Emergency Medicine Flashcards
What is the normal amount of IV fluid to give for resucitation?
500ml 0.9% saline bolus
Given over 15 minutes
What is the typical regimen for fluid maintenance given to patients?
[One salty, two sweet]
1L 0.9% saline + 20mmol KCL over 8hrs
1L 5% Dextrose + 20mmol KCL over 8hrs
1L 5% Dextrose + 20mmol KCL over 8hrs
What must you always check before giving patients maintenance fluids?
U&Es
As a general rule, what is the maximum amount of fluids that can be administered to a patient in 24hrs?
2-3 L
True or false, potassium supplementation should be avoided if the patient has acute renal failure
True
What is battle sign?
Bruising/bleed behind the ears. This indicates a basal skull fracture and is an emergency.
What is periorbital ecchymosis? Give two causes.
AKA “Raccoon eyes”
Basal Skull Fracture (BSF) Facial Fracture Rhinoplasty Neuroblastomas Amyloidosis
What are the three types of g-protein coupled opioid receptors? Which is the most common?
Mu (Most common)
Kappa
Delta
Name two weak opioids and one strong
Weak: Tramadol / Codeine
Strong: Morphine / Fentanyl / Methadone
What recreational drug presents with miosis?
Opiates e.g. heroin / fentanyl
Pin-point pupils
At what GCS score would you intubate a patient?
8 or less
What drug is given to reverse opioid toxicity?
Naloxone
IV/IM/SC
A patient who has OD on opiates is given naloxone and improves immediately. However, 2 hours later they crash again, why?
Naloxone has a shorter half-life than most opiates. Therefore, it can wear off in 60-90mins. Need to give a further dose of naloxone.
Give three risk factors for PE
Recent surgery / trauma Obesity Malignancy FHx clotting disorder Infection Pregnancy COCP/HRT
True or false, pregnant women are more at risk of PE?
True
What is the most common ECG finding in patients with PE?
Sinus tachycardia (most common)
[S1Q3T3]
- S wave in lead 1
- Q wave in lead 3
- Inverted T in lead 3
What is the target O2 sats range for patients with COPD or who are at risk of CO2 retention?
88-92%
True or false, in most cases, a CXR will be normal in PE?
True.
What is the Well’s score?
Risk of PE or DVT
Signs of DVT/PE Alternative Dx less likely HR >100 BPM Immobile >3days Previous DVT/PE Haemoptysis Malignancy
Score above 4 indicates PE likely –> CTPA (or V/Q if CTPA is contraindicated).
If Well’s is <4 then do a D-Dimer to rule out PE/DVT.
Give a contraindication for CTPA
Allergy to contrast media Kidney failure
What can cause D-Dimer to be raised other than a VTE?
Infection
Recent surgery
Malignancy
What is the initial treatment for a PE?
Anticoagulant e.g. apixaban or rivaroxaban (if there is a delay for CTPA).
If haemodynamically unstable then give unfractionated heparin infusion and consider thrombolytic therapy.
How long after a PE should patients be on anticoagulant therapy?
If provoked i.e. known cause then at least 3 months.
If unprovoked then longer.
What is the gold standard investigation for DVT?
If D-Dimer +ve then venous ultrasound.
Start on anticoagulation prior to getting the results - apixaban or rivaroxaban are 1st line.
What anticoagulant is first line in DVT?
DOAC:
- Apixaban
- Rivaroxaban
A skull fracture in the pterion region is likely to cause an extra-dural haemorrhage by rupturing which artery?
Middle Meningeal Artery (MMA)
Which four bones make up the pterion skull landmark?
It is the suture where the frontal, temporal, parietal and sphenoid bones meet.
It is thin and prone to fracture.
What shape haematoma is seen on CT of an extradural bleed?
Lemon-shaped / Bi-convex
(Lenticular)
[Also may see a midline shift]
Why does an extradural bleed come with a risk of sudden death 1-2 days later?
The increased intracranial pressure can compress the brain stem.
True or false, following a head trauma and extra-dural bleed, a patient may feel lucid again before then suddenly getting worse?
True.
What clinical test should you do in all patients with reduced consciousness level?
Blood glucose
What is the gold standard investigation for any patient suspected of having an intracranial bleed?
CT Head
A patient on warfarin has an extradural bleed confirmed on CT. How would you manage them?
Beriplex - warfarin reversal to normalise INR
Antibiotics (if open fracture)
Anticonvulsants e.g. phenytoin or levetiracetam
ICP reducing agents e.g. mannitol or barbiturates
Craniotomy (surgery)
In relation to acute heart failure, what is meant by wet-warm, wet-cold, dry-warm and dry-cold?
Wet = Congestion Cold = Hypoperfused
Give a cause of acute onset heart failure
MI (most common)
Acute valve dysfunction
Arrhythmias
What cardiac marker is used as a test for heart failure? Is it used to rule in or ruleout HF?
B-type natriuretic peptide (BNP). It is a sensitive but not specific test. Therefore, it is used to rule out HF if the result is normal.
True or false, troponins are often elevated in patients with acute heart failure even without an MI?
True
If Well’s score is high, do you do a D-Dimer?
No. Only do a D-Dimer if the Well’s score is low and you want to rule out a VTE.
What investigations do you do in a patient suspected of acute heart failure?
CXR Echocardiogram ECG BNP ABG FBC TFT Troponin
Give two CXR signs of heart failure
[ABCDE]
Alveolar oedema Kerley B lines (parallel horizontal lines at periphery) Cardiomegaly Dilated Upper lobe vessels Effusions
What is the HEART score used for?
