS complex;
- IV bicarbonate in suspected or confirmed TCA poisoning with a QRS>100ms
➜ 250ml NaCl 0.9% bolus + Sodium bicarbonate 50ml -100 ml (50mmol) of 8.4% SLOWLY IV injection
➜ Sodium bicarbonate will correct ECG changes and arrhytmia
45
Bicarbonate in TCA intoxication management?
**IV bicarbonate in suspected or confirmed TCA poisoning with a QRS>100ms**
➜ 250ml NaCl 0.9% bolus + Sodium bicarbonate 50ml -100 ml (50mmol) of 8.4% SLOWLY IV injection
➜ Sodium bicarbonate will correct ECG changes and arrhytmias
* Aim for PH of 7.5-7.55
* Plasma protein binding of tricyclic antidepressants tend to bind in a more alkaline ph environment, which will lead in ↓ amount availability of the active unbound drug.
46
What are the symptoms of salicylate intoxication?
**GI tract**
- Nausea
- Vomiting
**Hearing**
- Tinnitus
- Vertigo
- Deafness / Impaired hearing
**Respiratory**
- Hyperventilation
**Neuro**
- ↓ GCS
- Seizures
**Cardiovascular**
- Hypotension
- Heart block
**Metabolic**
- Mixed acidosis: Initially respiratory alkalosis due to stimulation of the central respiratory centre (hence the hyperventilation) ➜ Later metabolic acidosis
- Hypokalemia
47
What are the symptoms of **opioid** overdose
* ↓RR / respiratory depression;
* Miotic pupils;
* ↓ counscious level
* Constipation;
* Bradycardia;
* Hypotension
48
What is the antidote drug for **opioid** overdose?
**Naloxone**
* 0.8mg IV
* Fast onset (2 min to begin action)
* Short duration: - Can be given 2-3 times; -Need to be careful with intoxication using certain opioids with longer duration of action than Naloxone; -Naloxone will finish its effect whiles the opioid has not, which will prompt the intoxication symptoms to re-start.
- **Naloxone has a shorter half life compared to Methadone.**
49
What are the symptoms of **opioid withdrawal**?
- Increased body secretion:
- Sweating;
- Tearing;
- Runny nose;
- Diarrhoea.
- Pain:
- Muscle aches;
- Joints (arthralgia);
- Abdominal pain;
- Others:
- Dilated pupils
- Agitation
- Insomnia
- Anxiety
## Footnote
✾ Think of heroin as a girlfriend that has left you:
- You cry a lot: Watery eyes, runny nose, sweating
- You can't sleep: Insomnia
- You miss her: Agitation, anxiety
50
What is the time onset for **opioid withdrawal** symptoms?
* Withdrawal symptoms begins 12h after last use;
* It peaks in between 24-48h;
* May last up to weeks.
51
Describe the step by step management of **opioid overdose**
1. ABCD;
2. Clear the airway;
3. Administer O2 using bag and mask ventilation;
4. Naloxone IV;
5. Consider intubation (after bag & mask).
52
What are the drugs used to treat **opioid withdrawal**?
1. **Detoxification**: Methadone or Buprenorphine.
2. **Relapse prevention**: Naltrexone.
53
What are the symptoms of **benzodiazepines overdose**?
* Respiratory depression;
* Sedation;
* Anteretrogade amnesia.
* **Acid-base disorder**: Respiratory acidosis
- Resp. depression ➜ apnea ➜ accumulation of CO2 ➜ RA
54
What is the antidote drug for **benzodiazepines** overdose?
**Flumazenil**
* 200mcg over 15 sec ➜ then 100mcg at 60 sec intervals if needed.
* Usual dose range: 300–600mcg IV over 3–6min (up to 1mg; 2mg if on ICU).
55
What are the symptoms of **benzodiazepines withdrawal**?
* Panic attacks
* Agitation
* Insomnia
* Anxiety
56
What is the time onset for **benzodiazepines withdrawal** symptoms?
* Begins at 1-4 days after cessation of the medicine
* Peaks at 2 weeks
57
What are the drugs used to treat **benzodiazepines withdrawal**?
* Diazepam (slowly reduce the dose);
* Propanolol.
58
What are the symptoms of **cocaine overdose**?
