Emergency Medicine

Question 1

Supraventricular Tachycardia (SVT) is any ____ complex tachycardia characterised by a heart rate of more than 100 bpm and a QRS width of less than ____ ms on an ECG.Atrial Fibrillation (AF), AV Re-entry Tachycardia (AVRT) and AV Nodal Re-entry Tachycardia (AVNRT) are examples of SVTs.Patients with adverse features should be given _____ .These features can be remembered by the mnemonic HISS, which stands for:______

Answer 1

narrow 120

Question 2

Management of SVT in Stable patients with no adverse features.1. Determine if rhythm is regular or irregular. Regular:Irregular:

Answer 2

Regular Rhythm1. Vagal Manouevres - Carotid sinus massage / Valsava manouervre2. IV Adenosine (6mg) - (blocks conduction through av node) Prior to administering Adenosine, patients must be warned that they might experience difficulty breathing, chest tightness and flushing. It should then be given rapidly over 1-3 seconds, followed by a 20 ml IV Normal Saline bolus. If this fails, a second dose of Adenosine 12mg can be administered, followed by another 18mg. If this fails also - Beta blocker or Verapamil **Irregular rhythmManage according to AF algorithm:Rate control with Beta-blocker Rhythm control: Digoxin / Amiodarone (if Heart failure)If in AF>48hrs - Anticoagulate https://www.resus.org.uk/sites/default/files/2021-04/Tachycardia%20Algorithm%202021.pdf

Question 3

Drugs that potentiate the effect of adenosine and thus contraindicate the use of adenosine.

Answer 3

Dipyridamole (antiplatelet)Carbamazepine

Question 4

Adenosine cannot be given to ____ and thus ____ is used instead.

Answer 4

AsthmaticsVerapamilAdenosine is known to regulate myocardial and coronary circulatory functions. Adenosine not only dilates coronary vessels, but attenuates beta-adrenergic receptor-mediated increases in myocardial contractility and depresses both sinoatrial and atrioventricular node activities.

Question 5

Complications of SVT can include:

Answer 5

SyncopeDeep vein thrombosisEmbolismCardiac tamponadeCongestive cardiac failureMyocardial infarctionDeath

Question 6

Which drug is most appropriate to prescribe in aspirin overdose?

Answer 6

Sodium bicarbonate and fluid resuscitation (helps to eliminate the salicylate)Sodium bicarbonate increases plasma bicarbonate and buffers excess hydrogen ions, alkalinising the blood and urine and enhancing the elimination of aspirin. Glucose is also important to treat hypoglycaemia. ** Haemofiltration ± mechanical ventilation should be considered in severe toxicity **

Question 7

Clinical features of serotonin syndrome can be split into neurological and autonomic.Neurological features:Autonomic features:

Answer 7

Neurological:1. Altered mental state2. Tremor3. Ataxia4. Hyperreflexia.Autonomic:1. Tachycardia2. Hypertension3. Diarrhoea4. HyperthermiaNB - Distinct from *Neuroleptic malignant syndrome *which is caused by anti-psychotics or sudden reduction in dopaminergics (i.e parkinson’s). Predominant neurological feature of NMS is also** rigidity **

Question 8

Which antibiotic can cause prolongation of the QT interval, which can lead to a polymorphic VT, otherwise known as torsades de points?

Answer 8

Clarithromycin

Question 9

Causes of a long QT interval which may predispose a patient to developing TDP include the following. This can be remembered by a useful mnemonic - TIIMMES:

Answer 9

Toxins: drugs including clarithromycin, anti-arrhythmics, anti-psychotics and tricyclic antidepressantsInherited: congenital long QT syndromes such as Romano-Ward and Jervell and Lange-Nielson syndromes.IschaemiaMyocarditisMitral valve prolapseElectrolyte abnormalities, such as hypokalaemia and hypocalcaemiaSubarachnoid HaemorrhageTORSADES DE POINTES (VT) - PROLONGED QT INTERVAL

Question 10

Management of Torsades de Pointes

Answer 10

In *unstable patients *with haemodynamic compromise, **DC cardioversion **can be done. In stable patients, the choice of treatment is IV Magnesium Sulphate 2g over 1 to 2 minutes.