6 week risk of major cardiac event in patients with ACS
What medication is given to patients with acute heart failure?
Titrate O2 (94-98%)
Loop diuretic (furosemide)
Nitrates (GTN)
CPAP
if cardiogenic shock / low BP
- Ionotropes e.g. dobutamine (increase cardiac output)
- Vasopressors e.g. adrenaline (increase BP)
What drug is used in paracetamol OD?
Actelycysteine (Parvolex) IV
Only effective if given within 24hrs. Most effective witin 8hrs.
When would you use activated charcoal in a patient with paracetamol OD?
If within 1hr of ingestion of >150mg/kg of paracetamol
At what point should paracetamol blood levels be tested?
On admission
4hrs post ingestion
24hrs post
Above what level of paracetamol ingestion would you initiate treatement before getting blood test results?
> 150mg/kg
What is used to guide treatment of paracetamol OD?
Paracetamol Normogram Graph
Give two causes of an acutely raised anion gap
[MUDPILES]
Methanol Urea DKA Propylene glycol Iron Lactic acid Ethanol / Ethylene glycol Salicylate
Why might you test the osmolarity of the blood in a patient suspected of an OD?
Indicates if there is an additional solute in the blood.
Estimated osmolarity = 2 x Na + Urea + Glucose
Compare this with actual.
What is the treatment of ethylene glycol toxicity?
IV Fomepizole
+IV fluids +/- dialysis
What two main vitamins are given in Pabrinex?
Vit C
Thiamine
In the acute setting what drugs would you give for alcohol withdrawal?
IV Pabrinex
IV Benzo: Chlordiazepoxide or Diazepam.
[NB: Both these benzos can be given even if liver impairment. Lorazepam requires a functioning liver]
What is a normal range for the anion gap?
8-16
What is the initial treatment for a seizure?
Buccal midazolam 10mg
Rectal diazepam 10mg
IV Lorazepam
Anaesthetics: (Call post 2 doses of benzos)
- IV Phenytoin if protracted
- Propofol / Midazolam /
- Thiopental sodium (sedative)
What is AVPU
Alert
Voice
Pain
Unresponsive
What is SBAR
Situation
Background
Assessment
Recommendations
Which are the lateral, anterior, septal and inferior leads on an ECG?
Lateral: I, avL, V5, V6.
Anterior: V3, V4
Septal: V1, V2
Inferior: II, III, avF
With a posterior MI what would you expect to see on ECG?
ST depression in V1-3
What treatment do you give in an MI?
Aspirin 300mg Morphine Nitrates (GTN) Oxygen Ticagrelor Metoclopramide (antisickness)
What is the 1st line treatment for pain in an MI?
Nitrates (GTN)
- Act faster than morphine
Why would cardiologists want to know whether a patient who is admitted with an MI is still having chest pain?
Pain means the tissue is still alive. If the patient is not experiencing pain, then it is too late to save the tissue.
If a PCI cannot be done within two hours, what should you give the patient with an MI?
Thrombolysis (alteplase)
Other than HEART score name another score system used to assess the risk of ACS?
EDACS
T-MACS
TIMI
Post PCI what drug treatment should a patient be on?
Dual antiplatelet therapy
- Ticagrelor (P2Y12)
- Aspirin (COX1)
[For 12 months]
Which arteries are used to perform a CABG?
Internal thoracic
Radial artery
Saphenous vein
What is the best investigation for arterial limb ischaemia?
Doppler US
True or false, a limb with arterial limb ischaemia should never be rewarmed?
True. This can accelerate tissue necrosis
Which is more specific to the heart Troponin T or I?
Troponin I
Other than an MI, give two conditions that can cause elevated troponin?
Myocarditis
Pericarditis
Heart Failure
Kidney Failure
What does pericarditis look like on ECG?
Widespread ST elevation
(Saddle shaped)
PR depression
What is the QRISK score?
Risk of major CVD in 10 years
Age / Sex / Ethnicity / Smoker / DM / Angina/MI in 1st degree relative <60yo / CKD / AF / Rheumatoid Arthritis / Antipsychotics / Steroids / Migraines / SLE / BMI / Cholesterol
[If >10% then statin, or to anyone with T1 Diabetes]
What ECG changes would you expect to see in angina?
ST depression
[Transient if Prinzmetal, or when lying down if Decubitus]
What enzyme do statins inhibit?
HMG CoA Reductase
What are the three domains of GCS
Eye opening
Verbal response
Motor response
How do you ilicit pain to perform a GCS score?
Supraorbital notch pressure
Finger tip squeeze
Trapezius squeeze
True or false, if a patient has evidence of a skull fracture you should CT both the head and cervical spine?
True. You must look at both!
What is permissive hypotensive resuscitation?
Replacing fluids to maintain BP slightly lower than normal to avoid fluid overload. Particularly in patients with cardiac issues e.g. heart failure.
Give two signs of pneumothorax
Reduced air entry Tachycardia Hyperresonance Tracheal deviation Rapid desaturation
What is the initial treatment for a patient in anaphylaxis?
1: 1000 adrenaline IM
(0. 5mg)
Repeat in 5 minutes if no change.
IV Fluids
IV Chlorphenamine
IV Hydrocortisone
Which NIV is used for patients in T1 and T2 respiratory failure?
T1RF = CPAP T2RF = BPAP
In a tension pneumothorax, to which side does the trachea move?