**Unopposed 𝝰-adrenergic vasoconstriction**
► ↑HR
► ↑BP
► ↑RR
► Myocardial infarction (coronary vasoconstriction)
► Intracranial haemorrhage
► Mydriasis
► Perforated nasal septum
► Hyperthermia and sweating
► Metabolic acidosis
| Think of the symptoms as an association with vasoconstriction.
59
What are the drugs used to treat **cocaine overdose**?
1. **Benzodiazepines**: for treatment of cardiovascular symptoms.
2. **Phentolamine**: for management of refractory hypertension.
* 5 - 15mg IV (every 5-15min)
3. **Nitroglycerine or Nitroprusside** as an alternative to phentolamine.
## Footnote
B-blockers are not recommended due to coronary vasoconstriction seen in coke overdose
60
What is the time onset for **cocaine withdrawal** symptoms?
* Begins within hours of last dose;
* Peaks in few days.
61
What are the symptoms of **benzodiazepines withdrawal**?
* Depression
* Restlessness
* Insomnia
62
What are the drugs used to treat **cocaine withdrawal**?
* Propanolol
* Diazepam
63
What are the symptoms of **LSD overdose**?
* Colours become more vivid;
* Smelling colours;
* Seeing sounds.
64
What are the symptoms of **ecstasy overdose**?
* Seeing spots/flashing/floating colour;
* Tachycardia
* ↑ BP
* ↑RR
* Uncontrolled body movements
* Trismus
* Hyperthermia
* Rhambdomyolisis
* Insomnia
65
What is the time onset for **alcohol withdrawal** symptoms?
- Within 24;
-May last a few weeks.
66
What are the symptoms of **alcohol withdrawal**?
* Tremors
- Anxiety
- Sweating
- Nausea & vomiting
67
What is the time onset of **Delirium tremens**?
➜Begins at 24-72h
68
What are the symptoms of **delirium tremens**?
Alcohol withdrawal symptoms + **altered mental status** + **auditory & visual hallucinations**
69
Management of **alcohol withdrawal**?
1. **First line in uncomplicated withdrawal**:
- **Chlordiazepoxide** (a BZD)
- If complicated with seizures:
- Lorazepam
2. **Second line**:
- Diazepam.
3. **Prevention of Wernicke’s encephalopathy**:
- IV Pabrinex (Thiamine / vitamin B1).
4. **Deterrent / abstinence**:
- Disulfiram.
5. **Cravings reduction**:
- Acamprosate.
70
Management of **delirium tremens**?
**First line:**
- Lorazepam;
**Second line:**
- Diazepam.
71
What is **Wernicke’s encephalopathy**?
A disorder due to thiamine / vitamin B1 deficiency characterised by:
- Nystagmus / ophtalmoplegia
- Ataxia
- Confusion
72
What is the treatment for **Wernicke’s encephalopathy**?
- Thiamine IV
- Thiamine should be given first before Glucose (so that when glucose is given, it will be utilised to form ATP and prevent cell death in the brain).
73
Define the **Wernicke's- Korsakoff** Syndrome.
It's a syndrome that develops upon improper treatment of Wernicke's syndrome.
It's characterized by:
1. The Wernicke's triad;
2. **Amnesia**;
3. **Confabulation** (making up stories).
74
Describe **superficial epidermal burns**.
* Red;
* Painful;
* Do not blister.
| Former 1st degree burns.
75
Describe **partial thickness burns**
It's divided into:
* **Superficial dermal**: Blisters.
* **Deep dermal**: Shiny, intact sensation.
76
Describe **full thickness burns**.
* White / Brown / Black;
* No blisters;
* No pain.
77
Define cardiac tamponade.
It is a critical condition, in which there's fast development of pericardial effusion that compresses the heart.
78
What is the triad of symptoms in **cardiac tamponade**?
**Beck's triad**
1. ↑ JVP / Distended neck veins;
2. Muffled hear sounds;
3. Hypotension.
79
What is the investigation done in **cardiac tamponade**?
Echocardiography.
80
What is the ***initial management / treatment*** in cardiac tamponade?
Intravenous fluids.
| Patients usually present with shock (hypotension).
81
What is the ***most appropiate management / treatment*** in cardiac tamponade?
Pericardiocentesis.
