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MEDICINE NEW > Emergency Medicine > Flashcards

Emergency Medicine Flashcards

1
Q

In status epilepticus what Rx should be given?

A

Lorazepam 2-4mg
10 mins
Lorazepam 2-4mg IV
Phenytoin

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2
Q

What is the definition of status epilepticus?

A

Seizures lasting 30 minutes or repeated seizures without intervening consciousness

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3
Q

Features of systemic inflammatory response syndrome? (SIRS)

A 
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

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4
Q

What features indicate a red flag sepsis rather than just sepsis?

A 
HR >131
RR >25
BP <90 or a fall of 40
MAP <65
on AVPU- V, P, or U

=start sepsis six

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5
Q

What is the difference between severe sepsis, red flag sepsis and septic shock?

A

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

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6
Q

Summarise the Glasgow Coma Scale:

A 
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
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7
Q

What can the respiratory pattern of a patient in a coma tell you?

A

Hyperventilation: acidosis, hypoxia, neurogenic
Cheyne-Stokes: deep and irregular, suddenly fast breathing (brainstem affected)
Ataxic/apneustic (breath holding): brainstem damage with grave prognosis

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8
Q

What do pupils indicate in a coma?

A

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

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9
Q

What is the ice water calorics test?

A

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

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10
Q

What % blood loss is associated with different classes of shock?

A
  1. < 750mL or < 15%
  2. < 1500mL or < 30%
  3. < 2000mL or < 40% (low BP)
  4. > 2000 mL or > 40% (unreadable BP)
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11
Q

Rx for anaphylaxis:

A 
1 in 1000 0.5mL adrenaline IM 
   up to 5mLs
10mg chlorphenamine IV
200mg hydrocortisol IV
500mL saline
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12
Q

CI to thrombolysis:

A

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

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13
Q

Which anticoagulant is given in ACS with a STEMI or NSTEMI?

A

STEMI- bivalirudin (direct thrombin inhibitor)

NSTEMI- fondaparinux or LMWH but bivalirudin before PCI

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14
Q

Meds to write up for pulmonary oedema:

A

Furosemide 40-80mg IV
GTN 2 puffs SL
if BP >90mmHg

Isosorbide dinitrate 2-10mg/h IV
If BP >100mmHg

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15
Q

How does the use of aspirin and clopidogrel differ following MI and stroke/TIA?

A

Everyone gets Clopidogrel 75mg

But MI also gets Aspirin 75mg
Stroke has Aspirin 300mg for 2 weeks before Clopidogrel 75mg
TIA: just clopidogrel 75mg

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16
Q

Meds to write up for a haemodynamically stable broad complex tachycardia?

A

300mg Amiodarone IV (over 20 minutes)

CI if long QT

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17
Q

4 H’s + 4T’s to correct in cardiac arrest?

A

Hypoxia
Hypothermia
Hypo/hyperkalaemia/ calcaemia
Hypovolaemia

Tamponade
Tension pneumothorax
Toxins
Thrombosis

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18
Q

How are shockable and non-shockable rhythms managed differently?

A

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

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19
Q

What adverse signs indicate synchronised DC cardioversion is required?

A

Chest pain, heart failure
Systolic BP < 90mmHg
HR > 150bpm
Ischaemia on ECG

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20
Q

Which broad complex tachycardia’s can you use synchronised DC cardioversion for vs non-synchronised DC cardioversion?

A

VT- has an R wave so synchronised

VF- no R wave, non-synchronised

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21
Q

Meds to write up for narrow complex tachycardia:

A

Vagal manoeuvres
Adenosine 6mg bolus, 12mg, 12mg

Verapamil

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22
Q

Asthmatic patient with SVT Rx:

A
  1. Vagal manoeuvres
  2. Verapamil 2.5mg over 2 mins IV (rather than adenosine)
  3. If not unstable: IV metoprolol, IV amiodarone or digoxin IV may be tried
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23
Q

What extra meds need to be given if life-threatening features of asthma present?

A

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

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24
Q

In exacerbations of COPD what are the indications for non-invasive positive pressure ventilation vs intubation and ventilation?

A

NIPPV: RR >30 or pH < 7.35

Intubation: pH <7.26 or PaCO2 rising

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25
Q

Treatment for meningitis and the therapy that is not required for pure septicaemia rather than meningitis:

A

Rx: 2g cefotaxime

+ dexamethosone 4mg over 6hr IV if meningitic

Not needed for septicaemia

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26
Q

How do viral and TB meningitis look different on lumbar puncture?

A

Viral- clear, low protein

TB- fibrinous web, high protein (bacterial walls contribute)

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27
Q

How do the causes of encephalitis differ from encephalopathy?

A

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

28
Q

Tests for encephalitis:

A

Blood cultures, viral PCR, toxo IgM titre, thick + thin blood films

Contrast enhanced CT
Lumbar puncture
Urgen EEG- diffuse abnormalities

29
Q

What are the indications for immediate CT head vs CT head within 8 hours of injury?