It is pushed away from the pneumothorax
How quickly should thrombolytic agents be used in patients with stroke?
4.5 hrs
Otherwise too late to save cortical tissue
True or false, type O blood is less likely to clot than A or B?
True. It is 2-4X less likely.
Due to lower levels of VWF.
What is te HASBLED score?
Assesses risk of bleeding prior to giving anticoagulants
Hypertension Abnormal renal/liver Stroke Bleeding Labile INR Elderly (>65) Drugs/Alcohol
What drug is given to patients who have cyanide poisoning due to inhaled plastic smoke in fires?
Hydroxocobalamin (Vit b12 precursor)
What is the only DOAC that can be reversed and by what?
Dabigatran
Idarucizumab
What is deconditioning?
Loss of physical capacity dueto failure to maintain physical activity.
What is a Respect form?
Advanced statement (not legally binding) where a patient sets out what treatment they want and dont want.
True or false, a DNACPR is not legally binding?
True.
What is the difference between a Stanford type A and B aortic dissection?
A = Ascending aorta B = Descending aorta
Which nerve is most likely to be damaged in a scaphoid fracture
Median nerve
Sensory loss thumb + 2/5 fingers
Weak wrist / thumb flexion
Which nerve is most likely to be injured in a mid humeral fracture?
Radial nerve
Weak wrist extension + sensation on back of hand.
You suspect a patient of having acute hypoadrenalism, what is the gold standard investigation and treatment?
Plasma cortisol + ACTH
IV Hydrocortisone 100mg
How do you manage DKA?
Fluids 0.9% saline
Insulin (soluble IV)
+ KCL 10mmol/L
When glucose falls to <14mmol/L reduce saline and add 10% glucose + 20mmol KCL.
How do you manage hyperkalaemia? What are the ECG changes?
Calcium gluconate bolus
Soluble insulin
Calcium resonium
Tall tented T waves
Wide QRS
Reduced P waves
What is the treatment for hepatic encephalopathy?
Lactulose - alters pH of bowel reducing bacterial production of ammonia.
Neomycin - Antibiotic which reduces bacterial production of ammonia in the gut.
What is the management of an acute asthma attack?
O2 (94-98%)
Nebulised salbutamol
IV Hydrocortisone
IV Fluids (2-3L/d)
If no improvement:
- Add nebulized ipratropium bromide
- Add magnesium sulphate IV
- Inform ITU
- Salbutamol infused in saline
In paracetamol OD what fluid should be used when infusing NAC for a paracetamol OD?
5% Dextrose
What is the normal range for heart rate?
60-100 BPM
What is the normal range for systolic and diastolic BP?
Systolic: 120 - 140
Diastolic: 60 - 80
What is the normal range for respiratory rate?
12-20/min
What is the normal range for O2 sats (+T2RF)?
94-98%
88-92% (T2RF)
What is the normal temperature range?
36.5 - 37.5 degrees
What is the normal urinary output?
0.5 - 1.0 ml/kg/hr
Give two common causes of airway obstruction
Foreign body (blood, teeth, vomit etc)
Swelling e.g. anaphylaxis
Trauma
Low GCS (8 or less)
When would you use jaw thrust manoeuvre rather than a head tilt chin lift to open a patient’s airway?
If you suspect a spinal injury e.g. following a RTA
How are foreign bodies removed from the patient’s oral cavity?
Magill forceps
Yankauer suction tip
When would you use a nasopharyngeal airway vs an oropharyngeal?
Nasopharyngeal is better tolerated therefore it can be used in patients who are conscious. Oropharyngeal airways will cause a gag reflex.
What is a flail chest?
2+ ribs fractured in multiple locations resulting in detachment of the ribs. Increases risk of pneumothorax.
What is TRALI?
Transfusion Associated Lung Injury
Non-cardiogenic pulmonary oedema: Dyspnoea + Hypoxia + Hypotension.
What is ARDS? Give two causes
Sudden onset widespread inflammation in the lungs.
Shortness of breath, tachypnoea, cyanosis.
Sepsis / Foreign body aspiration / Pancreatitis / Pneumonia
What can make pulse oximetry unreliable?
Reduced peripheral perfusion
Anaemia
Atrial fibrillation
[Do an ABG in these circumstances]
What is the order of O2 delivery for the following devices from least to most O2 delivered?
Simple face mask Non-rebreather mask Nasal Cannulae Bag-valve mask Venturi mask
Nasal cannulae (1-4L/min)
Simple face mask (5-8L/min)
Venturi mask (4-12L/min)
Non-rebreathe mask (critically ill patients - 15L/min)
Bag-valve mask (peri-arrest/arrest situations)
What is the FiO2?
The % O2 in the air (21% in normal room air)
You have a patient going into cardiac arrest. What will you use to deliver O2 and at what rate?
Bag-valve mask
15L/min
Give two causes of type 1 and type 2 respiratory failure
Type 1: (Lungs are damaged)
- Pneumonia
- ARDS
- Altitude
- Pulmonary oedema
Type 2: “Ventilatory issue” (Pump is damaged)
- COPD
- Severe asthma
- Opioid OD
- Obesity
- MND
- Flail chest
Give two causes of metabolic alkalosis and acidosis
Alkalosis:
- Vomiting
- Bicarbonate administration
Acidosis:
- Diarrhoea
- Addison’s
- Shock
- Sepsis
- DKA
- Renal failure
What would you see on ABG in a mixed acidotic/alkalotic picture?