Question 11

Management of tension pneumothorax?

Answer 11

This is with a large bore cannula/needle in the 2nd intercostal space, midclavicular line on the same side as the pneumothoraxThis should be followed by chest drain insertion to reduce the risk of an immediate recurrence of the tension pneumothorax.A tension pneumothorax occurs when air enters the pleural cavity through a one-way valve and cannot escape

Question 12

Definition of Horners Syndrome and causes.

Answer 12

Horner’s syndrome is characterised by ptosis, meiosis with or without anhydrosis. It is due to an interruption of the sympathetic nerve supply to the eye and can be classified into pre-ganglion causes, post ganglionic causes and central causes.Causes:Pancoast tumour (affecting sympathetic nerve supply)StrokeCarotid artery dissection (Red flag: neck pain)

Question 13

Adult dose and route of adrenaline in anaphylaxis?

Answer 13

500ug MICROGRAMSIM

Question 14

Investigations and Management of pulmonary oedema due to Left Ventricular Failure.

Answer 14

InvestigationsBedside observationsArterial blood gasECGTroponin if concerned about a new cardiac eventSerum BNPChest X-rayManagement - POUR SOD- Take an ABCDE approach- Sit the patient up- Administer oxygen- Ensure IV access- IV Furosemide (40mg stat)* Consider non-invasive ventilation such as CPAP if failed medical therapy (usually in an intensive care setting)* Consider further therapies in the intensive care setting such as invasive ventilation and inotropic support if the above failshttps://www.nice.org.uk/guidance/cg187/chapter/1-Recommendations

Question 15

When taken as an overdose, the metabolism of paracetamol results in a buildup of a toxic substance called _____.

Answer 15

NAPQI (N-acetyl-p-benzoquinone-imine).NAPQI is inactivated by glutathione. In an overdose, glutathione stores are rapidly depleted, and NAPQI is left un-metabolised. It can cause liver and kidney damage.

Question 16

Management of Paracetamol overdose:

Answer 16

If ingestion less than 1 hour ago + dose >150mg/kg: Activated charcoalIf ingestion <4 hours ago: Wait until 4 hours to take a level and treat with N-acetylcysteine based on level using** nomogramIf ingestion 4-15 hours ago: Take immediate level and treat based on levelIf staggered overdose ( which is defined as being an overdose taken over > 1 hour) or ingestion >15 hours ago: Start N-acetylcysteine immediatelyObtain following bloods:FBCUrea and ElectrolytesINR**Venous gasIf a patient presents after 16 hours, there is *uncertainty about timing * or has a staggered overdose then NAC should be started regardless of the nomogram.NAC is associated with anaphylactoid reactions. These are not true anaphylactic reactions and can usually be managed by stopping the infusion temporarily and then restarting at a lower rate.Consider need for transfer to liver unit if blood tests are worseningManagement Flow chart: https://emj.bmj.com/content/19/3/202

Question 17

Emergency management of DKA?

