Initial Treatments

Question 1

ACC

Acute STEMI

Answer 1

MONAT (Morphine, Oxygen, Nitrates (GTN spray), Aspirin 300mg, Ticagrelor/clopidogrel)

PCI if within 120 minutes of admission

Question 2

ACC

Acute NSTEMI/Unstable angina

Answer 2

Fondaparinux/LMWH, Aspirin 300mg,
Morphine/nitrates, Ticagrelor/clopidogrel

Question 3

ACC

Massive PE (Hypotension and/or cardiac arrest)

Answer 3

Alteplase

Plus high flow O2 and IV fluids

Question 4

ACC

Sub-massive PE (Hypoxia, right heart strain, +ve cardiac biomarker)

Answer 4

LMWH heparin/fondaparinux

High flow O2 and IV fluids

Question 5

ACC

Acute Pneumonia

Answer 5

Abx (usually amoxicillin), O2, IV fluids, VTE prophylaxis, Analgesia

Question 6

ACC

Cellulitis with systemic upset

Answer 6

IV Antibiotics -usually flucloxacillin+benzylpenicillin, or co-amoxiclav

Question 7

ACC

DKA

Answer 7

IV infusion 0.9% saline (add potassium chloride if needed with K+ results), IV insulin 0.1 units/kg/hr, IV 5% Dextrose once CBG <15mmol/L

Switch to SC insulin once stable

Question 8

ACC

Hypoglycaemia

Answer 8

Quick acting carbohydrate (glucose based), then long-acting carbohydrate

If unconscious and cannot get IV access, use IM glucagon

Question 9

ACC

Prolonged hypoglycaemic coma

Answer 9

IV mannitol + dexamethasone + IV glucose

Question 10

ACC

Paracetamol overdose

Less than 1 hour

Answer 10

Give charcoal

Test paracetamol levels at 4 hours

Question 11

ACC

Paracetamol overdose

4-8 hours

Answer 11

Check levels, then if treatment needed, IV N-acetyl cysteine (glutathione replacement) in 5% glucose

Use TOXBASE

Question 12

ACC

Paracetamol overdose

8-15 hours

Answer 12

IV N-acetyl cysteine (glutathione replacement) in 5% glucose, stop if tests come back normal

Use TOXBASE

Question 13

ACC

Paracetamol overdose

15+ hours

Answer 13

IV N-acetyl cysteine (glutathione replacement) in 5% glucose, give full treatment

Stop based on clotting factors, use TOXBASE

Question 14

ACC

Delirium tremens

Answer 14

Correct electrolyte abnormalities, treat co-morbidities, give parenteral thiamine, prophylactic carbamazepine and chlordiazepoxide

Question 15

ACC

Acute alcohol withdrawal

Without delirium tremens, with other concerning features

Answer 15

Benzodiazepines (usually chlordiazepoxide) and Pabrinex (prophylactic treatment for thiamine deficiency)

Question 16

ACC

Sepsis

Answer 16

BUFALO - (blood cultures), (urine output), fluids, antibiotics, (lactate) and oxygen

Question 17

ACC

Anaphylactic shock

Answer 17

IM adrenaline 500mcg, IV chloramphenamine 10mg, IV hydrocortisone 200mg, fluid bolus, nebulised salbutamol 5mg if wheezy

Question 18

ACC

Haemorrhagic/hypovolaemic shock

Answer 18

IV access, fluid bolus +/- blood, high flow O2, treat cause

Question 19

ACC

Neurogenic shock

Answer 19

Vasoconstrictors

Question 20

ACC

Sepsis

Answer 20

STOP AKI - treat sepsis, stop nephrotoxins, optimise BP, prevent harm (treat complications), review medications

Question 21

ACC

Hyperkalaemia

Answer 21

IV calcium gluconate in large vein over 2 mins, IV insulin/dextrose infusion, nebulised salbutamol

Question 22

ACC

Pulmonary oedema

Answer 22

Sit up and give high flow O2, IV morphine, furosemide

Urgent haemodialysis if no response

Question 23

ACC

Acute bleeding

Answer 23

Fresh frozen platelets if clotting issue, blood transfusion, desmopressin

Question 24

ACC

Delirium

Answer 24

Treat underlying cause

Some sedation may be used if disruptive or very distressed (haloperidol)

Question 25

# ACC Acute exacerbation of COPD

Answer 25

Manage O2 88-92%, brochodilators (salbutamol and ipratropium), prednisolone 30mg oral, oral abx if indicated (usually amoxicillin, clarithromycin) | Assess need for non-invasive ventilation (NIV)

Question 26

# ACC Subarachnoid haemorrhage

Answer 26

Maintain SpO2, analgesia/antiemetics, manage hypertension, PO or IV nimodipine, IV mannitol | Contact neurosurgical team

Question 27

# ACC Hyponatraemia with mild symptoms

Answer 27

Fluid restriction | Identify cause

Question 28

# ACC Hyponatraemia with seizures or signs of raised ICP

Answer 28

Give up to 200mL of 2.7% saline over 30 minutes Vasopressor receptor antagonists | <120mmol/L associated with risk of brain herniation

Question 29

# ACC Hyperkalaemia

Answer 29

IV 30mL 10% calcium gluconate (with ECG changes), 10 units actrapid insulin with 50mL of 50 glucose via large vein, calcium resonium/loop diuretics/dialysis

Question 30

# ACC Hypocalcaemia

Answer 30

IV replacement - calcium gluconate 10mL over 10 minutes | ECG monitoring

Question 31

# ACC Hypercalcaemia

Answer 31

Rehydrate with saline Bisphosphonates/calcitonin

Question 32

# ACC Aortic dissection

Answer 32

Maintain oxygen, cross match, morphine, labetolol | Get cardiothoracic team and an HDU or ICU bed. Aim for BP 100-120mmHg

Question 33

# ACC Pericarditis

Answer 33

NSAIDs + PPI, cessation of potential causative drugs, avoid anticoag, antimicrobials | Admit with high temp, leucocytosis, tamponade, immunosuppressed etc.

