Emergency medicine

Question 1

What are the causes of shock?

Answer 1

Pump failure: cardiogenic shock; shock secondary to PE, tension pneumothorax or cardiac tamponade

Peripheral circulation failure: hypovolaemia, anaphylaxis, septic shock, neurogenic shock, endocrine failure, iatrogenic

Question 2

What is the general management of shock?

Answer 2

ABCDE
Raise foot of bed unless cardiogenic
IV access - wide bore x 2
IV fluids fast unless cardiogenic
Identify and treat underlying cause
Bloods: FBC, U&E, glucose, CRP, cross match and check clotting, blood cultures, lactate
Urine cultures
ECG, Echo
CXR, abdo CT, USS
Consider arterial line, central venous line and bladder catheter

Question 3

What treatment do you give for anaphylaxis?

Answer 3

Secure airway and give 100% oxygen
Remove cause
IM adrenaline 0.5mg - repeat every 5 minutes until better
Secure IV access
Chlorphenamine 10mg IV and hydrocortisone 200mg IV
IV fluids - titrate against blood pressure
If wheeze, treat for asthma
If still hypotensive, treat on ICU

Question 4

What are the features of cardiac tamponade?

Answer 4

Beck’s triad: hypotension, raised JVP and muffled heart sounds
CXR - globular heart
ECG - electrical alternans

Question 5

How would you treat a cardiac tamponade?

Answer 5

Prompt pericardiocentesis. There may be a role for cardiothoracic surgery in some cases as a definitive solution.

Introduce needle at 45 degrees to skin just below and left of the xiphisternum, aiming for tip of the left scapula. Aspirate continuously and watch ECG.

Question 6

What is the definition of status epilepticus?

Answer 6

Seizures lasting for >30 min or repeated seizures without intervening consciousness.

Aim to terminate seizures lasting more than a few minutes as soon as possible.

Question 7

What is non-convulsive status epilepticus?

Answer 7

Absence status or continuous partial seizures with preservation of consciousness may be difficult to distinguish. Look for subtle eye or lid movement.

EEG –> rhythmic discharge

Question 8

How do you manage status epilepticus?

Answer 8

Open and maintain airway - put into recovery position
100% oxygen and suction
IV access and bloods - FBC, U&E, LFT, glucose (BM and lab), calcium, ABG, toxicology screen if indicated. Consider anticonvulsant levels, LP and blood culture
Give thiamine 250mg IV if alcoholic/malnourished
Glucose 50ml 50% IV unless glucose known to be normal
Correct hypotension with fluids. Monitor ECG and BP
Lorazepam 2-4mg. Repeat if no response after 2 mins.
Phenytoin infusion
Diazepam infusion
General anaesthetic and ICU

Question 9

How do you manage someone with raised ICP?

Answer 9

ABC
Correct hypotension and treat seizures
Brief hx and examination
Elevate head of bed to 30-40 degrees
If intubated, hyperventilate –> cerebral vasoconstriction
Osmotic diuretics e.g. mannitol can be considered
Dexamethasone for oedema around tumours
Fluid restriction.
Monitor ICP
Definitive treatment: neurosurgery for focal causes e.g. haematomas.

Question 10

What investigations can you do for a suspected subarachnoid haemorrhage?

Answer 10

CT - detects >905 of SAH within first 48 hours
LP - if CT negative and no contraindication, perform >12 hours after headache onset. CSF in SAH is uniformly bloody early on and become xanthochromic after a few hours due to breakdown of Hb.

Question 11

What is the management of SAH?

Answer 11

Refer all proven SAH to neurosurgery immediately.
Re-examine often and repeat CT if deteriorating
Maintain cerebral perfusion to keep well hydrated and systolic BP>160mmHg
Nimodipine - calcium antagonist that reduces vasospasm
Endovascular coiling is preferable to clipping

Question 12

How do you manage DKA?

Answer 12

ABC
Restore circulating volume with normal saline - fluid challenge. If two boluses do not bring BP>90mmHg, seek senior medical advice
When systolic BP>90mmHg, give 1L normal saline over the next hour. Additional potassium is likely to be needed.
Start an IV insulin infusion at fixed rate 0.1 units/kg/hour. Established SC therapy should be continued.
Continue fluid replacement. once blood glucose 7.3 and patient is able to eat and drink.

Question 13

How do you manage HHS?

Answer 13

ABC
Rehydrate with 9L of 0.9% saline over 48 hours (half the rate used in DKA). Replace potassium when urine starts to flow.
Wait for 1hr before using insulin (it may not be needed)
Fully heparinise as occlusive events are a danger
Look for a cause

Question 14

How do you manage hypoglycaemia?

Answer 14

If patient is conscious: glucose 10-20g given by mouth, either in liquid form (glucogel), lucozade or jelly babies (5)

If unable to take things orally:
200-300ml of 10% dextrose IV
Glucagon IM 1mg (will not work on drunk patients)

Once able, give sugary drinks and a meal.

Question 15

How do you manage hypothermia?

Answer 15

ABC
Warm IV fluids
Cardiac monitor (VF or AF can arise without warning)
Consider antibiotics to prevent pneumonia
Consider urinary catheter to monitor renal function
Slowly rewarm - reheating too quickly causes peripheral vasodilation, shock and death. Aim for a rise of 0.5 degrees/hour. The first sign of too rapid warming is falling BP
Check rectal temperature, BP, pulse and RR every half hour.

