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Paediatrics RACP written exam > Emergency Medicine > Flashcards

Emergency Medicine Flashcards

1
Q

Neuroepileptic Malignant Syndrome

A

Caused by medications that block dopamine transmission, e.g. risperidone.
Fever, rigidity, mental status changes, and autonomic instability.
Severe rigidity: profound creatine kinase (CK) elevation.

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2
Q

Medication overdose causing wide QRS?

A

Tricyclic antidepressants e.g. amitryptilline

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3
Q

Describe the algorithm for VF/ pulseless VT

A

CPR - shock (4J/kg) - 2 min CPR - shock + adrenaline (after 2nd shock and then every 2nd shock i.e. 2,4,6,8) - 2 min CPR - shock + amiodarone (after 3rd shock)

Note: in non-shockable arrest (PEA/asystole), adrenaline is given immediately, and then every 2nd loop i.e. 1,3,5,7,9

Re-commence CPR after every shock, then assess rhythm after next 2 minutes i.e. if revert to sinus rhythm after shock, still need to give further 2 min CPR (as myocardial muscle is in refractory state and can easily revert back to VF) - don’t need to do this is signs of life are present

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4
Q

If the onset of VF/pulseless VT is witnessed on an ECG monitor then what is the next step?

A
  • Defibrillation (asynchronous shock) should be attempted before any other treatment. However, if unmonitored, or unable to get defib within 30 seconds then start CPR
  • Don’t use precordial thump (usually for sudden VF) in children
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5
Q

When might you use 3 shocks?

A
  • Where a patient with a perfusing rhythm suddenly develops a shockable rhythm in a witnessed and monitored setting, defib is immediately available, and they were previously well perfused and oxygenated pre-arrest.
  • Should not take >30 seconds to deliver all 3 shocks
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6
Q

What are the CPR ratios for: newborn, child, adult, lay person

A
  • Newborn 3:1
  • Child 15:2
  • Adult 30:2
  • Lay person 30:2
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7
Q

After the initiation of CPR, when do the coronary arteries start perfusing?

A

After the 5th compression (aortic pressure increases, RA pressure stays the same)

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8
Q

What are the 4 Hs + Ts of cardiac arrest?

A
  • Hypoxia, hypovolaemia hypo/hyperkalaemia, hypothermia

- Thrombosis, tension pneumothorax, tamponade, toxins

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9
Q

What are the main causes of asystolic arrest?

A

Hypoxia and hypovolaemia

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10
Q

What are the main causes of PEA (rare, usually go into asystole)?

A

Hypovolaemia, hyper/hypokalemia, tamponade, thrombosis

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11
Q

What are the main causes of VF?

A

Hypothermia/hyperthermia, toxins (TCA poisoning), underlying cardiac disease

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12
Q

What is the dose of adrenaline for anaphylaxis?

A

0.01ml/kg of 1:1000 IM adrenaline (IV = 0.1ml/kg of 1:10,000)
= 10mcg/kg
(always count 5 x zeros)

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13
Q

What is the most common cardiac cause of sudden collapse?

A

Dilated cardiomyopathy

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14
Q

What are the causes of sudden, unexplained cardiac death?

A
  • Congenital - hypertrophic CM, long QT, WPW, Brugada, Marfans, congenital CA abnormalities
  • Acquired - commotio cordis, drug abuse, myocarditis
  • Either: dilated CM, restrictive CM
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15
Q

What is commotio cordis?

A

Sudden death due to VF may occur when a projectile strikes the precordium of an individual with no underlying cardiac disease. One of the leading cuases of sudden cardiac death in young athletes (exceeded only by HOCM).

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16
Q

What is the formula for:

  • ETT size cuffed
  • ETT size uncuffed
  • ETT measurement at lip
  • ETT measurement at nose
A
  • age/4+3
  • age/4+4
  • ETT size x 3, age/2 + 12
  • age/2 +15
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17
Q

What is the formula for estimating weight?

A

(age + 4) x 2

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18
Q

What is the dose for DC shock?

A

4J/kg

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19
Q

What is the management for a scaphoid fracture?

A

Short arm plaster with thumb spica

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20
Q

What injuries would you backslab?

A
  • Non-displaced fractures, minor injuries, swelling, crsuh, open fracture.
  • Risk of ischaemic contractures with full plasters (Volkmann’s ischaemic contracture) - should only be used for displaced fractures to maintain reduction
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21
Q

What are the clinical signs and managmeent of a scaphoid fracture?