82
What is the ***most appropriate management*** for a patient presenting with cardiac arrest due to *cardiac tamponade* secondary to penetrating trauma?
Immediate thoracotomy.
83
Describe the step by step management of clinical suspicion of **PE**.
**Wells score >4**:
1. PE likely;
2. Anticoagulation (awaiting CTPA)
3. Order immediate CTPA (computer tomography pulmonary angiogram);
4. Allergy to contrast media / renal impairment ➔ *V/Q scan* instead of CTPA.
**Wells score <4**:
1. PE unlikely;
2. Order D-dimers;
3. If D-dimers positive ➔ CTPA (immediate).
4. If negative think of alternate diagnosis.
► In the eventuality of a delay in doing CTPA ➜ Theraupetic anticoagulation until CTPA is done.
84
Define **compartment syndrome**.
↑ in pressure in a closed anatomical space (due to trauma), that results in insuficient blood flow to the muscles and nerves causing ischemia.
85
What are the symptoms of **compartment syndrome**?
* Intense pain (that does not match the extense of the injury) despite analgesia;
* Pain on passive movement;
* Sensory deficit;
* Pulse is present (arterial pulse > compartment pressure) ➨ lack of pulse is late finding.
86
Investigation of choice for **compartment syndrome**?
Intracompartment pressure device.
87
What is the treatment in **compartment syndrome**?
Emergency **fasciotomy**.
88
# In compartment syndrome
What condition can develop after fasciotomy?
**Reperfusion injury**:
* When the ischaemic tissue starts being perfused (after fasciotomy), it releases myoglobin into the circulation.
* Myoglobin will cause AKI.
**How to prevente it?**
* Adequate hydration;
* Alkanisation of urine;
* In severe cases ➔ dialysis.
89
What are the risk factors for **PE**?
* Surgery;
* Pregnacy (postnatal period included);
* Lower limb injury;
* Immobility;
* Malignancy;
* Previous VTE (venous thromboembolism).
90
What is the gold standard / most appropriate diagnostic method for PE?
CTPA.
| Computed tomography pulmonary angiogram.
91
What is the initial investigation method for PE?
X-ray.
| To rule out other causes of dyspnoea.
92
# In **pulmonary embolism**
Describe the anticoagulation management.
**Haemodinamically stable**:
1. **First line**:
- Apixaban or Rivaroxaban;
2. **Second line**:
- LMWH for 5 days, followed by Dabigatran or edoxaban;
**OR**
- LMWH + Warfarin.
**Haemodinamically unstable**:
1. Unfractioned heparin;
2. Consider thrombolysis.
| Treatment doses and not the prophylathic doses.
93
Describe the pain in **costochondritis**.
* Usually in patients >40 yo;
* Sharp pain that is aggravated by movement, inspiration, sneezing, coughing;
* Sides of sternum tender.
94
Treatment for **costochondritis**?
NSAIDS
95
How is **CPR in adults** performed?
1. 30 chest compressions;
2. Two rescue breaths;
3. Continue with 30:2.
96
How is **CPR in children** performed?
1. Five rescue breaths;
2. 15 chest compressions;
3. Continue with 15:2.
97
How to administer breaths in **infants** during **CPR**?
- With your mouth, cover / seal the infant’s nose and mouth before administering a breath.
- If the above is not possible, cover / seal the mouth or nose with your mouth, while closing the other with your hand before administering a breath.
98
How to administer breaths in **>1 YO** during **CPR**?
Seal / cover the child's mouth with yours before administering a breath over 1 sec.
99
How to administer chest compressions in **infants** during **CPR**?
➨ Chest compressions are started **after rescuing breaths** (if there's no sign of life) ***at a rate of 100 bpm*.**
➨ The sternum should be compressed by at least **1/3rd of it's depht.**
1. **Encircling techique**: Place both thumbs over the lower half of the sternum for compression (the rest of the hand will encircle the lateral thorax and the back).
2. **Two-finger technique**: Place the tips of the index and middle finger on the lower sternum and compress.
100
How to administer chest compressions in **>1 YO children** during **CPR**?
➨ Chest compressions are started **after rescuing breaths** (if there's no sign of life), ***at a rate of 100 bpm*.**
➨ The sternum should be compressed by at least **1/3rd of it's depht.**
1. Start compressions with the **heel of one hand** placed on the lower sternum.
2. In a large children use **2 hands**, as you would in an adult.
101
# **CPR**
Name the pulseless **shockable** rhythms.
