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Phase 4 > Emergency Medicine > Flashcards

Emergency Medicine Flashcards

1
Q

describe treatment of anticholinergic overdose

A

consider charcoal if conscious

if hypotension
- fluids
- glucagon
- noradrenaline

give sodium bicarbonate if
- acidosis
- QRS >120 ms
- hypotension unresponsive to fluids
- ventricular arrhythmias

intralipid

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1
Q

Describe anticholinergic toxidrome

A

“Blind as a bat, dry as a bone, red as a beet, hot as a desert”

  • flushing
  • dry skin and membranes
  • mydriasis and loss of accommodation
  • clonus
  • confusion
  • hyperthermia
  • tachycardia
  • absent bowel sounds
  • urinary retention
  • constipation

e.g. tricyclic antidepressants (TCAs like amitriptyline), antipsychotics, antihistamines
> metabolic acidosis
> convulsions
> hypotension with dysrhythmia (mostly tachycardia)
> airway loss if obtunded

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2
Q

describe a cholinergic toxidrome

A

muscarinic symptoms: SLUDGE
- salivation
- lacrimation
- urination (increased)
- defecation (diarrhoea)
- GI cramping
- emesis (vomiting)

nicotinic symptoms: MTWTF
- muscle cramps
- tachycardia (or bradycardia in muscarinic)
- weakness
- twitching
- fasciculations (check tongue)

other symptoms
- miosis
- sweating
- seizure risk
- bronchorroea
- bronchospasm

most common cause - organophosphate insecticides, pesticides

also donepizole and overdose of agents used in myasthenia gravis e.g. pyridostigmine

also novichok nerve agents

antidote - atropine, pralidoxime

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3
Q

describe sympathomimetic toxicity

A
  • airway compromise less common unless rigid
  • tachypnoea
  • hypertension and tachyarrhythmias
  • mydriasis, seizure, psychosis
  • hyperthermia

causes: cocaine, MDMA, significant caffeine, amphetamines, theophylline excess in asthmatics

remember to monitor CK and myoglobin
> early ECG if chest pain, cocaine can lead to ACS due to coronary vasospasm

management
- charcoal if theophylline poisoning only
- benzodiazepines e.g. diazepam if agitation/confusion
- avoid beta blockers
- cool by any means possible then IV dantrolene
- sometimes sodium nitroprusside for hypertension

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4
Q

describe sympathomimetic serotonergic crisis / baclofen withdrawal

A

also caffeine, theophylline, SSRIs/SNRIs, GHB, MDMA

  • rigid jaw and airway compromise
  • tachycardia, hypertension, tachypnoea
  • cardiovascular collapse
  • acidosis
  • hypertonicity with clonus
  • confused and agitated before coma
  • refractory hypoglycaemia
  • seizures
  • rhabdomyolysis with K>10
  • malignant hyperthermia

management
- intubation (without fentanyl)
- large amounts of benzodiazepines
- aggressive cooling
- cyproheptadine orally or NG
- chlorpromazine IM

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5
Q

describe opioid toxicity

A
  • airway compromise
  • hypoventilation and hypoxia
  • hypotension and bradycardia
  • reduced GCS and pinpoint pupils
  • hypothermia

management
- naloxone (half-life 30 or 45 mins)
> naloxone infusion if modified release like MST
- supportive care

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6
Q

describe sedative / hypnotic toxicity

A

e.g. alcohol, benzodiazepines

  • airway loss if obtunded
  • respiratory compromise
  • cold
  • hypotension, bradycardia
  • mydriasis
  • dizzy, dysarthric, drowsy and ataxic

management
- watch for withdrawal (seizures)
- supportive treatment
- flumazenil only rarely