Question 16

How do you treat a paracetamol overdose?

Answer 16

Gastric lavage if >12g or >150mg/kg taken within 1 hour. activated charcoal if within 1 hour of ingestion.
Bloods - glucose, U&E, LFT, clotting, FBC, bicarbonate, ABG, blood paracetamol levels at 4 hours post ingestion and toxicology (do not assume that this is a single overdose)
Check revised paracetamol overdose treatment graph. If treatment needed, start N-acetylcysteine.

If staggered overdose, get expert help.

Question 17

What are the signs and symptoms of a paracetamol overdose?

Answer 17

None initially, or vomiting and RUQ pain.

Later: jaundice and encephalopathy from liver or renal damage.

Question 18

What are the signs and symptoms of an aspirin overdose?

Answer 18

Vomiting, dehydration, hyperventilation, tinnitus, vertigo, sweating

Rarely: lethargy, coma, seizures, hypotension and heart block, pulmonary oedema

Question 19

How does an aspirin overdose cause an acid base disturbance?

Answer 19

Salicylates stimulate the respiratory centre and cause a respiratory alkalosis. Compensatory mechanisms including excretion of bicarbonate and potassium result in metabolic acidosis. Salicylates also interfere with carbhoydrate, fat and protein metabolism and disrupt oxidative phosphorylation, producing increased concentrations of lactate, pyruvate and ketones.

This causes a mixed acid-base disturbance.

Question 20

How do you treat a salicylate overdose?

Answer 20

Correct dehydration. Gastric lavage and activated charcoal with within 1 hour.
Monitor urine output and blood glucose
Correct any metabolic acidosis with bicarbonate.
If plasma salicylate level >500mg/h, consider alkalinisation of the urine e.g. 1.5L 1.26% bicarbohnate with 40mmol KCl over 3 hours (nb monitor serum K)
Dialysis may be needed if salicylate level >700mg/L or if renal or heart failure, seizures, severe acidsis or persistently raised plasma salicylate.

Question 21

What are the symptoms of carbon monoxide poisoning?

Answer 21

Headache
Vomiting
Tachycardia
Tachypnoea
Cherry red lips
If COHb >50%, fits, coma and cardiac arrest may occur.

Question 22

How do you treat carbon monoxide poisoning?

Answer 22

Remove source
Give 100% oxygen
Metabolic acidosis usually responds to correction of hypoxia.
If severe, anticipate cerebral oedema and give mannitol.

Question 23

How do you treat a TCA overdose?

Answer 23

Supportive: give oxygen, control of convulsions and correct acidosis. A small number of overdoses will require ventilation.

Onset of SVT and VT should be treated with sodium bicarbonate, even if no acidosis present. If VT is compromising cardiac output, amiodarone should be given.

Question 24

What are the signs and symptoms of TCA toxicity?

Answer 24

Mild:

• Antimuscarinic: sinus tachycardia, dry mouth, dilated pupils, urinary retention
• increased reflexes
• extensor plantar responses
• drowsiness

Severe:

• coma
• divergent strabismus
• convulsions
• plantar, oculocephalic and oculovestibular reflexes may be abolished completely
• metabolic acidosis
• cardiorespiratory depression

Question 25

What are the ECG changes associated with TCA toxicity?

Answer 25

A wide QRS interval. There is a reasonable correlation between the width of the QRS complex and severity of poisoning.

Question 26

What are the different types of sickle cell crises?

Answer 26

Vasoocclusive (painful crisis)
Aplastic crisis
Sequestration crisis
Acute chest syndrome

Question 27

How do you manage a vaso-occlusive sickle cell crisis?

Answer 27

Prompt analgesia e.g. IV opiates
Crossmatched blood, FBC, reticulocytes, blood cultures, MSU and CXR if fever or chest signs
Rehydrate and keep warm
Oxygen if low PaO2 or saturations
Blind antibiotics if signs of infection
Monitor PCV, reticulocytes, liver and spleen size x2 daily and give transfusion if Hb or reticulocytes fall sharply.

Question 28

What causes an aplastic crisis and how is it treated/

Answer 28

Due to parvovirus B12 with sudden reduction in marrow production. Usually self limiting in <2 weeks but transfusion may be needed.

Question 29

What are the signs of a sequestration crisis?

Answer 29

This mainly occurs in children whose spleen have not yet undergone atrophy. There is pooling of blood in the spleen and liver with organomegaly, severe anaemia and shock. Urgent transfusion is needed.

Question 30

What are the signs and symptoms of acute chest syndrome?

Answer 30

Entails pulmonary infiltrated involving complete lung segments, causing pain, fever, tachypnoea and cough.

Question 31

How do you manage a patient with suspected aortic dissection?

Answer 31

Ix - CXR (widened mediastinum), with urgent CT, transoesophageal echo or MRI to confirm diagnosis.

Rx - >50% of patients are hypertensive therefore need urgent antihypertensive medication e.g. labetalol, metoprolol or vasodilators e.g. GTN

Type A dissections should undergo surgery if fit enough

Type B dissections should be managed medically unless there are complications.

Endovascular intervention with stents may be indicated in patients with rapidly expanding dissections, refractory pain, malperfusion, blunt chest trauma, penetrating aortic ulcers and intramural haematomas.

Question 32

What complications should you monitor for in HHS?

Answer 32

Occlusive events: focal CNS signs, chorea, DIC, leg ischaemia, rhabdomyolysis and DVT