Emergency Medicine Flashcards
In status epilepticus what Rx should be given?
Lorazepam 2-4mg
10 mins
Lorazepam 2-4mg IV
Phenytoin
What is the definition of status epilepticus?
Seizures lasting 30 minutes or repeated seizures without intervening consciousness
Features of systemic inflammatory response syndrome? (SIRS)
2 of: HR >90 RR >20 Temp >38 or <36 WCC <4 or >11 Blood glucose >7.7 (not normally diabetic)
+ infection proven or suspected = sepsis
What features indicate a red flag sepsis rather than just sepsis?
HR >131 RR >25 BP <90 or a fall of 40 MAP <65 on AVPU- V, P, or U
=start sepsis six
What is the difference between severe sepsis, red flag sepsis and septic shock?
Severe sepsis-objective lab evidence of end organ dysfunction:
Reduced urine output
Lactic acidosis
Rising creatinine, INR, aPTT, bilirubin
Dropping platelets
Red flag sepsis are bad signs that the sepsis six needs to be initiated
HR >130, RR >25, BP <90, MAP < 65, V/ P/ U
Septic shock is refractory hypotension
Summarise the Glasgow Coma Scale:
M: 6- normal 5- localises 4- withdraws 3- flexes 2- extends 1- no response
V: 5- normal 4- confused 3- words 2- sounds 1- none
E: 4- normal 3- to voice 2- to pain 1- none
What can the respiratory pattern of a patient in a coma tell you?
Hyperventilation: acidosis, hypoxia, neurogenic
Cheyne-Stokes: deep and irregular, suddenly fast breathing (brainstem affected)
Ataxic/apneustic (breath holding): brainstem damage with grave prognosis
What do pupils indicate in a coma?
Normal direct + consensual reflexes: intact midbrain
Pinpoint + reactive: pons
Mid position + non reactive or irregular: midbrain
Unilateral dilated + unreactive: 3rd nerve compression
Unilateral constricted pupil: Horner’s, lateral medulla + hypothalamus, may precede uncal herniation
What is the ice water calorics test?
In comatosed patients, tests vestibulo-ocular reflex
Pour cold water into the ear, normal if eye deviates to cold side with nystagmus of other side
Indicates that brainstem from medulla to midbrain is fairly intact
What % blood loss is associated with different classes of shock?
- < 750mL or < 15%
- < 1500mL or < 30%
- < 2000mL or < 40% (low BP)
- > 2000 mL or > 40% (unreadable BP)
Rx for anaphylaxis:
1 in 1000 0.5mL adrenaline IM up to 5mLs 10mg chlorphenamine IV 200mg hydrocortisol IV 500mL saline
CI to thrombolysis:
Brain: stroke <6 months, intracranial haemorrhage or malignancy
Main: aortic dissection, major surgery/trauma
Hole: liver biopsy or lumbar puncture < 24 hours
Bowl: GI bleed < 1 month
Which anticoagulant is given in ACS with a STEMI or NSTEMI?
STEMI- bivalirudin (direct thrombin inhibitor)
NSTEMI- fondaparinux or LMWH but bivalirudin before PCI
Meds to write up for pulmonary oedema:
Furosemide 40-80mg IV
GTN 2 puffs SL
if BP >90mmHg
Isosorbide dinitrate 2-10mg/h IV
If BP >100mmHg
How does the use of aspirin and clopidogrel differ following MI and stroke/TIA?
Everyone gets Clopidogrel 75mg
But MI also gets Aspirin 75mg
Stroke has Aspirin 300mg for 2 weeks before Clopidogrel 75mg
TIA: just clopidogrel 75mg
Meds to write up for a haemodynamically stable broad complex tachycardia?
300mg Amiodarone IV (over 20 minutes)
CI if long QT
4 H’s + 4T’s to correct in cardiac arrest?
Hypoxia
Hypothermia
Hypo/hyperkalaemia/ calcaemia
Hypovolaemia
Tamponade
Tension pneumothorax
Toxins
Thrombosis
How are shockable and non-shockable rhythms managed differently?