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7
Q

describe a paracetamol overdose

A

presentation
- early: nausea and vomiting

  • late (3-4 days):
    > nausea and vomiting
    > hepatic necrosis
    > hypoglycaemia
    > cerebral oedema
    > encephalopathy, coma, death

if plasma level >700 mg/L (rare) - different presentation
> sedation
> coma
> high lactate

reliable sign of liver damage: prolonged PT

prognostic factor: arterial blood gas pH

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8
Q

list adverse effects of N-acetylcysteine

A
  • nausea
  • urticaria
  • erythema
  • bronchospasm
  • angioedema
  • anaphylactoid reaction
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9
Q

describe beta blocker overdose

A
  • bradycardia
  • hypotension
  • prolonged QTc
  • cardiogenic shock: VF/VT
  • coma
  • seizures
  • propranolol: bronchospasm

management
- activated charcoal if <1h
- 8.4% sodium bicarbonate
- atropine
- IV glucagon
- consider inotropes
- intralipid if propranolol
- ECMO

cardiac pacing ineffective

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10
Q

describe calcium channel blocker overdose

A
  • sinus bradycardia
  • hypotension
  • prolonged QTc
  • high K, low glucose
  • cardiogenic shock: VF/VT

Management
- activated charcoal if <1h from ingestion
- calcium chloride
- insulin (aim for hyperinsulinaemic euglycaemia)
- 8.4% sodium bicarbonate
- intralipid
- inotropes
- ECMO

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11
Q

describe digoxin toxicity

A
  • QTc prolongation
  • bradycardia
  • “reverse tick” on ECG
  • metabolic acidosis
  • hyperkalaemia
  • nausea, vomiting
  • confusion

management
- stop digoxin
- charcoal
- sodium bicarbonate
- insulin/dextrose for hyperkalaemia
- atropine
- give digibind if plasma level > 10 nmol/L
- cardiac pacing
- ECMO

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12
Q

describe iron toxicity

A
  • nausea, vomiting
  • abdominal pain
  • diarrhoea
  • haematemesis
  • acidosis
  • potential for late deterioration with hepatic necrosis
  • worse in children

treatment
- gastric lavage
- endoscopy
- desferrioxamine
- dialysis

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13
Q

describe cannabinoid hyperemesis

A
  • cyclical vomiting
  • relieved by hot water over 41 degrees
  • standard antiemetics may not work
  • management
    > capsaicin cream
    > haloperidol
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14
Q

describe the RUSH protocol and HI-MAP approach

A

RUSH protocol
- pump: LV contractility, RV strain, tamponade
- tank: IVC variation, leaks, tank compromise
- pipe: aortic dissection, aneurysms, DVT

HI-MAP approach
- heart
- IVC
- Morrison’s pouch and E-fast
- aorta and deep veins
- pneumothorax, PLE, PN, pulmonary oedema

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15
Q

List causes of coma

A

AEIOU TIPS

  • acidosis / alcohol
  • epilepsy
  • infection
  • overdose
  • uraemia
  • trauma to the head
  • insulin (hypoglycaemia)
  • psychosis
  • stroke
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16
Q

list causes of delirium

A

PINCH ME

P - pain
I - infection
N - nutrition
C - constipation
H - hydration

M - medication (new, changes, AKI?)
E - environment, everything else
> glasses, hearing aids, change of location

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17
Q

describe the pharmacological treatment of delirium

A

if all other measures have failed

  • haloperidol (avoid in Parkinson’s / LBD / prolonged QTc)
  • lorazepam
  • avoid olanzapine or risperidone (increased risk of stroke and death)
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18
Q

what is the triangle of safety for ICD insertion?

A
  • lateral edge of pectoralis major
  • base of axilla
  • lateral edge latissimus dorsi
  • 5th intercostal space
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19
Q

what is the modified Parkland’s formula for calculation of fluids in burns patients

A

> 15% BSA in adults

BSA x weight (kg) x 4ml (fluid in 24h)

give first half of fluids (Hartmann’s) in first 8h

next half of fluids in next 16h

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20
Q

list the branches of the facial nerve

A

ten zebras bit my cock

  • temporal
  • zygomatic
  • buccal
  • mandibular
  • cervical
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21
Q

list maximum safe doses of local anaesthetics

A

lidocaine: short-acting voltage-gated sodium channel blocker
> 3mg/kg
> with adrenaline 7mg/kg
> to calculate dose multiply percentage by 10 e.g. 1% lidocaine contains 10mg/ml (1g in 100ml of solution)

bupivacaine: slower onset but longer duration
> dosage 2mg/kg not changed by addition of adrenaline

levobupivacaine
> 3mg/kg
> dosage calculation example, 0.25% levobupivacaine contains 2.5mg/ml
> improved cardiac safety profile compared to bupivacaine