1. Ventricular fibrillation;
2. Ventricular tachycardia (pulseless).
102
# **CPR**
Name the pulseless **non-shockable** rhythms.
1. Asystole;
2. Pulseless electrical activity.
103
# CPR in Advanced Life Support
Describe the step by step **management** in ALS.
► **Adult patient is unresponsive with absent / abormal breathing**
1. Give CPR 30:2;
2. Assess rhythm:
➔ ***Pulseless shockable rhythms:***
* Shock;
* Assess rhythm every 2 min;
* Administer adrenaline every 3-5 min;
* After 3 shocks give Amiodarone.
➔ ***Non-shockable rhythms:***
* Continue chest compressions;
* Assess rhythm every 2 min;
* Administer adrenaline as soon as IV line is inserted and continue every 3-5 min;
104
GCS: eyes assesment
**4 pts** - Eyes opes spontaneously;
**3 pts** - Eyes open in response to voice commands;
**2 pts** - Eyes open in response to pain stimulus;
**1 pt** - No response.
105
GCS: verbal assesment
**5 pts** - Oriented;
**4 pts** - Confused;
**3pts** - Inappropriate words;
**2 pts** - Incomprehensible sounds
**1 pt** - No response.
106
GCS: motor assesment
**6 pts** - Obeys command;
**5 pts** - Localizes pain;
**4 pts** - Withdraws from pain;
**3 pts** - (abnormal) Flexion in response to pain;
**2 pts** - (abnormal) Extension in response to pain;
**1 pt** - No response.
107
# *Pupillary response to light*
Unilateral dilated pupil
| Name the causes.
► Unilateral space occupying lesion:
* Haematoma;
* Tumors;
* Abscess.
108
# *Pupillary response to light*
Bilateral constricted pupils
| Name the causes.
* Cerebrovascular accident affecting the brainstem;
* Opioid overdose.
109
# *Pupillary response to light*
Bilateral dilated pupils
| Name the causes.
* TCA overdose
* Stimulants
110
When can you indicate a CT scan **within 1h** *in adults* after a head injury?
* GCS <13 on arrival to the hospital;
* 2h after the 1st evaluation a GCS of <15 ;
* Suspected open or depressed skull fracture;
* Any sign of basal skull fracture;
* Post-traumatic seizure;
* Focal neurologic deficit;
* More than 1 episode of vomiting.
| If any of the above present.
111
When can you indicate a CT scan **within 8h** *in adults* after a head injury **that present with loss of consciousness & amnesia**?
* ≥ 65YO;
* Patient on anticouagulation;
* History of bleeding or clotting disorder;
* Dangerous mechanism of injury;
* > 30 min retrograde amnesia
| If any of the above present.
112
When can you indicate a CT scan **within 1h** *in children* after a head injury?
* On arrival to the hospital, GCS<15 **if < 1 YO** ;
* On arrival to the hospital, the GCS is < 14 if **> 1 YO**;
* 2h after the head trauma a GCS of <15 ;
* Post-traumatic seizure;
* Suspected open or depressed skull fracture or tense fontanelle;
* Signs of basal skull fracture;
| If any of the above present.
113
Criteria to indicate a CT scan **within 1h** *in children* after a head injury **with ≥ 2** of it present?
* Loss of consciousness > 5 min;
* Abnormal drownsiness;
* Amnesia > 5 min;
* ≥ 3 episodes of vomiting;
* High speed RTA;
* Fall from a height >3m.
| 2 or more of the above to do the CT.
114
What are the signs of basal/basilar skull fracture?
* Racoon / panda eyes (bilateral periorbital bruising);
* Batle's sign (retroauricular / mastoid process bruising without direct trauma);
* Haemotympanum or bleeding from the auditory meatus;
* CSF rhinorrhea or othorrhea.
115
What is the bone affected in basal/basilar skull fracture?
Temporal bone
116
CT scan of epidural (extradural) haematoma?
An expanding lemon.
117
CT scan of subdural haematoma?
Banana.
118
Describe what is Flail chest
It is when multiple ribs (>3) are broken due to trauma, causing paradoxical respiration (chest in during inspiration, and out during expiration).