VF + VT every 2 minutes, check rhythm + shock
After 3 shocks:
Adrenaline, then every 3-5 minutes
Amiodarone 300mg
Asystole + PEA
No shocks + adrenaline once IV access obtained
What adverse signs indicate synchronised DC cardioversion is required?
Chest pain, heart failure
Systolic BP < 90mmHg
HR > 150bpm
Ischaemia on ECG
Which broad complex tachycardia’s can you use synchronised DC cardioversion for vs non-synchronised DC cardioversion?
VT- has an R wave so synchronised
VF- no R wave, non-synchronised
Meds to write up for narrow complex tachycardia:
Vagal manoeuvres
Adenosine 6mg bolus, 12mg, 12mg
Verapamil
Asthmatic patient with SVT Rx:
- Vagal manoeuvres
- Verapamil 2.5mg over 2 mins IV (rather than adenosine)
- If not unstable: IV metoprolol, IV amiodarone or digoxin IV may be tried
What extra meds need to be given if life-threatening features of asthma present?
For severe asthma would have given
5mg Salbutamol, 100mg Hydrocortisone IV
For life threatening add in:
500 micrograms Ipratropium
MgS04 1.2g IV over 20 minutes
In exacerbations of COPD what are the indications for non-invasive positive pressure ventilation vs intubation and ventilation?
NIPPV: RR >30 or pH < 7.35
Intubation: pH <7.26 or PaCO2 rising
Treatment for meningitis and the therapy that is not required for pure septicaemia rather than meningitis:
Rx: 2g cefotaxime
+ dexamethosone 4mg over 6hr IV if meningitic
Not needed for septicaemia
How do viral and TB meningitis look different on lumbar puncture?
Viral- clear, low protein
TB- fibrinous web, high protein (bacterial walls contribute)
How do the causes of encephalitis differ from encephalopathy?
Encephalitis- infectious prodrome of fever, rash, lymphadenopathy etc
Viral: HSV 1+2, EBV, CMV, Varicella, HIV, MMR, Jap B encephalitis
TB, bacterial, malaria, listeria, Lyme, legionella, aspergillosis, cryptococcus, schistosomiasis
Encephalopathy- low glucose, hepatic cencephalopthy, diabeteic ketoacidosis, hypoxic brain injury, uraemia, SLE, beri beri
Tests for encephalitis:
Blood cultures, viral PCR, toxo IgM titre, thick + thin blood films
Contrast enhanced CT
Lumbar puncture
Urgen EEG- diffuse abnormalities
What are the indications for immediate CT head vs CT head within 8 hours of injury?
Immediate: GCS <13 GCS <15 after 2 hours post injury Vomited more than once Focal neurology Post-trauma seizure Open or depressed skull fracture Basal skull fracture signs- panda eyes, battle sign, CSF leak
In 8 hours if loss of consciousness or amnesia with any RF:
Age 65 +
Clotting disorders or anti-coagulated
Dangerous mechanism of injury- fall, RTA
30 minutes retrograde amnesia (before the accident)
If any head injury and warfarin:
CT within 8 hours
What are the three types of cerebral hernia that may occur:
Uncal herniation: uncus of the temporal lobe gets pushed through the tentorium putting pressure on the midbrain
Signs- CN III palsy, hemiparesis, coma
Cerebellar tonsil: cerebellar tonsils through foramen magnum
Signs- ataxia, 6th nerve palsy, upgoing plantars, irregular breathing, coma
Subfalcian herniation: median frontal lobe (cingulate gyrus) forced under falx cerebri
Signs- silent or anterior stroke
How is plasma osmolarity determined?
GUNN
Glucose + urea + 2[Na]
Signs of severe DKA:
EHx:
GCS <12
Obs:
O2 sats <92%, HR >100 or <60, BP <90
IHx:
pH below 7.1, bicarb <5, anion gap >16, K+ < 3.5 on admission
GCS <12
Dehydrated
What are the exact parameters of DKA?
