Emergency Presentations

Question 1

What is included in the A section of the primary survey?

Answer 1

Stabalising the C spine
Assess for any signs of obstruction - is the airway patent
Management - jaw thrust/chin lift or use airway adjuncts to establish an airway

Question 2

What is included in B of the primary survery?

Answer 2

Assess to determine respiratory rate, check for bilateral chest movement, percuss, auscultate
Management: If no resp effort then treat as cardiac arrest, intubate and ventilate. If breathing compromised then give high flow O2 and manage according to findings e.g. relieve tension pneumothorax

Question 3

What is included in C of the primary survey?

Answer 3

Assessment: check pulse and BP, check if peripherally shut down, check cap refill and for evidence of haemorrhage - if in shock this needs to be treated

Question 4

What is included in D of the primary survey?

Answer 4

Assess the patients level of consciousness with AVPU, check pupils - size, equality and reactions
GCS if time allows

Question 5

What is included in E of the primary survey?

Answer 5

Assess by exposing patient to look for any rashes or bleeding points etc.

Question 6

What red flags do you want to ask for headache and what could they suggest?

Answer 6

First worst headache or thunderclap headache - subarachnoid haemorrhage
Scalp tenderness in over 50s - giant cell arteritis
Head with fever/stiff neck - meningitis

Question 7

What presentation would suggest increased intracranial pressure?

Answer 7

Cough induced headache, made worse by bending forwards

Question 8

What are your differentials for a headache with decreased conscious level?

Answer 8

Stroke
Encephalitis
Subarachnoid haemorhage
Venous sinus occlusion
Tumour
TB meningitis

Question 9

What differentials does wheezing suggest?

Answer 9

Asthma
COPD
Heart failure
Anaphylaxis

Question 10

What differentials does stridor suggest?

Answer 10

Upper airway obstruction:

• Foreign body or tumour
• Acute epiglottitis (younger patients)
• Anaphylaxis
• Trauma e.g. laryngeal fracture

Question 11

What differentials does crepitations suggest?

Answer 11

Heart failure
Pneumonia
Bronchiectasis
Fibrosis

Question 12

What respiratory differentials does a clear chest suggest?

Answer 12

Pulmonary embolism
Hyperventilation
Metablic acidosis e.g. diabetic ketacidosis
Anaemia
Shock

Question 13

What are the key emergency respiratory investigations?

Answer 13

OBS - o2 sats, pulse, temperature, peak flow
ABG if sats <94%
ECG
CXR
Baseline bloods

Question 14

What are the main life threatening chest pain differentials?

Answer 14

MI
Angina/Acute coronary syndrome
PE
Oesophageal rupture
Tension pneumothorax
Aortic dissection

Question 15

What are the metabolic causes of coma?

Answer 15

Drugs, poisoning e.g. carbon monoxide
Hypoglycaemia
Hypoxia, CO2
Septicaemia
Hypothermia
Addisonian crisis
Hepatic/ureamic encephalopathy

Question 16

What are the neurological causes of coma?

Answer 16

Infection
Trauma
Tumour
Vascular - stroke
Epilepsy - non convulsive status

Question 17

What is the management of coma?

Answer 17

A-E primary survey
Consider intubation if GCS is less than 8
Protect c spine unless known not to be trauma
Give IV fluids to support circulation if required
Check blood gluose and give 200mL of 10% glucose IV stat if hypoglycaemic
Give naloxone if opioid intoxication
Give flumazenil for benzodiazepine intoxication if airway compromised
Give IV thiamine if there is wernicke’s encephalopathy

Question 18

What are the three categories of the glasgow coma scale?

Answer 18

Best motor response
Best verbal response
Eye opening

Question 19

What are decorticate and decerebrate postures and what do these imply?

Answer 19

Decorticate posture is everything in flexion and implies midbrain injury above the level of the red nucleus
Decerebrate posture is everything in extension and implies midbrain injury below the level of the red nucleus

Question 20

What is shock?

Answer 20

Circulatory failure resulting in inadequate organ perfusion

Question 21

What are the clinical features that define shock?

Answer 21

A systolic BP of less than 90 with evidence of tissue hypoperfusion e.g. mottled skin, urine output <0.5mL/kg/h, serum lactate >2mmol/L

Question 22

What are the signs of shock?

Answer 22

Decreased GCS, Tachycardia, cool peripheries, slow capillary refill, oligouria and tachypnoea

Question 23

What are the two main types of shock?

Answer 23

Inadequate cardiac output

Peripheral circulatory failure (loss of vascular resistance)

Question 24

What are the two types of shock resulting that involve inadequate cardiac output?

Answer 24

Pump failure (cardiogenic shock) - heart not pumping properly
Hypovolaemic shock - there is not enough circulating blood for the heart to pump properly

Question 25

What are some causes of hypovolaemic shock?

Answer 25

Bleeding - trauma, ruptured aneurysm, GI bleed

Fluid loss - vomiting, burns, heat exhaustion

Question 26

What are some of the causes of pump failure in shock?

Answer 26

ACS
Aortic dissection
Arrhythmias
PE
Tension pneumothoorax
Cardiac tamponade

Question 27

What are the causes of peripheral circulatory failure leading to shock?

Answer 27

Anaphylaxis
Sepsis
Neurogenic e.g. spinal cord injury
Endocrine failure e.g. addison's
Drugs e.g. anesthetics, antihypertensives

Question 28

How would you assess a patient you think may be in shock?

Answer 28

A-E approach
Circulatory problem in shock so get 2 large bore cannulae in
Check ECG for rate and rhythm and signs of ischaemia
General review - cold and clammy suggests a cardiogenic or hypoperfusion shock
Warm and well perfused with bounding pulse points to a septic shock
BP can remain normal in the young and fit up to 30% blood loss

Question 29

If a shocked individual has a raised JVP what is the likely cause?

Answer 29

Cardiogenic shock

Question 30

How do you manage a hypovolaemic shocked patient?

Answer 30

Treat according to cause:
-Hypovolaemic - treat underlying cause, raise legs, give fluid bolus 10-15mL/kg crystalloid, if shock improves then repeat - aim for systolic BP over 90

Question 31

How do you manage a haemorrhagic shocked patient?

Answer 31

-Haemorrhagic shock - Attempt to stop bleeding, if still shocked with 2L crystalloid then crossmatch - give FFP with red cells 1:1 ratio, aim for platelets >100 and fibrinogen >1

Question 32

How do you manage a shocked patient from heat exhaustion?

Answer 32

Tepid sponging + fanning, avoid ice

Resuscitate with IVI of 0.9% saline +/- hydrocortisone 100mg IV, get core temp <39degrees

Question 33

What causes anaphylactic shock?

Answer 33

It is a Type 1 IgE-mediated hypersensitivity reaction

Question 34

What are the signs and symptoms of anaphylactic shock?

Answer 34

Itching, sweating, diarrhoea and vomiting, erythema, urticaria, oedema
Wheeze, laryngeal obstruction
Tachycardia, hypotension

Question 35

What is the management of anaphylactic shock?

Answer 35

Secure the airway and give 100% O2
Remove the cause and raise the feet to help improve circulation
Give 0.5mg adrenaline (0.5mL of 1:1000)
Repeat every 5 min until better
Secure IV access
Chlorphenamine 10mg IV and hydrocortisone 200mg IV
IVI saline infusion to increase blood pressure
If wheeze treat for asthma
If still hypotensive - get expert help
Measure serum tryptase 1-6hr after suspected anaphylaxis