A
  • Pain on dorsiflexion of the wrist, tenderness in snuffbox, pain on gripping.
  • Can have normal x-rays first few days - treat all with below elbow POP with thumb spica, remove if normal x-ray at 2 weeks
  • Complications: avascular necrosis (of prox segment) and non-union
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22
Q

Describe the anatomy surrounding a supra-condylar fracture

A
  • Above elbow = brachial artery, below elbow = radial and ulnar artery
  • Median and radial nerves most likely affected (ulnar nerve runs posterior to elbow joint)
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23
Q

Describe the nerve innervation of the hand

A
  • Radial nerve - posterior thumb, 2 + 3rd finger to level of PIPJ
  • Ulnar nerve - ant and posterior 1/2 of 4th + 5th finer
  • Median nerve - ant hand thumb to 1/2 of 4th finger, back of hand top of 2+3rd fingers
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24
Q

What nerve is injured in a wrist drop?

A
  • Radial nerve palsy - supplies triceps + extensor muscles of the forearm
  • From spooning, crutches, Saturday night palsy
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25
Q

What sign on x-ray is suspcious for a supracondylar fracture?

A

Posterior fat pad on x-ray indicates bleeding into joint capsule - sail sign - lifts fat pad upwards/becomes more visible. Anterior fat pad is normal.

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26
Q

What is a monteggia’s injury, and what is the management?

A
  • Proximal ulnar fracture and radial head dislocation

- Refer to ortho - needs reduction

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27
Q

What is a galleazi injury, and what is the management?

A
  • Distal radius fracture (at wrist) and ulnar dislocation

- Refer to ortho

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28
Q

What is the order of ossification in the elbow joint?

A

CRITOE

  • Capitellum
  • Radial head
  • Internal (medial) epicondyle (often avulsed in children)
  • Trochlear
  • Olecranon
  • External (lateral) epicondyle
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29
Q

What is the normal retropharyngeal space appearance on lateral neck x-ray?

A
  • At C2 <1/2 AP diameter of vertebral body

- At C6 < full width

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30
Q

Describe a hangman’s fracture

A
  • Fracture C2 pedicles, ant subluxation C2 on C3
  • Due to hyperextension of neck e.g. hitting face on windscreen in MVA
  • Unstable fracture, risk of cord injury
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31
Q

What is a Jefferson fracture?

A
  • Compression fracture of the bony ring of C1
  • Unstable
  • Due to diving into pool/blow to vertex head
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32
Q

Describe the Salter Harris Classification

A 
1 - physis (through growth plate)
2 - physis + metaphysis (most common)
3 - physis + epiphysis
4 -physis + metaphysis + epiphysis
5 - crush of physis

80% are 1 or 2
3, 4, 5 - may result in growth disturbance as epiphysis is involved
Dsipalced 3 + 4 may require ORIF

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33
Q

SUFE appearance on x-ray?

A

Superior border of prox femoral epiphysis will lie on Klein’s line (line along femoral neck), when it should be higher

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34
Q

Describe Osgood-Schlatter’s disease

A
  • Normal radiology
  • Traction aphophysis
  • Osteochondritis of tibial tubercle where patellar tendon inserts
  • Painful, worse with activity and kneeling
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35
Q

Describe perthes disease

A
  • Osteonecrosis of the femoral head due to ischaemia
  • Abnormal moth-eaten femoral head
  • Increased risk with thrombophilia, infection, trauma
  • M>F, increased risk age 4-8y, bilat in 10%
  • Pain groin, thigh, knee
  • Tx: cast or surgery, maintain head in acetabulum
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36
Q

Describe osteoid osteoma

A
  • Benign bone tumour

- X-ray: new bone formation, occassionally lucent spot

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37
Q

Osteomyelitis vs. septic arthritis

A
  • OM: more vague history, consider if unexplained fever, irritability, assymetrical use of limb. Most commonly tibia and femur. X-ray abnormalities in 7-10 days
  • Septic arthritis: may be vague history of trauma, surgerical emergency in hip (pus causes AVN), not usually associated with swelling or limb tenderness
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38
Q

What is an eschar and when does it bleed?

A
  • Dead tissue, contains necrotic tissue, not the same as a scab (whcih has exudate)
  • Seen in burns, gangrene, ulcer, spider bit wounds
  • Risk of haemorrhage from eschar separation greatest at 2-3 weeks
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39
Q

What are the risks of lightening strike?

A
  • Deafness (ruptured ear drum)
  • Amnesia
  • Prolonged QT
  • Seizure
  • Peripheral neuropathy (delayed)
40
Q

What are the causes of fatality in burns?