Glucose > 11
PH < 7.3
Bicarbonate < 15
Ketones > 3 or ++ on dipstick
Management of hypoglycaemia?
Which patient group won’t this work in?
Oral glucose drink
10% dextrose IV
Glucagon 1mg IV/IM won’t work in drunk patients (no sugar reserve)
What is hyperosmolar hyperglycaemic state and what are the dangers of it?
Type 2 diabetics, over 1 week who can’t switch on ketosis
Dehydrated, glucose >35, osmolality >350
Hyperviscosity + occlusion: focal CNS signs, chorea, DIC, leg ischemia, rhabdo
Hydrate slowly, gradual K+ add in
Rx for thyroid storm:
- Propranolol or short acting b-blocker if low CO
- Carbimazole
- Lugol’s solution (high iodine blocks T4 release)
- Hydrocortisone prevents T4 conversion to T3
Meds to write up for phaeochromocytoma:
IV a blocker: phentolamine 2-5mg
(Short acting)
PO a blocker: phenoyxbenzamine 10mg
(Long acting, once BP controlled)
B1 blocker (atenolol, metoprolol)
Meds to write up for hyperkalaemia:
10mL 10% calcium gluconate
10 units actrapid in 50mL of 20% glucose
Saline 500mL over 30 minutes
When is dialysis needed urgently in hyperkalaemia:
Refractory hyperkalaemia or patient remains oligouric
Refractory pulmonary oedema
Uraemic complications (pericarditis)
Severe acidosis <7.2
Name 3 drugs that cause an irregular pulse if OD-ed on:
- Salbutamol (B1 agonist)
- Antimuscarinics
- Tricyclics (anticholinergic actions, reduces parasympathetic input)
2 drugs that cause respiratory depression and how an overdose of each may be distinguished:
Opiates: constricted pupils
Benzodiazepines
Drug overdoses that will result in dilated pupils:
Cocaine
Amphetamines
Tricyclics (anticholinergic)
Drug overdoses that cause metabolic acidosis:
Alcohol, ethylene glycol, methanol
Paracetamol, salicylates (respiratory alkosis initially)
CO poisoning, cyanide (binds Fe in cytochromes preventing aerobic respiration)
Which overdoses are likely to require haemodialysis?
Ethylene glycol, methanol
Lithium, sodium valproate
Salicylates
Phenobarbitol
Antedote for benzodiazepines:
Flumazenil
Suspect if respiratory depression
Antedote for beta blockers:
Indications: severe bradycardia or hypotension
Atropine 3mg IV
Consider glucagon, phosphodiesterase inhibitors or pacing
Rx for moderate to severe cyanide poisoning:
100% oxygen (cyanide binds Fe, preventing aerobic respiration)
Sodium nitrite/sodium thiosulfate
Also 50% glucose or hydrocobalamin
When are digoxin-specific antibody fragments indicated for digoxin poisoning:
Serious arrhythmias
Correct hypokalaemia’s first
Antidote for opiates:
Naloxone, repeating every 2 minutes until breathing is adequate
May precipitate diarrhoea + cramps as it precipitates opiate withdrawal- may need atropine + diphenoxylate (form of opioid) or methadone
Management of phenothiazine poisoning (like chlorpormazine antipsychotic) + signs of it:
Signs: dystonia, torticollis, opisthotonus
Procyclidine
If neuroleptic malignant syndrome hyperthermia, rigidity, extrapyramidal signs, mutism autonomic dysfunction- sweating, labile BP, urinary incontinence Confusion High WCC + CK
Rx: cool + dantrolene can help
Why does salicylate overdose have the effects it does?
It uncouples oxidative phosphorylation causing anaerobic metabolism
Like you’ve exercised too much: sweating, vomiting, dehydration
Resp alkalosis- due to direct stimulation of central respiratory centres
Vertigo + tinnitus
Rx of salicylate poisoning:
IV fluids
If plasma salicylate >500mg/L or severe metabolic alkalosis:
Alkalinize urine with sodium bicarbonate IV
If plasma salicylate >700 or AKI/HF or pulmonary oedema, seizures, confusion, severe acidosis:
Dialyse
Patient has dropped GCS and become confused and weak after 3L of 5% dextrose, what blood test is it important to check?