A 
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

30
Q

What are the three types of cerebral hernia that may occur:

A

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

31
Q

How is plasma osmolarity determined?

A

GUNN

Glucose + urea + 2[Na]

32
Q

Signs of severe DKA:

A

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

33
Q

What are the exact parameters of DKA?

A

Glucose > 11
PH < 7.3
Bicarbonate < 15
Ketones > 3 or ++ on dipstick

34
Q

Management of hypoglycaemia?

Which patient group won’t this work in?

A

Oral glucose drink
10% dextrose IV
Glucagon 1mg IV/IM won’t work in drunk patients (no sugar reserve)

35
Q

What is hyperosmolar hyperglycaemic state and what are the dangers of it?

A

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

36
Q

Rx for thyroid storm:

A
  1. Propranolol or short acting b-blocker if low CO
  2. Carbimazole
  3. Lugol’s solution (high iodine blocks T4 release)
  4. Hydrocortisone prevents T4 conversion to T3
37
Q

Meds to write up for phaeochromocytoma:

A

IV a blocker: phentolamine 2-5mg
(Short acting)

PO a blocker: phenoyxbenzamine 10mg
(Long acting, once BP controlled)

B1 blocker (atenolol, metoprolol)

38
Q

Meds to write up for hyperkalaemia:

A

10mL 10% calcium gluconate
10 units actrapid in 50mL of 20% glucose
Saline 500mL over 30 minutes

39
Q

When is dialysis needed urgently in hyperkalaemia:

A

Refractory hyperkalaemia or patient remains oligouric
Refractory pulmonary oedema
Uraemic complications (pericarditis)
Severe acidosis <7.2

40
Q

Name 3 drugs that cause an irregular pulse if OD-ed on:

A
  1. Salbutamol (B1 agonist)
  2. Antimuscarinics
  3. Tricyclics (anticholinergic actions, reduces parasympathetic input)
41
Q

2 drugs that cause respiratory depression and how an overdose of each may be distinguished:

A

Opiates: constricted pupils

Benzodiazepines

42
Q

Drug overdoses that will result in dilated pupils:

A

Cocaine
Amphetamines
Tricyclics (anticholinergic)

43
Q

Drug overdoses that cause metabolic acidosis:

A

Alcohol, ethylene glycol, methanol
Paracetamol, salicylates (respiratory alkosis initially)
CO poisoning, cyanide (binds Fe in cytochromes preventing aerobic respiration)

44
Q

Which overdoses are likely to require haemodialysis?

A

Ethylene glycol, methanol
Lithium, sodium valproate
Salicylates
Phenobarbitol

45
Q

Antedote for benzodiazepines:

A

Flumazenil

Suspect if respiratory depression

46
Q

Antedote for beta blockers:

A

Indications: severe bradycardia or hypotension

Atropine 3mg IV

Consider glucagon, phosphodiesterase inhibitors or pacing

47
Q

Rx for moderate to severe cyanide poisoning:

A

100% oxygen (cyanide binds Fe, preventing aerobic respiration)
Sodium nitrite/sodium thiosulfate

Also 50% glucose or hydrocobalamin

48
Q

When are digoxin-specific antibody fragments indicated for digoxin poisoning:

A

Serious arrhythmias

Correct hypokalaemia’s first

49
Q

Antidote for opiates:

A

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

50
Q

Management of phenothiazine poisoning (like chlorpormazine antipsychotic) + signs of it:

A

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

51
Q

Why does salicylate overdose have the effects it does?

A

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

52
Q

Rx of salicylate poisoning:

A

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

53
Q

Patient has dropped GCS and become confused and weak after 3L of 5% dextrose, what blood test is it important to check?

A

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

54
Q

What three tests help delineate cause of hyponatraemia?

A

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

55
Q

Patient is hypotonic (2Na + urea + glucose), what are the causes in a hypovolaemic, euvolaemic and hypervolaemic patient?

A

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

56
Q

If trying to correct hyponatraemia, what rate of Na+ increase should not be exceeded?

A

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

57
Q

What level of K+ is considered normal and what level would worry you?

A

3.5-5mmol

> 6.5 = emergency

58
Q

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?

A

Chest pain
Palpitations, fast/irregular pulse
Weakness
Light headed

59
Q

Rx of non-urgent hyperkalaemia:

A

Review medications

Polystyrene sulfonate resin PO (binds K+ in gut)

60
Q

What is calcitonin a marker for?

A

Thyroid medullary cancer

61
Q

Two tests for hypocalcaemia:

A

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

62
Q

Rx for urate stones?

A

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

63
Q

Questions to ask to assess risk of osteoporosis:

A

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

64
Q

Medical Rx of osteoporosis:

A

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

65
Q

What are the signs of a severe paracetamol overdose?

A

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

66
Q

When would you give NAC to a patient who presents 24 hours after a paracetamol overdose?

A 
If severe (liver failure, abdo pain)
Or high risk OD (taking phenytoin, carbamazepine, existing liver impairment or HIV +)
67
Q

Which antidepressant causes arrhythmias in overdose?

A

Tricyclic antidepressants

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