A
  • Early mortality due to fluid loss/dehydration

- Late mortality due to sepsis/infection

41
Q

Describe the first aid management of burns

A
  • Running water at room temp, around 18 degrees
  • Effective for up to 3 hours post burn
  • Cool for 20 min
  • Don’t use icepack
  • Stops progression in zone of stasis which leads to necrosis (zone of coagulation is central area, already damaged)
42
Q

Describe the rule of 9s in paeds burns

A
  • Head 18%
  • Torso 18% front, 18% back
  • Arms 9% each
  • Legs 14% each
  • Perineum 1%
43
Q

What are the side effects of ketamine sedation?

A
  • Laryngospasm and bronchodilation
  • Tachycardia and hypertension
  • Vomiting
  • ? inc ICP
  • Emergent reactions, like waking up from nightmare
  • Good for analgesia and amnesia
44
Q

What are the effects of midazolam for sedation?

A
  • Amnesia, sedation, anti-anxiolytic, anticonvulsant
  • Respiratory depression
  • May cause paradoxical hyperactivity
  • Atagonist: flumezanil
45
Q

What sedative cuases chest wall rigidity?

A

Fentanyl

46
Q

What are the contraindications to using entonox (nitrous oxide) for sedation?

A
  • Gas-filled space (pneumothorax, bowel obstruction)
  • Severe head injuries (risk of pneumocranium)
  • Intoxication/depressed LOC
  • If requiring >50% FiO2
  • 1st trimester pregnancy
47
Q

Presentation of pericarditis?

A
  • Usually well, chest pain, recent viral illness
  • Normal CXR heart and lungs
  • May have friction rub (inflammation)
  • May have fluid accummulation -> no rub, decr voltages on ECG, inc heart size on CXR
  • If no fluid: ST segment elevations, T wave inversion
48
Q

What are the complications of myocarditis?

A
  • Inflammation of heart muscle/myocardium
  • Cardiomegaly
  • Increased pressures (LV, LA, PV, arterial)
  • Pulmonary oedema and congestive heart failure
49
Q

What are the causes of myocarditis?

A
  • Usually viral: coxsackie A +B, adenovirus, CMV, echovirus, EBV
  • Drug hypersensitivity
  • Drug toxicity
  • Immune-mediated: rheumatic fever, Kawasaki
50
Q

What are the symptoms and signs of myocarditis?

A
  • Non-specific malaise, fever, anorexia
  • Dysrhythmias (AV conduction or junctional, tachy)
  • Chest pain (due to ischaemia or pericarditis)
  • Tachypnoea
  • Decr cardiac output: tachycardia, weak pulses, cool periph, mottling
  • Muffled HS, S3, AV valve regurgitation murmur
  • Hepatomegaly, oedema, inc JVP
  • Rash (viral illness)
51
Q

What are the ECG findings in myocarditis?

A
  • Low voltage QRS
  • Pseudo-infarction: pathological Q waves, poor progression R waves
  • TWI or flattening
  • LVH
  • Prolonged PR or QTc
  • Arrythmias
52
Q

Treatment of SVT?

A
  • Vagal stimulation - ice to face, carotid sinus massage, valsalva
  • Adenosine
  • Synchronised DC cardioversion
53
Q

What is the management of a button battery in the stomach?

A

If asymptomatic and in stomach, then can be allowed to pass. Follow up xray in 24-48 hours, if still in stomach then for endoscopic removal. Check for disruption of battery on x-ray (heavy metal poisoning)

54
Q

What are the complications of Kawasaki Disease?

A
  • Urethritis with sterile pyuria
  • Hepatic dysfunction
  • Arthritis or arthralgias
  • Aseptic meningitis
  • Pericardial effusion or arrythmias
  • Hydrops of the gallbladder
55
Q

Commonest cause of painless abdominal distension in a neonate?

A

Sepsis (would have vomiting with volvulus)

56
Q

Describe the ligaments in malrotation?

A
  • Ligament of Treitz is absent (by distal end of transverse colon)
  • Ladd’s bands present (between caecum and duodenum, lead to midgut volvulus)
57
Q

What is the mortality risk of measles encephalopathy?

A

15%

58
Q

Risk factors, symptoms, and treatment for SUFE?

A
  • Obesity, hypothyroidism, hypopituitary, renal osteodystrophy
  • Vague acute or chronic groin/thigh/knee pain, may have sudden exacerbation, history of small trauma, limp and externally rotate leg
  • Posterior and inferior displacement head compared to femoral neck
  • Abnormal Klein’s line
  • M>F, L>R, 11-16yo
  • Tx: bed rest and pinning
  • Risks: osteonecrosis
59
Q

What is the mechanism of a pulled elbow, and how do you treat it?

