Emergency Medicine Flashcards

Question

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

Answer 1

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

Answer 2

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

Answer 3

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)

Answer 4

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

Answer 5

- 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

Answer 6

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

Answer 7

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

Answer 8

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

Answer 9

- 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

Answer 10

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

Answer 11

- hypothermia - hypokalaemia - hypocalcaemia - hypomagnesaemia

Answer 12

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.

Answer 13

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

Answer 14

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

Answer 15

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

Answer 16

Clinical features - neuro: agitation, anxiety, confusion, ataxia - cardiovascular: tachycardia, hypotension - hyponatraemia due to SIADH - hyperthermia - rhabdomyolysis management - supportive - dantrolene for hyperthermia if simple measures fail

Answer 17

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

Answer 18

- 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

Answer 19

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

Answer 20

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

Answer 21

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

Answer 22

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

Answer 23

early - circumoral tingling and numbness, pallor, tinnitus progresses to agitation, restlessness, twitching, excessive eye movements late - convulsions - coma - cardiac arrest (especially bupivacaine)

Answer 24

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

Answer 25

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

Answer 26

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

Answer 27

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

Answer 28

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

Answer 29

- rhinorrhoea - needle track marks - pinpoint pupils - drowsiness - watering eyes - yawning

Answer 30

haemoglobin which has been oxidised from Fe2+ to Fe3+ leading to tissue hypoxia causes - congenital - drugs: > sulphonamides > nitrates: including recreational nitrates e.g. amyl nitrite 'poppers' > dapsone > sodium nitroprusside > primaquine - chemicals: aniline dyes Features - 'chocolate' cyanosis - dyspnoea, anxiety, headache - severe: acidosis, arrhythmias, seizures, coma - normal pO2 but decreased oxygen saturation Management - NADH methaemoglobinaemia reductase deficiency: ascorbic acid - IV methylthioninium chloride (methylene blue) if acquired