PCO2 and HCO3 would be opposite directions
What is the normal base excess range and what does it indicate?
-2 to +2
-ve = reduced bicarbonate \+ve = increased bicarbonate
What is the typical positioning of a CXR, PA or AP? When would you use the alternative?
PA is the typical position.
AP is often used for acutely unwell patients who are laying down supine. This distors the image and so is less reliable.
How do you assess a CXR?
[DRABCDE]
Demographics: Right patient?
Rotation: Correct alignment/Positioning/Penetration?
Airway: Trachea central?
Breathing: Collapse or consolidation
Circulation: Hilum, aorta dilated e.g. dissection? Cardiac size (<50% thoracic width)
Diaphragm: Costophrenic angles / Air under diaphragm
Everything else: Bones / Foreign bodies.
What investigation would you do if you suspect an aortic dissection? What is the recommended treatment for Type A and Type B Stanford dissections?
CT angiogram (Gold standard)
Type A (ascending aorta): Surgery Type B (descending aorta): Usually medical
[NB: Aortic dissection = a tear in intima of the aorta. Tearing central chest pain radiating to the back]
How many anterior ribs should you normally see on a PA CXR?
6 ribs (If more then its hyperinflation e.g. emphysema)
What is blunting of the costophrenic angles a sign of?
Pleural effusion
What is the typical daily requirement for Na+, K+ and Cl-?
2-4mmol/kg for each
What electrolytes are contained in Hartmann’s solution?
Na+ 131 mmol/L
K+ 5 mmol/L
Cl- 111 mmol/L
Ca2+2 mmol/L
What is the maximum rate at which potassium can be administered?
10 mmol/hr
[Risk of cardiac arrhythmias]
How often should fluid boluses of 500mls be given to patients who are acutely unwell?
Up to 2000ml can be given this way.
500ml over 15 mins each time.
If this fails, escalate as may need ionotropes.
What is the difference between Group and Save and Cross match?
G&S: Tests blood for ABO, RhD and common RBC antibodies.
Cross-match: Same as G&S + tests for common blood product antibodies. This is used in an emergency setting.
What is the normal rate of the ECG? What does one large square represent?
25mm/second
One large square = 0.2seconds and 0.5mV
What is the normal PR interval?
3-5 small squares
120 - 200 ms
What is the normal width of the QRS?
3 small squares
120 ms
What amount of ST elevation is considered pathological?
> 1mm in limb leads
>2mm in chest leads
Give two assessments you would do as part of D of the ABCDE check?
Disability:
- AVPU/GCS
- Blood glucose
- Pupils (reaction to light)
[Lack of reaction could suggest brainstem pathology e.g. raised ICP]
Give two assessments you would do as part of E in the ABCDE check?
Exposure/Examinations:
- Blood tests (FBC, U&E, Troponin, BNP, blood cultures)
- Imaging (X-ray, CT, angiography)
- Endoscopy
Give two signs of a tension pneumothorax
Tracheal deviation (Away)
Hyperinflation (ipsilateral)
Hyperresonant to percussion
Reduced/no air entry
Where should you insert the needle, to decompress a tension pneumothorax?
2nd ICS mid clavicular line
[“Thoracostomy”] - Gold standard treatment.
A Chest tube thoracostomy afterwards in HDU is a more permanent solution (4th ICS Anterior Axillary line).
A recurrent leak in the lungs can be fixed by video-assisted thoraoscopy and stapling + Pleurodesis (sticks the lung to the chest wall to prevent pneumothorax).
What score system would you use to assess the severity of a patient with pneumonia?
CURB-65
Confusion Urea >7mmol/L Resp Rate >30 Blood Pressure <90/<60 >65yo
2+ consider hospital admission
A patient with pneumonia has sats on 89% on air, how would you administer O2?
High flow O2 via a non-rebreathe mask
Name two common causative organisms for community and hospital pneumonia?
Community:
- Strep pneumoniae (most common)
- Haemophilus influenzae
- Staph aureus
- Mycoplasma pneumoniae
Hopsital:
- Pseudomonas Aeruginosa
- MRSA
A patient comes in with exacerbation of COPD and sats of 89%. How do you manage them?
Venturi mask O2 (88-92%)
Give salbutamol, ipratropium via nebuliser
Oral prednisolone
Ix: ABG / CXR / Sputum microscopy + culture / Urine antigens
What type of drug is ipratropium?
Short Acting Muscarinic Antagonist [SAMA]
What is COPD?
Irreversible
Progressive
Airway obstruction
FEV1:FVC <70% predicted
What are the two types of COPD and how do they differ pathophysiologically?
Emphysema and Chronic bronchitis
Both involve chronic inflammation of the lungs. In emphysema this results in elastin breakdown and loss of alveoli.
In chronic bronchitis it results in cillary dysfunction, goblet cell proliferation and increased mucus production.
A patient is having an asthma attack with sats of 92% on air. How would you manage them? What investigations would you do?
O2 via non-rebreathe mask
Nebulised salbutamol + ipratropium
Oral prenisolone or IV Hydrocortisone
Ix: ABG / CXR / Peak expiratory flow / ECG
[Give TTO meds and ref to GP in 2 weeks for review]
You suspect a patient of having a PE (desaturating, chest pain, tachypnoeic post surgery etc). What investigations would you do? Give three. What treatment would you start him on?