A
  • The annular ligament becomes trapped between
    the radius and humerus
  • Stabilise radial head, supinate or pronate forearm, and flex elbow
60
Q

Overdose with high anion gap metabolic acidosis?

A
  • Methanol
  • Ethylene glycol
  • Salicylates
61
Q

Anticholinergic toxidrome

A
  • Tricyclic antidepressants (amitriptyline), antihistamines, atropine
  • Mad hatter, blind bat, dry bone, hot hell, flushed beet
  • Dilated pupils (non reactive), tachycardia, hypertension, tachypnoea
  • Dry skin and mucous membranes
  • Decr bowel sounds, ileus, urinary retention
  • Myoclonus, choreoathetosis, picking/plucking at things
  • Agitation, delirium, hallucinations
  • ECG: prolonged QRS, arrhythmia
  • Tx: sodium bicarbonate, physostigmine (acetylcholinesterase inhibitor)
62
Q

Hallucinogenic/sympathomimetic toxidrome

A
  • e.g. amphetamine, MDMA, LSD, ecstasy
  • Dilated pupils (brisk reactive), tachycardia, hypertension, tachypnoea, sweaty, nystagmus
  • Hallucination, agitation, depersonalisation, distorted perception
  • Fear, panic, dysphoria
  • Tx: calm environment, midazolam or haloperidol for agitation PRN
63
Q

Opioid toxidrome

A
  • Opioids e.g. morphine, methadone, heroin
  • Miosis (small pupil)
  • Drowsiness, coma, slurred speech, impaired attention
  • Respiratory depression and bradycardia
  • Euphoria, dysphoria, impaired judgement
  • Can develop pulmonary oedema and dyspnoea
  • Tx: naloxone
64
Q

Sedative hypnotic toxidrome

A
  • e.g. benzodiazepines, ethylene glycol, methanol, ethanol
  • Dilated or small pupils
  • Bradycardia, bradypnoea, hypotension, hyporeflexia
  • Confusion and stupor
  • Ethanol - slurred speech, unsteady, inappropriate behaviour
  • Ethylene glycol - CN palsies and tetany
  • Tx: flumazenil for benzo (not for chronic abuse as triggers seizures), fomepizole or ethanol for methanol/EG + urgent dialysis if high AN metabolic acidosis
  • Tx (others): supportive, IVF for hypotension, benzo and haloperidol for sedation
65
Q

Cholinergic toxidrome

A
  • Organophosphates and insecticides, nerve agents, mushrooms
  • Small pupils (miosis)
  • SLUDGEBBB
  • Lacrimation, salivation, urination, defecation, vomiting
  • Bronchospasm, bradycardia, bronchorrhea
  • Fasciculations, weakness, paralysis, seizures, coma
  • Tx: atropine (competes with acetylcholine), pralidoxime (for fasciculations or weakness)
66
Q

Serotonin syndrome

A
  • e.g. SSRIs (fluoxetine), tramadol, amphetamines
  • Dilated pupils, tachycardia, hypertension
  • Hyperthermia
  • Clonus and trismus, hypertonia, hyperreflexia
  • Sweating, flushing, tremor, rigidity, diarrhoea
  • Tx: supportive, diazepam if agitated, antidote is cyproheptadine (serotonin antagonist)
67
Q

Salicylate intoxication

A
  • e.g. aspirin
  • Respiratory alkalosis followed by high anion gap metabolic acidosis
  • Can be fatal >3g in children
  • Tinnitus, vertigo, N and V
  • Tachypnoea, hyperpnea
  • Agitation, lethargy, hyperthermia >41, coma
  • Pulmonary oedema or cerebral oedema
  • Tx: glucose/dextrose (decr CSF glucose), IV sodium bicarbonate for alkalinisation, may need dialysis
68
Q

What are the main effects seen in digoxin toxicity?

A

Hyperkalaemia (blocks Na-K ATPase) and arrhythmias (AV dissociation - 1st to 3rd degree heart block)

69
Q

Carbon monoxide intoxication

A
  • Headaches, confusion, vomiting, seizures, coma
  • Tx: 100% O2, hyperbaric oxygen
  • Neuropsych assessment 1-2 months
70
Q

Neuro-epileptic malignant syndrome

A
  • Idiosyncratic reaction to neuroleptic or antipsychotic drugs (4-14 post starting) - highest in haloperidol. Can also happen in olanzapine, quetiapine, metoclopramide
  • Gradual onset, prolonged course
  • Hyperthermia, sweating, unstable BP, stupor
  • Diffuse rigidity (hypertonia)
  • Reduced reflexes
  • Normal pupils
  • Tx: stop meds immediately, supportive, cooling, hydration
71
Q

Management of unidentified ingestion

A
  • Min 12 hrs observation
  • Check BSL
  • IV access if toxicity
  • Monitor LOC, vital signs, BSL +/- cardiac monitoring
  • Discharge only in daylight
72
Q

What ECG changes do you see in tricyclic antidepressant overdose and how do you treat it?