119
Describe the presentation of Flail chest
* RTA;
* Chest pain;
* Dyspnoea.
120
What is the management of Flail chest?
* High flow O2;
* Analgesia (3 steps analgesia, intercostal block / T4 thoracic epidural);
* If fatigue of breathing: Intubation + Positive pressure ventilation
121
What are the 3 features of DKA (diabetic ketoacidosis)?
1. Hyperglycaemia;
2. Acidosis;
3. Ketonaemia.
122
What are the (most common) causes of DKA?
* Infections;
* Missed insulin doses;
* Cardiovascular disease’s (MI, cerebral stroke).
123
What are the symptoms of DKA?
* Polyuria, polydipsia, vomiting, dehydration;
* Abdominal pain;
* Kussmaul respiration;
* Acetone smelling breath;
* Altered mental status —> Coma.
124
How is the diagnosis of DKA made?
**All of the following must be present**
* Capillary glucose > 11 mmol/L or known DM.
* Capillary ketones > 3mmol/L or urinary ketones > ++.
* Arterial blood gas PH< 7.3 and/or HCO3 < 15.
125
What is the initial management of DKA?
Hydration / fluid replacement with NaCl 0.9%.
126
After the initial management with saline, what is the follow up management of DKA?
*After appropriate saline infusion*
- Correct potassium (if needed) with KCl 40mmol/L
- Insulin therapy (if given early, before the IV fluids, can cause cerebral oedema);
- When plasma glucose reaches 14, add dextrose 10% alongside the saline infusions and consider reducing the IV insulin.
127
What glucose value is considered hypoglycaemia?
4 mmol/L.
128
What are the causes of hypoglycaemia?
- Anti-diabetic medications.
- Binging of alcohol;
- Post gastric surgery.
129
Symptoms of hypoglycaemia?
- Sweating
- Anxiety
- Hunger
- Tremors
- Dizziness
- Palpitations
- Confusion
- Seizures
- Coma
130
What is the management of hypoglycaemia?
*Conscious patient*
- Carbohydrated snack
- Glucose gel.
*Unconscious patient*
- 1mg glucagon IM (if outside the hospital);
- Glucose IV:
**Glucose 20%** 75ml IV (10-15 min);
**Glucose 10%** 50ml IV, every 2 min until patient is conscious or 250 ml has been given.
**Glucose 50%** 25-50ml (in large vein followed by saline flush, hypertonic solution that can damage veins).
131
What are the contraindications for the use of Glucagon?
- Alcohol intoxication
- Chronic alcoholism
- Liver failure
- Hypoglycaemia due to sulfonylurea drugs
132
When to suspect **foreign body aspiration** in toddlers?
Story of a child playing with a toy, followed by a cough, wheeze, stridor (acute respiratory symptoms).
133
What is the *management* in a **unstable toddler** with suspected or confirmed **foreign body aspiration**?
| Unconscious & basic life support already done.
Laryngoscopy.
134
What is the *management* in a **stable toddler** with suspected or confirmed **foreign body aspiration**?
| No cyanosis, mild wheezing, child relatively well.
1. X-ray;
2. Bronchoscopy (even if normal x-ray).
135
Define haemothorax.
Blood accumulation in lung pleural cavity. Usualy caused by RTA or stab injury.
136
What are the symptoms of haemothorax?
* Hypotension
* Tachycardia
* Dullness on percussion
* Chest x-ray: homogenous opacity on the lower lung field.
137
What is the initial management of haemothorax?
1. Oxygen;
2. Insertion of 2 large venous cannulae and request blood.
138
What is the definitive management of haemothorax?
* Chest drain insertion;
* Surgery (rarely done).
139
Define pneumothorax.
It is air accumulation in the pleural cavity that results in lung collapse on the affected side.
140
What are the symptoms of pneumothorax?
* Sudden onset of chest pain;
* Dyspnoea;
* Hyperressonance on the affected side.
141
What is the classification of pneumothorax?
1. *Based on the cause*
* **Primary / Spontaneous**: No identifiable cause;
* **Secondary**: idenfiable cause such as COPD/Asthma.
2. *Based on the nature*
* **Closed**: the volume of air doesn't change in the pleural cavity;
* **Open**: Communicates with the athmosphere;
* **Tension**: volume of air int pleural cavity expands.