ABG CXR Clotting screen ECG Cardiac monitor Echocardiogram CTPA
[DDimer only if low suspicion to rule out a VTE]
Tx:
Medium risk: LMWH/Warfarin or DOAC
High risk: Thrombolysis
True or false, rivaroxaban is contraindicated in active cancer or renal failure?
True.
Warfarin is a better alternative in these situations
In CPR how many compressions and breaths do you do?
30 compressions to 2 breaths.
2 breaths administered via a bag-valve mask.
Post intubation patient can be ventilated with 10-12 breaths per minute.
How often should the defibrillator be used when doing CPR?
Every 2 minutes. Check signs of life. Then shock.
Inbetween:
Cycles of 30 compressions / 2 breaths [repeat]
(Keep track of cycle number)
After 3rd shock:
IV adrenaline (repeat every 3-5 minutes after)
IV Amiodarone
What are the two shockable rhythms when using a defibrilator in CRP?
What are the two “non-shockable rhythms”
Shockable:
Pulseless Ventricular Tachycardia
Ventricular Fibrillation
Non-Shockable:
Pulseless electrical activity (activity but no contraction)
Asystole (sign of clinical death)
[NB: With non-shockable you still administer 1mg IV adrenaline every 3-5 minutes]
A patient comes in with a sudden increased BP of 212/140 in both arms. What investigations do you do and what immediate management do you give?
Ix: (Look for end organ damage) Urinalysis (haematuria & albumin-creatinine ratio) Fundoscopy (haemorrhage, papilloedema) ECG (arrhythmia or LVH) U&E
Tx:
ACEi
Diuretics (Thiazide)
CCB e.g. nifedipine, diltiazem
IV nitroprusside or labetalol if severely unwell!
[Caution! Lowering BP too quickly can cause rebound hypotension or a stroke]
What is the gold standard investigation for DVT?
B mode venous compression US
What treatment should a patient with DVT be given?
LMWH then warfarin long term
What do the following suggest:
- Pink frothy sputum
- Rusty sputum
Pink frothy = Pulmonary oedema
Rusty = Pneumonia
What antibiotic would you typically prescribe in a patient with community acquired pneumonia?
Amoxicillin + Erythromycin (or clarithromycin)
What is the treatment for pneumocystis jiroveci?
IV co-trimoxazole + IV steroids if deteriorates
[Ref to HIV specialist]
CXR- B/L perihilar shadowing
True or false, amiodarone can cause hypo or hyperthyroidism?
True.
What is the treatment of a thyroid storm?
Cool patient (sponge/fan) Beta blockers e.g. propanolol IV fluids Hydrocortisone IV Propylthiouracil Potassium iodide (blocks thyroxine synthesis)
What is the treatment for a hypertensive crisis (HTN, nausea, vomiting,headache)?
IV bolus Labetolol (requires senior supervision).
High flow oxygen. Admit to HDU.
[Invasive BP monitoring via an arterial line can be done]
What is the threshold for severe hypertension?
> 180 systolic
>110 diastolic
What is the difference between Hypertensive urgency and Malignant Hypertension?
Both are above 180/110 (eithersystold or diastolic).
However, malignant involves end organ damage brain, eyes, kidneys.
Give two investigations you would carry out for a patient with hypertensive crisis
Urinary protein-creatinine ratio + Dip for haematuria 24hr urine catecholamines/metanephrines Urinary cortisol Dexamethasone suppression test HbA1c Lipid profile Renin-aldosterone levels
What is the Dexamethasone suppression test for?
Assesses adrenal function by measuring cortisol levels following dexamethasone suppression. This test is frequently used in diagnosing Cushing’s syndrome.
What initial treatment is given in aortic dissection?
IV labetolol (to reduce BP) IV morphine Surgical intervention (typically for stanford type A)
Give two risk factors for aortic dissection
Marfan's Ehler's Danlos Syndrome HTN Smoking Hyperlipidemia
What investigations would you perform in a patient with acute heart failure?
ECG ABG BNP CXR Echocardiogram Troponin
What is the acute management of a patient with acute heart failure?
High flow O2 Sit them upright Furosemide Nitrates Morphine
Once stable:
ACEi
BBlockers
Thromboprophylaxis
A patient has had an MI, and requires a coronary angiogram + PCI, however this will be delayed. What drug should you give them?
Thrombolysis - Alteplase
PCI delayed if longer than 2 hours from onset
What is the GRACE score?
6 month risk of mortality in patients with ACS
If NSTEMIC above 1.5% then dual antiplatelet therapy (clopidogrel + ticagrelor). If abover 3% then coronary angiography and PCI.
What ECG change shows a posterior MI?
ST depression in septal / anterior chest leads.
What constitutes fast AF?
It does not refer to the rate (misnomer). It refers to patients presenting with palpitations and dyspnoea.
(All AF is irregular and tachycardic).
Give two causes of AF
[PIRATES]
PE Ischaemia Respiratory disease Atrial enlargement Thyroid disease Ethanol Sepsis
How do you manage AF?
If haemodynamically unstable: (low BP / reduced consciousness etc): Electrical cardioversion (DC).
If haemodynamically stable then:
Rate control: BB, CCB or Digoxin.
Rhythm control: Amiodarone, Flecanide
Anticoagulation: Warfarin or DOAC (apixaban)
[NB: Digoxin increases cardiac output while reducing rate and is often preferred in elderly patients or patients at risk of hypotension].
What is the treatment for bradycardia?