Answer 17

Treating DKA (FIG-PICK)Follow local protocols carefully.F – Fluids – IV fluid resuscitation with normal saline.If patient is alert, not significantly dehydrated and able to tolerate oral intake without vomiting –> encourage oral intake and give subcutaneous insulin injection.If patient is vomiting, confused, or significantly dehydrated –> **give IV fluids (initial bolus of 10ml/kg 0.9% NaCl then discuss with a senior) and insulin infusion at 0.1 units/kg/hour 1hr after starting IV fluids. If there is evidence of shock, the initial bolus should be 20ml/kg.If patient is shocked or comatose –> ABCDE approach for emergency resuscitationDo not stop intravenous insulin infusion until 1 hour after subcutaneous insulin has been given.I – Insulin – Add an insulin infusion (e.g. Actrapid at 0.1 Unit/kg/hour)*G** - Glucose – Closely monitor blood glucose and add a dextrose infusion if below a certain level (e.g. 14 mmol/l)P – Potassium – Closely monitor serum potassium (e.g. 4 hourly) and correct as required - Aim for a reduction in blood ketones of 0.5 mmol/L/hour ** I ** - Infection – Treat underlying triggers such as infection** C ** - Chart fluid balanceK - Ketones – Monitor blood ketones (or bicarbonate if ketone monitoring is unavailable)Establish the patient on their normal subcutaneous insulin regime prior to stopping the insulin and fluid infusion.Remember as a general rule **potassium should not be infused at a rate of more than 10 mmol per hour.

Question 18

Diabetic ketoacidosis (DKA) is a medical emergency that is characterised by ____ , _____ and _____ .Specific cut off for these markers that indicates DKA ____.

Answer 18

hyperglycaemiaacidosisketonaemiaSpecific values to make the diagnosis:* Ketonaemia: 3mmol/L and over* Blood glucose over 11mmol/L* Bicarbonate below 15mmol/L or venous pH less than 7.3**NB: ** - Hyperglycaemia may not always be present.

Question 19

Emergency Management of PE:Massive PE and HD unstable - ______Acute PE and stable - _____Recurrent PE or Anticoagulation resistant - _____

Answer 19

Unstable: Thrombolysis - (Streptokinase/Alteplase - seek senior input)Stable: LMWH or UFH infusion (5 days - and INR >2 on 2 consecutive days) -** bridge with NOAC or Warfarin ** NB - Provoked PE - 3 months DOAC and check INR. Unprovoked PE - 6 months DOAC and check INR(Side note: remember warfarin takes time to titrate INR but also can be reversed quickly with Vit.K) Recurrent or treatment resistant: Inferior Vena Cava FilterNICE visual summary:https://www.nice.org.uk/guidance/ng158/resources/visual-summary-pdf-11193380893

Question 20

What reaction/side effect needs to be considered in the use of NAC?

Answer 20

Anaphalactoid Stop infusion (temporarily - start IV chlorphenamine or other antihistamine - resume NAC infusion but at a slower rate)Normal rate of infusion - 300mg/kg 21 hr infusion -https://www.toxbase.org/Chemical-incidents/Management-Pages/Acetylcysteine-Doses—Adults/

Question 21

TCA’s are _ and _ inhibitors. Signs of a TCA overdose include:InvestigationsManagement

Answer 21

Tricyclic antidepressants are noradrenaline and serotonin re-uptake inhibitors, and can be fatal in overdose.They can cause drowsiness, coma, seizures and cardiac dysrhythmia.Clinical FeaturesSigns of a TCA overdose include:Neurological and cardiovascular!DrowsinessConfusionArrhythmiasSeizuresVomitingHeadacheFlushingDilated pupils (not pinpoint as in opiate toxicity)InvestigationsBloods: FBC, UE, CRP, LFTs, Venous Blood gas (look for evidence of acidosis)ECG may show evidence of QT interval prolongation which can precipitate a cardiac arrhythmia.ManagementOverall management is supportive and dictated by the patient’s symptoms (sodium bicarbonate can be used). Patients should be reviewed by intensive care if any concerns about their airway (particularly in drowsy patients) or severe metabolic acidosis that might require renal replacement therapy.Activated charcoal can be considered within 2-4 hours of the overdose

Question 22

How does NAC work in paracetamol overdose?

Answer 22

NAC replenishes the store of glutathione which binds with the hepatotoxic metabolite of paracetamol, which is then excreted

Question 23

What is the best prognostic marker of acute liver failure in acetaminophen overdose?