22
Q

describe carotid artery dissection

A

common cause of stroke in younger patients

presentation
- local pain
- ipsilateral headache / neck pain
- ischaemic stroke
- ipsilateral Horner’s syndrome without anhidrosis
- retinal ischaemia

causes
> spontaneous: especially in connective tissue disorders e.g. Marfan’s/Ehlers-Danlos
> traumatic
> iatrogenic e.g. cerebral angiography

investigations: CT angiogram brain or MRI

management
- conservative: antiplatelets +/- anticoagulation
- gentle angioplasty and stent placement

23
Q

What is the muscle relaxant of choice for Rapid Sequence Intubation (RSI)?

A

Suxamethonium

or rocuronium (but risk of allergy)

24
Q

What is the management of Vfib according to UK Advanced Life Support Guidelines?

A

Chest compressions 30:2

Single shock with defibrillator

1mg IV adrenaline after 3 shocks
repeat 1mg IV adrenaline after 3-5 minutes
> 1 mg - 10ml 1:10,000 IV or 1ml 1:1000 IV

If unsuccessful 300mg amiodarone IV

after 5 shocks 150mg amiodarone IV

25
Q

list reversible causes of cardiac arrest

A

4 H’S
- Hypoxia
- Hypovolaemia
- Hyperkalaemia, hypokalaemia, hypoglycaemia, hypocalcaemia, acidaemia & other metabolic disorders
- Hypothermia

4 T’s
- Tension pneumothorax
- Toxins
- Thrombosis (coronary or pulmonary)
- Tamponade - cardiac

26
Q

Describe the clinical features and treatment of aspirin overdose

A

Aspirin OD: >125mg/kg

Clinical features
- Tinnitus
- hyperventilation
- lethargy
- Nausea and vomiting
- Sweating, pyrexia
- hyperglycaemia / hypoglycaemia
- Severe: confusion, drowsiness, seizures

  • Mixed respiratory alkalosis and metabolic acidosis

Management
- Oral activated charcoal if ingestion <1h
- IV sodium bicarbonate if ingestion >1h
» urinary alkalinisation increases urinary excretion of aspirin
- Haemodialysis (severe or serum concentratio >700 mg/L)

27
Q

List indications for N-acetylcysteine in paracetamol overdose

A

give activated charcoal if ingestion within 1h of >150mg/kg paracetamol

N-acetylcysteine stimulates glutathione biosynthesis and binds toxic metabolites

  • plasma paracetamol concentration: on or above a single treatment line
  • staggered overdose* or doubt over the time of paracetamol ingestion or
    patients who present 8-24 hours after ingestion of an acute overdose of more than 150 mg/kg of paracetamol even if the plasma-paracetamol concentration is not yet available
  • patients who present > 24 hours if they are clearly jaundiced or have hepatic tenderness, ALT is above upper limit of normal

if presentation >24h acetylcysteine should be continued if the paracetamol concentration or ALT remains elevated whilst seeking specialist advice

28
Q

describe the management of caustic ingestion e.g. bleach

A
  • high dose IV PPI
  • symptomatic ingestion e.g. drooling, vomiting, dysphagia, odynophagia, chest pain
    > urgent assessment with upper GI endoscopy
  • urgent upper GI surgical referral if signs of perforation
  • don’t neutralise with milk due to damage from exothermic reaction
  • asymptomatic ingestion can usually be discharged after a trial of oral fluid and period of observation
29
Q

list complications of ingestion of caustic substances

A

acute
- upper GI ulceration, perforation
- upper airway injury and compromise
- aspiration pneumonitis
- infection
- electrolyte disturbance e.g. hypocalcaemia in hydrofluoric acid ingestion

chronic
- strictures, fistulae, gastric outlet obstruction
- upper GI carcinoma

30
Q

describe LSD intoxication

A

psychoactive symptoms
- colourful visual hallucinations
- depersonalisation
- psychosis
- paranoia

somatic symptoms
- nausea
- headache
- dry mouth
- drowsiness
- tremors

signs
- tachycardia, hypertension
- mydriasis
- paraesthesia
- hyperreflexia
- pyrexia

management
- benzodiazepines
- antipsychotics if psychosis

31
Q

explain the choice of location for chest drain insertion

A

triangle of safety
- anterior border: lateral border of pec major
- posterior border: mid-axillary line
- inferior border: nipple

usually level of 6th-8th ribs

as neurovascular bundle runs along inferior surface of ribs, aim inferiorly to avoid it