If patient is severely symptomatic fatigue, dizzy, difficulty breathing, haemodynamically compromised with a HR <40 then give a muscarinic antagonist ATROPINE or beta-agonist e.g. ISOPRENALINE
[Both these drugs require senior supervision]
Pt. may require transcutaneous pacing and eventually a permanent pacemaker
How do you diagnose and treat cardiac tamponade?
CXR - large cardiac silhouette with pulmonary oedema
High flow O2
IV fluids
Pericardiocentesis under US guidance
Ionotropes e.g. dobutamine
[Involve seniors as its a medical emergency]
Give a common cause of cardiac tamponade?
Cancer (esp. lung) Trauma Infection (HIV, TB) SLE CKD Hypothyroidism
What is the management for an acute upper GI bleed?
2 x large-bore cannulae IV fluids (30ml/kg saline/hartmans) O2 ECG CXR Crossmatch 4-6 U RBC ABG LFT Clotting screen
NBM IV fluid replacement (blood/crystalloid) Urinary catheter to monitor fluid balance Terlipressin infusion prior to OGD Prophylactic antibiotics OGD + banding/sclerotherapy PPI TIPSS (long term if varices)
[Sengstaken-Blakemore tube if severe bleeding and OGD is delayed].
What are the Blatchford and Rockall scores?
Assess bleeding risk in patients with acute upper GI bleeds.
Blatchford is done prior to endoscopy
Rockall is done after endoscopy
Give two common causes of an upper GI bleed
Peptic ulcer
Oesophageal varices
Mallor-weiss tear
Oesophagitis/gastritis/duodenitis
Give two common causes of pancreatitis
[GET SMASHED]
Gallstones (50% of cases) Ethanol (20% of cases) Trauma Steroids Mumps Autoimmune Scorpion stings Hypercalcaemia ERCP Drugs (diuretics, metronidazole, azathioprine)
What scoring system is used to assess the severity of pancreatitis?
Modified Glasgow Criteria
PaO2 Age Neutrophils Calcium Renal function Albumin Blood glucose Enzymes (LDH, AST)
What are the sepsis six
[BUFALO] - All must be done with in an hour
Blood cultures Urine output (hourly) Fluids IV (Saline or Hartmann's) Antibiotics Lactate Oxygen (high flow)
What is sepsis and what scoring tool can be used to identify it? What is septic shock?
Dysregulated response to a pathogen resulting in organ dysfunction.
Sequential Organ Failure Assessment (SOFA)
- Systolic BP <100mmHg
- Altered mental state / GCS <15
- Respiratory rate 22+
[2+ = confirmed likely sepsis]
Shock:
Peristent hypotension despite fluids/vasopressor
A lactate of > 2mmol/L
What is the treatment of chronic liver ascites?
Fluid restriction (<1.5L/day) Low salt diet (40-100mmol/day) Spironolactone Paracentesis + albumin infusion TIPSS Liver Transplant
What is the gold standard investigation for a toxic megacolon?
CXR (checks for perforation)
CT abdo/pelvis
Give two common causes of toxic megacolon
IBD (UC/Crohn’s/pseudomembranous colitis)
Gastroenteritis infective: salmonella, shigella
Ischaemic colitis
Radiation colitis
Secondary to chemotherapy
How is toxic megacolon managed?
IV fluids Broad spectrum IV antibiotics IV steroids NG tube (decompression) Monitor (Xray every 12 hours)
Urgent colectomy indications:
- Free perforation
- Massive haemorrhage
- Progression of dilatation
- No improvement in 24-72 hrs on medication
What criteria are used to assess the severity of ulcerative colitis?
Truelove & Witts (assesses flare up severity)
Motions/day Rectal bleeding Resting pulse Hb ESR
[Mild / Moderate / Severe]
What are the advantages of VBG over ABG?
Faster
Less painful
Lower risk of complications e.g. arterial damage
What is a FAST scan?
Focused Assessment with Sonography in Trauma
Bedside US used in emergency cases e.g. pericardial efusion or organ trauma e.g. splenic rupture.
When is the Hospital’s Major Haemorrage Protocol activated?
> 5L blood loss (70kg person) / 70ml/kg loss in 24hrs
OR
150ml/min
Give two methods of treating a splenic rupture
Active observation if small
Angioembolisation (mechanical or chemical)
Splenectomy
True or false, patients who have had a splenectomy must be on lifelong antibiotics?
True. The spleen detects defective WBC as well as RBC and produces opsonins, complement and other immune components.
[They have increased susceptibility to bacterial infection and may also have a reduced response to some vaccines. They require Flu, Hib and Men vaccines]
A patient presents with sudden onset abdominal pain radiating to the back and fainting. You suspect a AAA may be the cause. He is haemodynamically unstable, what do you do?
FAST scan (may show free fluid in the abdomen) If suspicion is high and they are unstable then straight to surgery for a repair.
- Open surgical replacement (prosthetic graft)
- Endovascular Aneurysm Repair (EVAR): stenting via femoral arteries (aneurysm then thromboses).
[Only CT if they are stable!]
What diameter of dilatation is diagnostic for an abdominal aortic aneurysm (AAA)?
> 3cm (or >50% of the normal expected diameter)
[NB: Aortic aneurysm are either thoracic or abdominal]
How often is AAA monitored?
US scan (all men over 65)
Diameter 3 - 3.9cm every 3 years
Diameter 4 - 4.4cm every 2 years
Diameter 4.5 - 5.4cm every year
Give two risk factors for AAA
FHx HTN Male sex Smoking Hyperlipidemia Obesity
How to you confirm your supsicion of a strangulated inguinal hernia?