142
What is the management of **primary / spontaneous pneumothorax**?
* Erect chest x-ray, to confirm the diagnosis;
* **≤ 2cm**: O2 & conservative management.
* **> 2cm or distressed patient**: Needle aspiration;
143
What is the management of **secondary pneumothorax**?
* **< 1cm**: O2 & conservative management.
* **1-2 cm**: Needle aspiration.
* **> 2cm**: Chest drain.
144
What are the symptoms of **tension pneumothorax**?
* Acute respiratory distress;
* Hypotension;
* Tracheal deviation from the pneumothorax side;
* ↓ air entry on the affected side;
* ↑ JVP.
145
What is the management of **tension pneumothorax**?
1. High flow O2;
2. **Needle decompression**: Insert large bore cannula (14-16G) into the 5th mid-axillary intercostal space;
3. Chest drain;
4. X-ray.
146
Causes of hypercalcaemia?
* Primary hyperparathyroidism;
* Malignacy: Multiple myeloma, Lung carcinoma (produces PTH like molecule);
* Sarcoidosis;
* Immobilization.
147
Symptoms of hypercalcaemia?
* **Gastro (Moans)**: Constipations due to ↓ bowel activity;
* **Renal (Stones)**: Kidney stones & nephrolithiasis due to calcium deposits in kidney. Polyuria & polydipsia due to induction of diabetic insipidus;
* **Neuro & Psych (Groans)**: Lethargy, confusion and depression;
* **Bone pain (Bones)**: seen in hyperthyroidism.
148
What is the management of **hypercalcaemia**?
1. Hydration with (3-4L) of NaCl 0.9% to induce urinary output and excretion of calcium;
2. Bisphosphonates IV (Zoledronic acid or pamidronate);
3. **In sarcoidosis**: steroids;
4. **2ry hyperparathyroidism**: Cinalcet hydrochoride;
5. **Renal failure**: hemodialysis;
149
What ECG changes are seen in **Hyperkalaemia**?
1. Tall tented **T waves**;
2. Flattening of the **P wave**;
3. Widening of the **QRS complex** ➜ sinusoidal pattern ➜ asystole.
150
What is the classification of **hyperkalaemia** based on severity?
* **Mild**: 5.5-5.9 mmol/L
* **Moderate**: 6.0-6.4 mmol/l
* **Severe**: ≥6.5 mmol/L
151
What are the causes of **hyperkalaemia**?
* Potassium sparing diuretics / ACE-inhibitors / ARB's / Spironolactone;
* Acute renal failure;
* Metabolic acidosis;
* Addison's
152
What is the management of moderate or severe hyperkalaemia with ECG changes?
1. Stop caustive drugs (if any);
2. Calcium gluconate (if ECG changes or K>6.5)
3. Insulin IV & Dextrose.
## Footnote
Other methods:
* Calcium resonium (binds K+ to the gut);
* Salbutamol
* Bicarbonate
* Hyperventilation
* Loop diuretics;
* Dialysis.
153
What is the most initial management of hyperkalaemia with ECG changes?
Calcium gluconate.
154
What is the most aproppriate management of hyperkalaemia with ECG changes?
Dialysis.
155
What is the management of mild or moderate hyperkalaemia asymptomatic and without ECG changes or signs of AKI?
1. Stop the causative drugs;
2. Repeat K+ levels in 1-3 days in primary care.
156
What are the causes of hypovolaemic hyponatremia?
►**Develops when Na+ and water are lost but only water gets replaced**
* GIT losses (diarrhoea, vomiting);
* Skin loss (burns, sweating);
* Diuretics (Na & water are lost through renal excretions but only water gets replenished by mouth);
* Addison's disease (Aldosterone causes renal Na reabsortion and K excretion, when aldosterone is lost, there is Na and water loss and accumulation of K).
157
What are the causes of euvolaemic hyponatremia?
* SIADH
* Diuretics
* Psychogenic polydipsia
158
What are the causes of hypervolaemic hyponatremia?
* Excess water;
* Cirrhosis;
* Congestive heart failure;
* Nephrotic syndrome;
* Renal failure (free water is not excreted).
159
What are the **other causes** of hyponatraemia?
* **Pseudohyponatraemia**: In hyperglycaemia, the high glucose amount causes a shift of water **without** Na from cells and into the vascular space.