A
  • Prolonged QRS (normal QRS < 0.12sec)

- IV sodium bicarbonate

73
Q

What is the antidote for B-blocker overdose?

A

Glucagon

74
Q

What is the antidote for CCB overdose?

A

Calcium gluconate/chloride or high-dose insulin and glucose (calcium channel blockers block insulin release leading to hyperglycaemia)

75
Q

What is the antidote for sulfonylurea (eg glipizide) overdose?

A

Octreotide (inhibitor of growth hormone, glucagon, and insulin, is like somatostatin)

76
Q

What is the antidote for tricyclic antidepressant overdose?

A

Sodium bicarbonate

77
Q

What is the antidote for isoniazid (anti-TB) overdose?

A

Pyridoxine

78
Q

What is the antidote for iron overdose?

A

Desferroxime

79
Q

What is the antidote for methaemoglobin overdose?

A

Methylene blue

80
Q

What is the antidote for ethylene glycol overdose?

A

Fomepizole or ethanol

81
Q

What is the antidote for benzodiazepine overdose?

A

Flumazenil

82
Q

Beta-blocker or calcium channel-blocker overdose presentation

A
  • Drowsiness, altered mental status
  • Bradycardia, hypotension
  • Normokalaemia (c.f. digoxin with hyperkalaemia)
  • ECG: sinus brady, abnormal AV node conduction, accelerated junctional rhythm
  • Tx: glucagon (BB) or calcium gluconate (CCB)
83
Q

Discuss colchicine ingestion

A
  • Heart sink ingestion
  • Rapidly absorbed
  • Gastro symptoms within 24 hours
  • > 0.8mg/kg associated with 100% mortality
  • No antidote, give activated charcoal
84
Q

Activated charcoal is not useful (or is contraindicated) in which settings?

A
  • Pesticides, petroleum
  • Hydrocarbons, heavy metals >1hr since ingestion
  • Acids, alkali, alcohol
  • Iron
  • Lithium
  • Solvents
85
Q

What are the causes, signs, and symptoms of neurogenic shock?

A
  • Stimulation of parasympathetic, or inhibition or sympathetic
  • Widespread vasodilation
  • Bradycardia, hypotension, warm skin
  • Causes: spinal cord injury above T5, spinal anaesthesia, vasomotor center depression (pain, drugs)
86
Q

Discuss the movements for C4-S1 nerves

A 
Shrug shoulders - C4
Flex elbow - C5
Pull wrist back - C6
Straighten arm - C7
Open and close fingers - C8
Spread fingers - T1
Flex hip - L1 and 2
Straighten knee - L3
Flex ankle up - L4
Push ankle down - L5, S1
87
Q

Pulsating proptosis and cannot look down. Injury is…?

A

Superior wall orbital fracture

Cannot look away from the injury = superior

88
Q

Treatment of head injury in Haemophilia A?

A

Give factor 8 to bring factor levels to 100%, even if no evidence of bruising or swelling

89
Q

What are the cases of wound infections post human bite?

A

Staph aureus, strep, Eikenella corrodens

90
Q

At what level of paracetamol ingestion would you be concerned?

A

> 200mg/kg or >10g total, based on ideal body weight

91
Q

When do you check parecetamol levels

A

2hrs for elixir, will need repeat if equivocal
4hrs for tablets
If >8hrs then start NAC while awaiting paracetamol levels

92
Q

Typical vs atypical antipsychotics

A
  • Typical = haloperidol, chlorpromazine - can cause QT prolongation
  • Atypical = olanzapine, risperidone (can cause acute dystonia)
93
Q

What is the toxic dose for iron?

A

> 60mg/kg elemental iron

94
Q

FFP vs cryoprecipitate

A

FFP contains all factors.

Cryoprecipitate contains fibrinogen, vWF, F8 + 13

95
Q

What is the timing or primary, mixed, and permanaent dention?

A
  • Primary 6m-6y, lower central are first, then upper central
  • Mixed 6y - 12y
  • Permanent >12y
96
Q

What is a Bohn’s nodule?

A

Remnant of salivary gland located on buccal or lingual mucosa, or hard palate. No treatment needed. Epstein’s pearls = keratin nodules on palate

Paediatrics RACP written exam (18 decks)

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