Abdominal Xray
Abdominal CT
[NBM]
What is a hernia? Give two risk factors
Protrusion of viscus through its containing cavity e.g. peritoneum through the abdominal wall.
Chronic cough Constipation Obesity Surgery Heavy lifting/strain
What is the most common kind of hernia?
Indirect inguinal (80% of inguinal hernias)
[Deep then superficial ring through the inguinal canal]
Give two common causes of viral and bacterial meningitis
Viral (most common)
- Enteroviruses
- Coxsackie virus
- Echo virus
- Influenza
- Mumps
Bacterial:
- Neisseria meningitidis
- Haemophilus influenzae
- Listeria monocytogenes
What is the difference between meningitis, encephalitis and meningococcal disease?
Meningitis = inflammation of the meninges
Encephalitis = inflammation of the brain parenchyma
Meningococcal disease = disease caused specifically by neisseria meningitidis (G -ve diplococcus)
What imaging study must you perform in a patient you suspect of meningitis prior to a lumbar puncture?
CT head to exclude a mass effect which could result in coning
What is the initial empirical antibiotic for bacterial meningitis in adults?
Ceftriaxone
[Chloramphenicol if penicillin allergy]
A patient comes in who you suspect has meningitis. What investigations would you perform?
Bloods (FBC, U&E, CRP, glucose, clotting, lactate) Blood cultures (within 1 hr) Urine microbiology ECG (sinus tachy) CT head (mass effect?) Lumbar puncture (if CT clear!)
In infants with bacterial meningitis, what antibiotics would you use?
Cefuroxime + Amoxicillin (to cover listeria)
A patient presents with colicky bilateral flank pain, what diagnosis should you assume until proven otherwise?
Abdominal aortic dissection/aneurysm
True or false, a blood pressure of >220/130 is a contraindication to thrombolysis?
True
What does the Rosier score assess?
Recognition of Stroke in the Emergency Room
Loss of consciousness Acute onset Asymmetric facial weakness Asymmetric leg weakness Speech disturbance Visual field defect
Score >0 means stroke is likely.
Following a stroke and CT head to rule out haemorrhage, what drug should be given to a patient within 4.5hrs of admission?
Tissue plasminogen activator (TPA e.g. Alteplase)
Give two contraindications for thrombolysis?
Recent surgery Recent trauma Platelets <100 x 109/L INR >1.7 Severe hypertension Intracranial malignancy Known bleeding disorder
What is the Bamford (AKA Oxford) classification?
Categorises ischaemic stroke based on the presenting symptoms/clinical signs.
1) Total Anterior Circulation Infarct (TACI) [must have all 3]
- Unilat weakness (face/arm/leg)
- Homonymous Hemianopia
- Dysphasia/Dysarthria
2) Partial Anterior Circulation Infarct (PACI) [2 of]
- Unilat weakness face/arm/leg
- Homonymous hemianopia
- Dysphasia/dysarthria
3) Posterior Circulation Infarct (PCI) [One of]
- Cerebellar/brainstem syndrome
- Loss of consciousness
- Homonymous Hemianopia
4) Lacunar Syndrome (LACS)
- Pure motor
- Pure sensory
- Ataxic hemiparesis
What is status epilepticus?
> 30mins seizure or repeated episodes of seizure without the patient regaining consciousness in between
Give two complications of status epilepticus
Hypoxia Lactic acidosis Rhabdomyolysis Raised ICP Hyper/Hypotension Hypoglycaemia
A patient presents with colicky bilateral flank pain, what diagnosis should you assume until proven otherwise?
Abdominal aortic dissection/aneurysm
True or false, a blood pressure of >220/130 is a contraindication to thrombolysis?
True
What does the Rosier score assess?
Recognition of Stroke in the Emergency Room
Loss of consciousness Acute onset Asymmetric facial weakness Asymmetric leg weakness Speech disturbance Visual field defect
Score >0 means stroke is likely.
Following a stroke and CT head to rule out haemorrhage, what drug should be given to a patient within 4.5hrs of admission?
Tissue plasminogen activator (TPA e.g. Alteplase)
Give two contraindications for thrombolysis?
Recent surgery Recent trauma Platelets <100 x 109/L INR >1.7 Severe hypertension Intracranial malignancy Known bleeding disorder
What is the Bamford (AKA Oxford) classification?
Categorises ischaemic stroke based on the presenting symptoms/clinical signs.
1) Total Anterior Circulation Infarct (TACI) [must have all 3]
- Unilat weakness (face/arm/leg)
- Homonymous Hemianopia
- Dysphasia/Dysarthria
2) Partial Anterior Circulation Infarct (PACI) [2 of]
- Unilat weakness face/arm/leg
- Homonymous hemianopia
- Dysphasia/dysarthria
3) Posterior Circulation Infarct (PCI) [One of]
- Cerebellar/brainstem syndrome
- Loss of consciousness
- Homonymous Hemianopia
4) Lacunar Syndrome (LACS)
- Pure motor
- Pure sensory
- Ataxic hemiparesis
What is status epilepticus?
> 30mins seizure or repeated episodes of seizure without the patient regaining consciousness in between
Give two complications of status epilepticus
Hypoxia Lactic acidosis Rhabdomyolysis Raised ICP Hyper/Hypotension Hypoglycaemia
What drug should be given to patients with a subarachnoid haemorrhage to prevent rebleeding and cerebral iscahemia?