* SSRI;
* ACEi;
* Elderly patients (prone to SIADH cause they're unable to suppress ADH effectively) (investigations necessary only if Na <130)
160
What investigations / lab analysis should be requested in **hyponatraemia**?
* Urinary sodium (High sodium in urine = hypovolaemia).
* Volume status of patient
161
What is the management of hyponatraemia?
1. **Emergency cases** (coma/seizure): IV hypertonic solution 1.8% or 3% NaCl & furosemide;
2. **Hypovolaemic**: Normal saline 0.9%
3. **Euvolaemic**: Normal saline 0.9% given slowly (1L over 8h); **Euvolaemic due to SIAHD**: Fluid resctrition / demeclocycline or vaptans if fluid resctritions is inadequate;
4. **Hypervolaemic**:Treat the underlying cause.
162
What are the symptoms of panic attacks?
* **Numbness or tingling sensation**: Hyperventillation ➔↓CO2➔Respiratory alkalosis➔Hypocalcaemia.
* Palpitations;
* Chest pain
* Sweating;
* Tremors;
* Difficulty breathing.
163
How long do panic attacks last for?
10-20 min.
164
Management of panic attacks?
* **Acute**: breathing into a bag;
* **Long term**: CBT, Antidepressants (SSRI)
165
Define sepsis
Life threatening organ dysfunction caused by desregulation of host's response to infection.
166
What are the **red flags** in sepsis?
* SBP <90mmHg / a fall of >40 mmHg from the baseline;
* HR >130 bpm;
* Lactate >2 mmol/L;
* SPO2 <91% (<88% in COPD);
* RR >25 breaths/min;
* Neuro: unresponsive / responds to voice or pain only;
* Urine output <0.5ml/Kg/h in ≥ 2h;
## Footnote
If ≥1 red flag present, complete the **Sepsis six** within 1h.
167
What are the sepsis 6?
*If ≥1 red flag present, complete the Sepsis six within 1h.*
**Take 3 & Give 3**
**Take 3**:
* Blood cultures;
* FBC, U&E, clotting, **serial lactate**;
* Urine output (monitor);
**Give 3**:
* High flow O2;
* IV fluids;
* IV antibiotics.
168
What is the initial management of sepsis ?
* High flow O2;
* IV fluids;
* IV antibiotics.
| If all options given then follow ABC protocol according to the symptoms.
169
Define septic shock?
Hypotension that is persistent and refractory to fluids administration.
170
Describe qSOFA?
* RR ≥22 breaths/min;
* Altered mentation;
* SBP ≤ 100mmHg
171
What is the management for upper GIT bleeding secondary to varices?
- Fluid resuscitation;
- Endoscopy (especially if the patient is unstable) ——> Band ligation;
- Terlipressin 2mg IV 4/4h
- If prolonged INR, give Vit K;
- Platelets transfusion if <50;
- Prophylactic antibiotics (cipro or cephalosporin);
**Omeprazole should be avoided unless known peptic ulcer disease**.
**PPI’s shouldn’t be given prior to endoscopy diagnosis**.
172
How to manage urethral injuries secondary to pelvic fractures / perineal trauma?
- Refer to urology;
- Do not insert an urinary catheter;
173
**ABCDE evaluation**
Describe the Airway evaluation.
- Look for signs of airway obstruction:
•Noisy air entry;
•Paradoxical chest and abdominal movements;
- Clear airway:
•Airway opening manoeuvre;
•Airway suction;
•Insertion of nasopharyngeal or oropharyngeal airway;
•If all fails, tracheal intubation;
- High concentration O2.
174
**ABCDE**
Describe the breathing evaluation.
- RR, chest expansion, auscultaste the breathing sounds;
- If RR inadequate or absent —> Bag-mask ventilation;
- NIV and intubation can be consider.
175
**ABCDE**
Describe the cardiovascular evaluation.
- Look for signs of circulation problems (BP, HR, peripheral and central pulses);
- If hypotension give 500 ml of crystaloids (saline 0.9% or Hartmann’s).
176
**ABCDE**
Describe the disability evaluation.
- Look for common causes of unconsciousness (hypoxia, cerebral hypoperfusion, low glucose)
- Check pupils.