Question 34

# ACC Pneumothorax | Non-tension

Answer 34

Chest drain and oxygen if needed | Surgery if bilateral or lung fails to expand

Question 35

# ACC Tension pneumothorax

Answer 35

Needle decompression, 2nd ICS MCL | Always insert chest drain immediately after

Question 36

# ACC Opiate overdose

Answer 36

Naloxone (may require multiple doses) & respiratory support | Consult TOXBASE

Question 37

# ACC Tricyclic antidepressant overdose

Answer 37

No reliable antidote IV bicarb, IV lipid emulsion, treat symptoms | Consult TOXBASE

Question 38

# ACC Stroke

Answer 38

Correct hypoglycaemia, maintain O2, Aspirin if haemorrhage excluded | Admit to stroke unit asap

Question 39

# ACC TIA

Answer 39

300mg aspirin immediately, clopidogrel long-term, no driving until seen by specialist | Aspirin may contraindicated (bleeding disorder, anticoagulatants)

Question 40

# ACC Acute exacerbation of asthma | Moderate or severe

Answer 40

Sit pt up, 15L high flow O2, nebulised salbutamol 5mg, ipratropium bromide 500mcg, IV hydrocortisone 200mg OR PO prednisolone 40mg | Senior can add IV magnesium sulphate, check for pneumothorax & sepsis

Question 41

# ACC Asthma | Life threatening

Answer 41

Back to back salbutamol, consider IV amiophylline (senior), IV salbutamol | Contact critical care outreach team, follow ALS in cardiac arrest

Question 42

# ACC Seizures | First fit

Answer 42

Maintain airway, manage conservatively. Consider rectal diazepam, buccal midazolam or IV lorazepam | Most self-limiting and stop spontaneously

Question 43

# ACC Status epilepticus

Answer 43

Maintain airway + 15L O2, IV lorazepam* 1-2mg slow bolus (or 10mg diazepam, phenytoin IV 20mg/kg, thiamine for alcohol/malnutrition cause, IV magnesium sulphate for pregnancy related | *if no IV access, use buccal midazolam/rectal diazepam

Question 44

# GOSH Nausea and vomiting in pregancy | Minor

Answer 44

Eat small meals, increase fluids, acupressure, antiemetics

Question 45

# GOSH Reflux in pregnancy

Answer 45

Sleep propped up, avoid spicy food, alginates/antacids, H2 receptor antagonists

Question 46

Constipation in pregnancy

Answer 46

Increased fruit and fibre intake, water, fibre supplements, osmotic laxatives

Question 47

# GOSH Symphis pubic dysfunction in pregnancy

Answer 47

Physiotherapy, simple analgesia, limited leg abduction at delivery

Question 48

# GOSH Backache and sciatica in pregnancy

Answer 48

Adjust sleeping position, relaxation, massage, physiotherapy, analgesia

Question 49

# GOSH Carpal tunnel syndrome in pregnancy

Answer 49

Sleeping with hands over bedside, splints, ?surgical referral

Question 50

# GOSH Haemorrhoids in pregnancy

Answer 50

Avoid constipation, ice packs, digital reduction, suppositories | Surgical referral if thrombosed

Question 51

# GOSH Varicose veins in pregnancy

Answer 51

Regular exercise, compression, hosiery, consider VTE prophylaxis

Question 52

# GOSH Urinary symptoms in pregnancy

Answer 52

Avoid caffeine, avoid late fluid at night

Question 53

# GOSH Vaginal discharge in pregnancy

Answer 53

Exclude STI & rupture of membranes Reassure that it is normal

Question 54

# GOSH Acute fatty liver of pregnancy

Answer 54

Stabilise & treat symptoms Delivery is definitive management

Question 55

# GOSH Itching and rashes in pregnancy

Answer 55

Exclude infectious causes Check for obstetric cholestasis - treat with ursodeoxycholic acid for symptoms, induce at 37 weeks Otherwise emollients and reassurance

Question 56

Hyperemesis gravidum

Answer 56

Often reassurance and simple advice sufficient If dehydrated and not tolerating oral fluids, requires admission, check serum electrolytes and LFTs, IV hydration, antiemetics (promethazine 1st line) | If prolonged, may require vitamin supplements, particularly thiamine

Question 57

# GOSH Small for gestational age | Dopplers normal

Answer 57

Carry out growth scans every 2-3 weeks, aim for IOL at 37 weeks

Question 58

# GOSH Small for gestational age | Dopplers abnormal & baby-pre-term

Answer 58

Consider delivery, give steroids

Question 59

# GOSH Prolonged pregnancy

Answer 59

Offer 'stretch and sweep' at 41 weeks