Oral Nimodipine
Reduces cerebral vasospasm
Following a head CT after a head trauma, what might xanthochromia of the CSF indicate?
Xanthochromia is the presence of bilirubin in the CSF. This is a major indicator of blood in the CSF and therefore of a subarachnoid bleed. You can see it visually.
True or false, patients who go on to have a thunderclap headache of a subarachnoid bleed, often have “herald bleeds” in the days/weeks before where they have distinct severe headaches?
True
What is the most common cause of a subarachnoid bleed?
Ruptured aneurysm (70%)
Idiopathic (20%)
Arterio-venous malformations (5%)
What scale is used to assess the prognosis of subarachnoid haemorrhages?
Hunt & Hess Scale
(Grade 1-5)
1) Asymptomatic, mild headache [70% survival]
2) Neck stiffness, moderate headache, no neurological deficits [60% survival]
3) Drowsy [50% survival]
4) Stuporous, hemiparesis [20%]
5) Coma, decerebrate rigidity [10%]
True or false, in addition to IV mannitol, hyperventilation is a means of reducing ICP?
True
Give two indications for someone having a CT scan following a head injury
[Scan within ONE hour if…]
GCS <13 initially GCS <15 2 hours post injury Suspected skull fracture Any base skull fracture signs Seizure Focal neurological deficit >1 episode of vomiting
[Within 8 hours if]
>65yo
Hx bleeding/clotting disorder
>30 mins of retrograde amnesia
True or false, patients who have had a minor head injury who live alone can be discharged home?
False.
You need to safety net them and they need to be supervised in case of complications.
If a diabetic patient is severely hypoglycemic and unable to swallow what is the treatment?
IV glucose 200ml of 10% glucose or 100ml of 20% glucose STAT
If no IV access then 1mg glucagon IM while obtaning IV access
If they can swallow then give sugary drink or glucose gel followed up with a sandwich/toast.
What are the normal ranges for blood glucose? Fasting and post prandial
4-7mmol/L (Fasting)
7.8-11.1 mmol/L (2hrs post prandial )
Give two common causes of hypoglycaemia
Excessive insulin
Oral hypoglycaemics e.g. sulfonylureas
Alcohol
[Rare: Addison’s, Pituitary insufficiency, Pancreatic tumours]
How is DKA confirmed?
Blood glucose + VBG
- Low pH <7.3
- Hyperglycemia
- High blood ketones
What HbA1c is diagnostic of DM?
> 48 mmol/L
>6.5%
How do you differentiate Hyperosmolar hyperglycemic state from DKA?
Patients with HHS are not acidotic and their osmolality is >320 mosmol/kg + raised Na+
How do you treat Hyperosmolar Hyperglycemic state?
Slow rehydration with 0.9% NaCl over 2 days
DVT prophylaxis (LMWH)
Replace K+
Consider insulin when the fall in glucose has plateaued
A patient is having a thyroid storm, what is the treatment?
Paracetamol (for pyrexia)
Beta blocker e.g. propanolol (or CCB if contraindicated)
Digoxin
Carbimazole
Hydrocortisone (reduces peripheral conversion of T4 to T3)
Give two triggers of a thyroid storm
Abrupt withdrawal of anti-thyroid meds
Radioiodine
Stressor (sepsis, trauma, MI)
Grave’s
Toxic adenoma
Viral thyroiditis (De Quervain’s thyroiditis)
Drugs (lithium, amiodarone, levothyroxine etc).
What investigations would you do to confirm adrenal insufficiency?
Short Synacthen test (ACTH stimulation test): measure serum cortisol 30mins after.
Blood glucose (low due to glucocorticoid deficiency)
Electrolytes (low Na high K+ due to reduced aldosterone)
Give two causes of adrenal insufficiency
Autoimmune destruction (most common in UK)
TB (most common world wide)
Adrenal mets
Infection
Long term steroids
Adrenal haemorrhage
How do you treat adrenal insufficiency?
Hydrocortisone + fludrocortisone
[Prevent it by sick day rules on steroids (increased dose when ill)]
What is the treatment for hyperkalaemia?
Calcium glucoronate 10ml 10%
Insulin-glucose infusion
Nebulised salbutamol
How is AKI diagnosed?
Creatinine raised >26 umol/L in 48hr
Creatinine raised >1.5 baseline
Urine output <0.5mL/kg/hr for 6 consecutive hours
[One is sufficient]
[KDIGO classification is based on these for staging].
How do you treat hyponatraemia?
0.9% saline
Max rate of 10-15 mmol/L per day
Risk of Central Pontine Myelinolysis (CPM) [irreversible demyelination of the pons] if done too quickly!
[Should be managed in the ITU if needs to bemore rapid]
How do you manage neutropenic sepsis?
Broad specrum Abx e.g. IV piperacillin + Tazobactam or meropenem.
[Neutropenic sepsis is an oncological emergency]
What is a +ve Babinski sign indicative of?
AKA “upgoing plantars”
UMN lesion specifically of the cortico spinal tract
[Normal in babies under 2yo]
A patient with cancer comes in complaining of weakness in his legs and anuria. What do you suspect? How do you manage them?
Spinal cord compression
Urgent MRI spine
IV Dexamethasone or methylprednisolone
Analgesia if required
Surgery if needed / Targeted radiotherapy
How do you treat hypercalcaemia?
Rehydration
Bisphosphnates (take 2-4 days to work; slow bone resorption)
Furosemide (increase calcium excretion)
Calcitonin (fast acting) reducing bone resorption