Answer 23

Prothrombin time (INR) The King’s College Criteria (of which INR is a component) can be used in patients with acute liver failure due to acetaminophen in order to assess their prognosis and facilitate assessment for consideration of a hepatic transplant.

Question 24

Organophosphates (found in pesticides) cause over-activity of the cholinergic system giving the symptoms _____

Answer 24

Organophosphate (blocks acetylcholinesterase enzymes increasing ACh) - SLUDSalivationLacrimationUrinationDiarrhoeaSmall pupilsFasciculationsBradycardia

Question 25

ECG interpretation method

Answer 25

Details - patient/time/previous ECG’sRate - Rhythm strip X 6 Rhythm - count boxes between each QRS wave (use ruler and dots if neccessary)P wave - Present before every QRS? Yes - sinus NO? - AF etc.PR interval - <200ms or 5 boxes (each box 40ms or 0.04 secs). NO? - heart block. Primary secondary etc. QRS wave - < 3 boxes or 120ms/0.12 seconds. NO? - Bundle Branch BLock (BBB). - William Marrow (V1 and V6)ST segments - Compare with isoelectric line after the complex. (ST elevation is caused by a lack of blood supply to the muscle. The potassium channels responsible for depolarization are ATP dependent and thus cannot open when there is a lack of blood)T waves - inverted or flattened more than twice in each segment? Axis - look at leads 1 and 3 If lead 3 is greater in amplitude than lead 1 - consider axis deviation If leads arriving - right axis deviation If leads leaving - left axis deviationEverything else is normal.Other stuff - QT/QTc Interval / P wave morphology / Ventricular hypertrophy / Strain (amplitude of QRS - can be nromal in a skinny person)

Question 26

Hallmark 2 treatments of cocaine induced NTEMI (vasospasm)

Answer 26

Benzodiazepine (diazepam)Labetalol (beta and alpha blocker)

Question 27

Hallmark 2 treatments of cocaine induced NTEMI (vasospasm)

Answer 27

Benzodiazepine (diazepam)Labetalol (beta and alpha blocker)

Question 28

Antidote to benzodiazepine overdose?

Answer 28

Flumazenil(a selective GABAA receptor antagonist)Only given in rare life-threatening circumstances

Question 29

Acute Pulmonary Oedema Management

Answer 29

ABCDE - treat as appropriate Remember **POUR SOD MAN **Pour away IV fluids Oxygen (high flow) Diuretic (IV furosemide 40mg)Morphine (venous system dilatory effect and reduces preload)Anti-emetic (Metaclopramide 10mg IV)Nitrates in severe pulmonary oedema (IV if systolic bp >110 2 sprays if systolic BP > 90) Step up therapy if this is refractory: Treat any other underlying cause (arrythmia/MIValvular dysfunction etc)CPAP Inotropes and Intra-aortic balloon therapy (ICU)

Question 30

Long Term Heart failure Treatments

Answer 30

Treat underlying cause if appropriate Pharmacological therapy:ABALACEi/ARB Beta-blockerDiuretic if fluid overloaded If this fails to control symptoms:Aldosterone antagonist or Ivabradine Non-Pharmacological:Cardiac resynchronisation therapy if ORS > 0.12s/ 3 squaresICD if risk of Ventricular arrythmia *Ivabradine is a heart-rate-lowering agent that acts by selectively and specifically inhibiting the cardiac pacemaker current (If), a mixed sodium-potassium inward current that controls the spontaneous diastolic depolarization in the sinoatrial (SA) node and hence regulates the heart rate.This is based on NICE guidelines 2018. See the full guidelines before implementing treatment.Refer to specialist (NT-proBNP > 2,000 ng/litre warrants urgent referral)Careful discussion and explanation of the conditionMedical management (see below)Surgical treatment in severe aortic stenosis or mitral regurgitationHeart failure specialist nurse input for advice and supportAdditional management:Yearly flu and pneumococcal vaccineStop smokingOptimise treatment of co-morbiditiesExercise at tolerated