177
**ABCDE**
Describe the exposure evaluation.
Expose the patient but do respect their dignity.
178
Describe the presentation of **Orbital blowout fractures**.
- Associated with fracture of the maxilla (orbital floor);
- Presents with vertical diploplia due to involvement of **inferior rectus muscle**;
- Enophtalmos (sunken eye);
- Infraorbital anaesthesia.
179
What is the management of **Orbital blowout fractures**?
- **Initial**: X-ray or the skull.
- **Most appropriate/definitive/gold standard**: CT scan.
- Surgery.
180
What are the causes of **Mallory-Weiss syndrome**
- Persistent vomiting / retching —> Oesophageal tear —> Haematemesis;
- Alcoholism;
- Bulimia nervosa.
181
What is the investigation in Mallory-Weiss Syndrome?
Endoscopy.
182
What is the management of Mallory-Weiss Syndrome?
- ABCDE
- IV fluids and blood transfusion if needed;
-Endoscopy immediately after resuscitation.
183
What is the **choking** management for an infant?
- While seating down, put the infant on your lap on prone position with the head tilting down;
- Deliver 5 back blows with the heel of the hand, along the spine in between the shoulders blades.
- Turn the infant supine and deliver 5 chest thrusts (less intense than chest compressions).
184
What is the **choking** management for a child and adult?
- Deliver 5 back blows;
- Stand behind the patient and give 5 abdominal thrusts as the patient is leaning forward. Clench one fist and grip the fist with the other hand and pull upwards and inwards sharply.
- Alternate in between step 1 and 2.
185
What is the **choking** management for an unconscious patient?
- Lay the patient on the floor;
- Call ambulance;
- Start CPR.
186
Describe what is **hereditary angioedema**.
It’s an autosomal dominant hereditary condition, due to C1-esterase inhibitor deficiency.
It can be precipitated by:
- Stress;
- Infection;
- Trauma;
- Surgery.
187
What are the symptoms of hereditary angioedema?
- Lip, mouth and face swelling;
- Dyspnoea and stridor (laryngeal oedema);
- Abdominal pain.
188
What is the investigation done in hereditary angioedema?
- Serum C4 level;
- C1 inhibitor level.
189
Management of hereditary angioedema?
- **C1 inhibitor concentrate IV or SC**;
- Bradykinin receptor inhibitor;
- Kallikrein inhibitor;
- Severe laryngeal oedema —> intubation and ventilation.
190
What are the symptoms of an acute case of peptic ulcer?
- Epigastric pain;
- Haematemesis;
- Melaena.
191
What is the management for an acute case of peptic ulcer?
- Endoscopy
- Acid suppression (PPI/H2 antagonist);
192
What are the risk factors for peptic ulcer
- NSAID’s
- Steroids
- H. pylori infection
193
What are the symptoms of a perforated peptic ulcer?
- Epigastric pain
- Melaena
- Rebound tenderness
- Guarding
- Abdominal rigidity
194
What is the investigation in perfurated peptic ulcer?
Erect X-ray: air under diaphragm.
195
What is the treatment of perforated peptic ulcer?
Laparoscopic or laparotomy repair.
196
What is the Serotonin syndrome?
Increased levels of serotonin in the synapses due to drug overdose or interaction between MAOI, SSRI and SNRI.
197
What are the symptoms of Serotonin syndrome?
**Autonomic hyperactivity**
- Hypertension
- Tachycardia
- Hyperthermia
**Neuromuscular abnormalities**
- Tremor
- Ocular clonus
- Hypertonicity
**Mental status changes**
- Anxiety
- Confusion
198
What is the management of serotonin syndrome?
- Stop the offending drug
- BZD
- IV fluids
- Cyproheptadine
199
Define status epilepticus
Single epileptic seizure lasting for > 5 min OR two epileptic seizures with less than 5 min in between them without full recovery in between.
200
What is the management of Status epilepticus?
- ABCDE (including glucose)
- Lorazepam IV (max 2 doses)
- Buccal midazolam or rectal diazepam (if no IV) (max 2 doses)
**If after 2 doses or 1 dose of bucal MDZ and then later 1 dose of Lorazepam IV**
- Phenytoin IV (1st)
- Phenorbabital IV (if seizures refractory to phenytoin)
- Intubation and ICU.