32
Q

describe the management of upper GI bleeds

A
  • resuscitation
    > insert 2x wide bore cannulas in ACF
    > IV fluids 0.9% NaCl
    > stop anticoagulants & NSAIDs
  • send group + save & cross-match 2 units
    > blood transfusion if Hb <70
  • if oesophageal varices: terlipressin, broad-spectrum antibiotics

upper GI bleed is classified during endoscopy - proximal to ligament of Treitz

  • endoscopic haemostasis
    > thermal coagulation
    > mechanical clipping
    > adrenaline injection
    > variceal band ligation

if ongoing acute bleeding despite repeated endoscopic therapy: surgery
> oversewing of ulcer

PO or IV PPI after endoscopy

33
Q

Describe the adult tachycardia resus council guidelines

A

If adverse signs are present, up to 3 synchronised DC cardioversion shocks after which expert help should be sought
> synchronisation to R wave

adverse signs
- shock: hypotension, pallor, sweating, cold, clammy
- severe heart failure
- myocardial ischaemia
- syncope

If broad complex tachycardia (QRS>120ms)

> regular: assume VT unless previously confirmed SVT with BBB, treat with loading dose of amiodarone (300mg IV over 10-60mins) followed by 24h infusion
verapamil is contraindicated

> irregular
> most commonly AF with BBB, treat as for irregular narrow complex tachycardia
> could be AF with pre-excitation of ventricles
could be polymorphic VT (Torsades de Pointes), treat with magnesium 2g over 10 mins

If narrow complex tachycardia (QRS <120ms)
- regular
> assume SVT, attempt vagal manoeuvres
> if unsuccessful 6mg adenosine via wide bore cannula, then 12mg, then 18mg
> if unsuccessful consider atrial flutter and attempt rate control with beta-blocker

  • irregular
    > assume AF, if onset <48h attempt chemical or electrical cardioversion
    > flecainide or amiodarone if no evidence of structural heart disease
    > amiodarone if structural heart disease

> > if onset >48h anticoagulation should be given for at least 3 weeks prior to cardioversion. attempt rate control with beta-blocker.
consider digoxin or amiodarone if evidence of HF

34
Q

list causes of torsades de pointes

A
  • hypothermia
  • hypokalaemia
  • hypocalcaemia
  • hypomagnesaemia
35
Q

describe the types of pneumothorax

A

Accumulation of air in pleural space, resulting in the partial or complete collapse of the affected lung

Classification

  • spontaneous pneumothorax
    > primary spontaneous pneumothorax: without underlying lung disease, often in tall, thin, young individuals; associated with the rupture of subpleural blebs or bullae

> secondary spontaneous pneumothorax: pre-existing lung disease e.g. COPD, asthma; connective tissue diseases e.g. Marfan’s syndrome

  • traumatic pneumothorax: penetrating / blunt chest trauma
  • iatrogenic pneumothorax: complication of medical procedures e.g. thoracentesis, central venous catheter placement, ventilation

Tension pneumothorax: severe pneumothorax resulting in the displacement of mediastinal structures; results in severe respiratory distress and haemodynamic collapse

Catamenial pneumothorax: spontaneous pneumothorax occurring menstruating women. Caused by endometriosis within the thorax.