Question 31

Max potassium in level 1 care (As an F1) Per 500ml bag ____Per Litre bag ____Max rate ____

Answer 31

20mmol 40 mmol 10mmol/hr

Question 32

Make sure to avoid metaclopramide in patients _____

Answer 32

Parkinsons and Bowel Obstructionalso avoid Prochlorperazineand Promethazine in parkinsons because of their antidopimenergic effect ast D2 receptors

Question 33

Important St.Johns wort interactions to be aware of

Answer 33

Anti-depressantsWarfarin Oestrogen and Progesterone

Question 34

Causes of Hyperkalaemia?

Answer 34

3 causes:1. Reduced excretion from kidneys 2. Release from cells 3. Acidosis1. Reduced excretion from kidneys:AKIand Addison’sDRUGs that reduce K+ excretion from the kidneys : KBANK :K+ containing laxatives (movicol/fybogel)Beta BlockersACE inhibitorsNSAIDsPotassium Sparing Diuretics (i.e aldosterone antagonists - spironolactone/eplerenone etc.) but also diuretics in generalHeparin (which inhibits aldosterone release)andCiclosporin/Tacrolimus (immunosuppressants) 2. Cellular Release:RhabdomyolysisDigoxin Toxicity (NB - Can be precipitated by hypokalemaia) - “Reverse tick sign” on ECGTumour Lysis SyndromeMassive Haemolysis3. Acidosis:DKA or any other metabolic acidosis

Question 35

Hyperkalaemia is a potentially life threatening electrolyte abnormality.Treat K+ >___ mmol/L or any hyperkalaemia with ECG changes with the following;Give 10ml of 10% _____ (or chloride) over 10 mins - this is cardioprotectiveIntravenous ____ (10u soluble insulin) in 25g ____ (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemiaNebulised salbutamol - also causes intracellular K+ shiftTreatment with sodium bicarbonate is controversialOther aspects of management:Check contributing drugs (e.g. ACE inhibitors, spironolactone)Once initial measures completed, recheck urea and electrolytes and ECG and glucoseUrinary potassium

Answer 35

Hyperkalaemia is a potentially life threatening electrolyte abnormality.Treat K+ >6.5mmol/L or any with ECG changes with the following;Give 10ml of 10% calcium gluconate (or chloride) over 10 mins - this is cardioprotectiveIntravenous insulin (10u soluble insulin) in 25g glucose (50mL of 50% or 125ml of 20% glucose) - insulin causes intracellular K+ shift and glucose to required to prevent hypoglycaemiaNebulised salbutamol - also causes intracellular K+ shiftTreatment with sodium bicarbonate is controversialOther aspects of management:Check contributing drugs (e.g. ACE inhibitors, spironolactone)Once initial measures completed, recheck urea and electrolytes and ECG and glucoseUrinary potassium

Question 36

Causes of Hyponatraemia?

Answer 36

Remember to classify into:Hypovolaemic (In the elderly dehydration is a very common cause especially in patients with dementia)Euvolaemic (SIADH / Hypothyroidism)Hypervolaemicand drugs:Thiazide diuretics > Loop Diuretics > K+ sparing diuretics

Question 37

This question asks about the first-line medical management of ascites. The BNF recommends _____ for managing oedema and ascites secondary to liver cirrhosis. Furosemide is recommended as an adjunct.

Answer 37

spironolactone

Question 38

Post MI Complications

Answer 38

DARTH VADER

Dressler’s syndrome ( or post-infarction pericarditis typically presents with persistent fever and pleuritic chest pain 2-3 weeks or up to a few months after an MI.)

Arryhythmias

Rupture (septal wall)

Tamponade

Heart Failure/Heart Block

Valvular dysfunction

Aneurysm

Death

Embolism

Recurrence Regurgitation