U+Es
As glucose is used, a hypotonic solution is left, diluting Na+ levels, may be hyponatraemic
Need to exclude pseudohyponatraemia causes: high glucose, high lipids or protein
What three tests help delineate cause of hyponatraemia?
Tonicity = 2Na + glucose + urea
Isotonic- hyperlipidaemia or high protein
Hypertonic- high glucose
Hypotonic- true low sodium
Then need volume status + urine Na/osmolality to delineate hypotonic causes
Patient is hypotonic (2Na + urea + glucose), what are the causes in a hypovolaemic, euvolaemic and hypervolaemic patient?
Hypovolaemia + pissing Na:
Addison’s, diuretics, raised glucose
Hypovolaemia + not pissing Na:
Extra-renal loss like burns, D+V, fistulae, CF
Euvolaemia + concentrated urine:
SIADH, diuretics
Euvolaemia + dilute urine:
Hypothyroid, low cortisol, Beer potomania/psychogenic polydipsia
Hypervolaemia:
The failures- heart, kidney, liver
If trying to correct hyponatraemia, what rate of Na+ increase should not be exceeded?
15mmol in a day if chronic low Na
Or 1mmol/L per hour if acute low Na
Risk of central pontine myelinolysis = subacute lethargy, confusion, psuedobulbar palsy, paraparesis, locking in syndrome, coma
What level of K+ is considered normal and what level would worry you?
3.5-5mmol
> 6.5 = emergency
A patient has a high K+ on U+Es, you get the ECG machine but are not sure if it’s an artifactual result- what can you ask to determine if they are being affected?
Chest pain
Palpitations, fast/irregular pulse
Weakness
Light headed
Rx of non-urgent hyperkalaemia:
Review medications
Polystyrene sulfonate resin PO (binds K+ in gut)
What is calcitonin a marker for?
Thyroid medullary cancer
Two tests for hypocalcaemia:
Trousseau’s sign: inflate the cuff- wrist + finger flex
Chvostek’s sign: tapping the facial nerve over the parotid gland causes the corner of the mouth to twitch
Low Ca+ causes neuromuscular hyperexcitability or irritability as it increases permeability of neuronal membrane to Na+ causing depolarisation
Rx for urate stones?
Urate is formed by purine breakdown which precipitates in tubules
Low-purine diet, avoiding shellfish and red meats
Alkalinize urine with potassium citrate or potassium bicarbonate
Questions to ask to assess risk of osteoporosis:
Age
PC: immobility, BMI <22, (2) low Ca intake
PMH: rheumatoid arthritis
(2) hyperparathyroidism, hyperthyroidism, hypercalcaemia
(2) early menopause
(2) myeloma, antiandrogen ca prostate
(2) diabetes type 1, malabsorption
DHx: steroid use
FHx: osteoporosis
SHx: 4 units alcohol a day, smoking
Medical Rx of osteoporosis:
Bisphosphonates (SE jaw osteonecrosis)
Strontium- those intolerant of bisphosphonates
Raloxifene: selective oestrogen modulator (blocks RANK ligand)
Teriparatide: recombinant PTH (if fracture)
Denosumab: antibody against RANK ligand (twice yearly)
HRT, Testosterone
What are the signs of a severe paracetamol overdose?
PC: vomiting within a few hours of ingestion
Abdominal pain
More than 150mg/kg
IHx:
Liver failure- abnormal LFTs within 12 hours, AST > 10000, hyperbilirubinaemia, prolonged INR
Paracetamol level
When would you give NAC to a patient who presents 24 hours after a paracetamol overdose?
If severe (liver failure, abdo pain) Or high risk OD (taking phenytoin, carbamazepine, existing liver impairment or HIV +)
Which antidepressant causes arrhythmias in overdose?
Tricyclic antidepressants