36
Q

describe the clinical features in pneumothorax

A

Clinical features:
- sudden dyspnoea
- pleuritic chest pain

Signs:
- hyper-resonant percussion
- reduced breath sounds
- reduced lung expansion,
- tachypnoea
- tachycardia
> In tension pneumothorax: respiratory distress, tracheal deviation away from the side of the pneumothorax, hypotension

37
Q

Describe the management of pneumothorax

A

rim of air is < 2cm and patient not short of breath: discharge and outpatient review in 2 days

rim of air >2cm or patient symptomatic
> aspiration: 2nd intercostal space midclavicular line
> if this fails (> 2 cm or still short of breath) insert chest drain

high-risk features require a chest drain

high risk features
- haemodynamic compromise (suggesting tension pneumothorax)
- significant hypoxia
- bilateral pneumothorax
- underlying lung disease
- >= 50 yo with significant smoking history
- haemothorax

If persistent air leak / recurrent pneumothorax: refer for VATS to allow mechanical/chemical
pleurodesis (usually talc) +/- bullectomy

38
Q

Describe the management of bradycardia

A

Adverse features
- shock e.g. hypotension, confusion or impaired consciousness
- syncope
- myocardial ischaemia
- heart failure

Atropine (500mcg IV) is the first line treatment

If there is an unsatisfactory response the following interventions
> atropine, up to a maximum of 3mg
> transcutaneous pacing
> isoprenaline/adrenaline infusion titrated to response

Specialist help should be sought for consideration of transvenous pacing if there is no response to drugs or transcutaneous pacing

39
Q

Describe ecstasy (MDMA) poisoning

A

Clinical features
- neuro: agitation, anxiety, confusion, ataxia
- cardiovascular: tachycardia, hypotension
- hyponatraemia
- hyperthermia
- rhabdomyolysis

management
- supportive
- dantrolene for hyperthermia if simple measures fail

40
Q

what are the indications for thoracotomy in haemothorax?

A

> 1.5L blood initially or losses of >200ml per hour for >2h

41
Q

Describe the management of variceal haemorrhage

A
  • Terlipressin
  • Blood transfusion if required
  • Prophylactic IV antibiotics, usually quinolones

Procedures
- Endoscopic variceal band ligation
- Sengstaken-Blakemore tube if uncontrolled haemorrhage
- Transjugular Intrahepatic Portosystemic Shunt (TIPSS) if above measures fail
> can exacerbate hepatic encephalopathy

Prophylaxis: propranolol

consider rectal varices in lower GI bleeding and portal hypertension

42
Q

describe hypothermia and its management

A

mild: 32-35 degrees
moderate/severe: <32 degrees

features
- shivering
- cold pale skin
- slurred speech
- tachypnoea, tachycardia hypertension (mild)
- respiratory depression, bradycardia, hypotension (moderate)
- confusion/impaired mental state

management
- warming with blankets
- if not responding to passive warming, use warm IV fluids or applying forced warm air directly to patient’s body

risk:
> rapid rewarming can lead to distributive shock
> cardiac arrest
> avoid IV drugs, can have drastic response

43
Q

describe the clinical presentation of an upper GI bleed

A

clinical features
- haematemesis
- coffee ground vomit
- melaena
- haemodynamic instability

investigations
- elevated urea, low haemoglobin

  • Glasgow-Blatchford score: risk for upper GI bleed
  • Rockall score: post-endoscopy to estimate risk of re-bleeding and mortality
44
Q

describe anaphylaxis and its management

A

Features
- airway compromise: swelling of the throat and tongue →hoarse voice and stridor
- Breathing problems: respiratory wheeze, dyspnoea
- Circulation problems: hypotension, tachycardia
- generalised rash, urticaria

serum tryptase levels can confirm anaphylaxis

Management
- adults: 500mcg or 0.5ml 1 in 1000 adrenaline (IM)
- 6-12 years: 300mcg or 0.3ml 1 in 1000 adrenaline (IM)
- 6 months - 6 years: 150 mcg or 0.15ml 1 in 1000 adrenaline (IM)
- <6 months: 100-150 mcg or 0.15ml 1 in 1000 adrenaline (IM)

adrenaline can be repeated every 5 mins

best site for injection - anterolateral aspect of middle third of thigh

if refractory anaphylaxis: respiratory or cardiovascular compromise despite 2 doses

management following stabilisation
> non-sedating oral antihistamine

45
Q

describe ethylene glycol toxicity

A

aka antifreeze

features
- confusion, slurred speech, dizziness
- metabolic acidosis with high anion gap and high osmolar gap
- tachycardia, hypertension
- AKI

management
- fomepizole first-line: alcohol dehydrogenase inhibitor
- ethanol
- haemodialysis in refractory cases

46
Q

describe local anaesthetic toxicity

A

early
- circumoral tingling and numbness, pallor, tinnitus

progresses to agitation, restlessness, twitching, excessive eye movements

late
- convulsions
- coma
- cardiac arrest (especially bupivacaine)

47
Q

list criteria for CT head within 1 hour in adults

A

GCS <13 on initial assessment
GCS <15 at 2 hours post-injury
suspected open or depressed skull fracture
any sign of basal skull fracture (haemotympanum, panda eyes, CSF leakage from ear or nose, Battle’s sign)
post-traumatic seizure
focal neurological deficit
more than 1 episode of vomiting

48
Q

describe the management of a tricyclic antidepressant overdose

A

e.g. amitriptyline, dosulepin

  • IV bicarbonate: first-line for hypotension or arrhythmias, also widening QRS >100
  • other drugs for arrhythmias (not flecainide or amiodarone)
  • Intravenous lipid emulsion
  • Dialysis is not effective
49
Q

Describe the effects of cocaine and the management of cocaine toxicity

A

cocaine blocks the uptake of dopamine, noradrenaline and serotonin

Adverse effects
- cardiovascular
> coronary artery spasm → myocardial ischaemia/infarction
> both tachycardia and bradycardia may occur
> coronary artery dissection
> hypertension
> QRS widening and QT prolongation
> aortic dissection

  • neurological
    > seizures
    > mydriasis
    > hypertonia
    > hyperreflexia
  • psychiatric effects: agitation, psychosis, hallucinations
  • GI: ischaemic colitis, perforated ulcer
  • hyperthermia
  • metabolic acidosis
  • rhabdomyolysis

Management
> benzodiazepines are first-line for most cocaine-related problems

> chest pain: benzodiazepines + glyceryl trinitrate; if myocardial infarction develops then primary percutaneous coronary intervention

> hypertension: benzodiazepines + sodium nitroprusside

50
Q

describe the adult advanced life support algorithm

A

Adult advanced life support

> ‘shockable’ rhythms: ventricular fibrillation/pulseless ventricular tachycardia (VF/pulseless VT)

> ‘non-shockable’ rhythms: asystole/pulseless-electrical activity (asystole/PEA)

Major points include:
chest compressions
> ratio of chest compressions to ventilation is 30:2

defibrillation
> a single unsynchronised shock at 200J for VF/pulseless VT followed by 2 minutes of CPR

> if the cardiac arrested is witnessed in a monitored patient (e.g. in a coronary care unit) then up to three quick successive (stacked) shocks

> IV access should be attempted and is first-line

> adrenaline 1 mg as soon as possible for non-shockable rhythms

> > during a VF/VT cardiac arrest, adrenaline 1 mg is given once chest compressions have restarted after the third shock
repeat adrenaline 1mg every 3-5 minutes whilst ALS continues

> amiodarone 300 mg in VF/pulseless VT after 3 shocks have been administered
> a further dose of amiodarone 150 mg should be given to patients who are in VF/pulseless VT after 5 shocks have been administered

> lidocaine if no amiodarone available

thrombolytic drugs should be considered if a pulmonary embolus is suspected
> if given, CPR should be continued for an extended period of 60-90 minutes

51
Q

Describe serotonin syndrome and its management

A

Caused by
> SSRIs (tramadol may precipitate with SSRIs)
> MAOIs
> ecstasy
> amphetamines / novel psychoactive stimulants

Onset within hours

Features
- hyperreflexia, clonus
- tremor
- tachycardia, increased BP
- Pyrexia / hyperthermia, sweating
- Rigidity
- dilated pupils
- altered mental state / confusion

diagnosis: elevated creatine kinase

Management
- IV fluids
- Benzodiazepines
- Severe cases: cryptoheptadine, chlorpromazine

52
Q

describe the clinical features of opioid misuse

A
  • rhinorrhoea
  • needle track marks
  • pinpoint pupils
  • drowsiness
  • watering eyes
  • yawning
53
Q
A

Phase 4 (14 decks)

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