Medical

Question 1

1. What is Rx for undifferentiated N/V?

Answer 1

• Ondansetron 4mg ODT, repeat after 5-10mins - if unable to tolerate ODT, or IV in situ, 8mg IV
• C/I to Ondans and ≥21years, Prochlorperazine 12.5mg IM
• If dehydrated:
  < adequate perfusion: NS max 40mL/kg, consult for further or additional 20mL/kg
  Adequate perfusion but significant dehydration: NS 20mL/kg over 30mins

Question 2

2. What is the Rx for Vestibular nausea (motion sickness, aeromedical evac, vertigo)?

Answer 2

If pt ≥21: Prochlorperazine 12.5mg IM, otherwise Ondansetron as per N/V
[Opposite for prophylaxis for immobilised spinal injury or eye trauma]

Question 3

3. What does undifferentiated N/V include:

Answer 3

Secondary to cardiac chest pain, opioid analgesia, cytotoxic drugs/radiotherapy, severe gastro

Question 4

4. What needs to be considered in regards to Ondansetron and Tramadol?

Answer 4

Ondans is antagonist at same site that tramadol is active as analgesic, therefore use prochlorperazine if possible.

Question 5

5. What is the Rx for BGL<4 and responding to commands?

Answer 5

Glucose 15g oral

Inadequate response after 15mins, consider repeat dose, max 30g, or Dextrose IV or Glucagon IM

Question 6

6. What is the Rx for BGL<4 and NOT responding to commands?

Answer 6

IV cannula in large vein and confirm patency

• Dextrose 10% 15g (150mL) and 10mL flush - GCS or BGL not normal after 5-10mins, another 10g (100mL) titrating to effect
• Unable to insert IV - Glucagon 1 IU IM

Question 7

7. What are the clinical features of DKA/HHS?

Answer 7

Dehydration, tachypnoea, polydipsia, polyphagia, polyuria, Kussmaul’s breathing, confusion

Question 8

8. What is the Rx for BGL>11?

Answer 8

Less than adeq perf and clinical features of DKA/HHS - NS 20mL/kg titrated to perfusion status

• consult for further doses, consider reduced vol for elderly or impaired cardiac/renal
• consider antiemetic

Question 9

9. What is the Rx for GCSE?

Answer 9

• Mx airway and ventilation as required, if airway patent high flow O2
• Midazolam 10 mg IM - No response after 10mins - repeat full dose, consult for further
• 5mg for <60kg/elderly/frail (repeat at 5mins)

Question 10

10. What needs to be confirmed prior to Adrenaline administration for Anaphylaxis?

Answer 10

Sudden onset of symptoms (usually <30mins up to 4hrs) AND
≥2 of RASH with or without confirmed antigen exposure
- Respiratory distress (SOB, wheeze, cough, stridor)
- Abdominal symptoms (N/V/D, pain/cramps)
- Skin/mucosal symptoms (hives, welts, itch, flushing, angioedema, swollen lips/tongue)
- Hypotension (or ACS)

OR Isolated hypotension <90 following exposure to known antigen
OR isolated respiratory distress following exposure to known antigen

Question 11

11. What is the Rx for Anaphylaxis?

Answer 11

• Do not allow pt to stand or walk
• Adrenaline 500 mcg IM - repeat at 5mins until satisfactory result/side effects
• Request MICA if risk factors or unresponsive to initial Adrenaline
• Insert IV
• O2
• Stridor: Adrenaline 5mg neb, consult for repeat, notify hospital
• Bronchospasm: Salbutamol 5mg neb or 4-12 doses pMDI (repeat at 20mins) + IB 500mcg neb or pMDI 8 doses + Dexa 8mg IV/Oral
• BP<90 despite adrenaline: NS max 40mL/kg, consult for further or 20mL/kg

Question 12

12. Rx for pt who remain hypotensive after two doses of Adrenaline for anaphylaxis?

Answer 12

Glucagon 1mg IV/IM, repeat once at 5mins - in the setting of pt with phx of heart failure or taking beta blockers
Must not delay continued adrenaline administration

Question 13

13. What is the Rx for Inadequate/EP perfusion? non-cardiogenic or hypovolaemic

Answer 13

If sepsis suspected and chest clear and MICA not immediately available - Confirm MICA support
- NS up to 20mL/kg over 30mins

Question 14

14. What are the Sepsis criteria? When are they relevant?

Answer 14

• Temp >38 or <36
• HR >90
• RR >20
• BP <90
  Presence of infection or severe clinical insult such as multi trauma leading to systemic inflammatory response syndrome

Question 15

15. What are the typical s/s of meningococcal septicaemia?

Answer 15

• Typical purpuric rash
• Septicaemia signs: fever/rigor/joint muscle pain, cold hands and feet, tachy/hypotensive, tachypnoea
• Meningeal signs: headache, photophobia, neck stiffness, n/v, ACS

Question 16

16. What is the Rx for meningococcal septicaemia?

Answer 16

• IV access: Ceftriaxone 1g IV, dilute with water for injection to make 10mL, administer over 2mins - Rx as per inadeq perf
• No IV access: Ceftriaxone 1g IM, dilute with 3.5mL 1% Lignocaine to make 4mL, administer into upper lateral thigh or other large muscle mass

Question 17

17. What is the Rx for Opioid OD?

Answer 17

• Heroin: Naloxone 1.6-2mg IM - assist and maintain airway/ventilation - inadequate response after 10mins, Tx w/o delay and consider SGA
• Other opioid: Naloxone 100mcg IV, repeat every 2mins (max 2mg), assist and maintain airway/ventilation, if unable to insert IV - 400mcg IM (single dose)

Question 18

18. What are the s/s of TCA OD?

Answer 18

QRS>0.12, Hypotension, Ventricular arrhythmias

Severe: coma, resp depression, conduction delays, PVC, SVT, VT, Hypotension, Seizures, ECG changes

Question 19

19. What are the common TCAs?

Answer 19

• Amitriptyline (most common) - Endep/Entrip
• Clomipramine
• Dosulepin
• Doxepin
• Imipramine
• Nortriptyline

Question 20

20. What is the Rx for Agitation?
    - Mild
    - Moderate
    - Severe

Answer 20

• Mild: Olanzapine 10mg oral - 5mg for elderly/frail, <60kg or significant effect from sedating drug/alcohol - repeat dose at 20mins if pt remains mildly agitated
• Moderate: Midazolam 5-10mg IM - 2.5-5mg for elderly/frail, <60kg, SBP<100 or significant effect from sedating drug/alcohol - repeat dose at 10mins if necessary, max 20mg, consult for further - consider Olanzapine if pt remains agitated but becomes cooperative

- Severe: Ketamine IM
<60kg 200mg
60-90kg 300mg
>90kg 400mg
Consult for further if required, if pt hyperthermic or increased muscle tone consult for midazolam IV or IM

Question 21

21. What is required in post sedation care?

Answer 21

Airway mx
supplemental O2 - route if ketamine used
use of capnography where available
perfusion mx - inadequate perf
temp mx
reassessment and mx of clinical causes of agitation
insert IV

Question 22

22. SAT scores:

Answer 22

+3: violent + continual loud outbursts
+2: very anxious/agitated and loud outbursts
+1: restless and talkative
-1: rouses to name called
-2: response to physical stimulation, few recognisable words
-3: no response to stimulation

Question 23

23. Key considerations and s/s of organophosphate poisoning:

Answer 23

Look out for anticholinesterase on label - remove contaminated clothing and wash skin with soap and water, while minimising staff involved and transfers between vehicles
S/S: excessive cholinergic effects - salivation, bronchospasm, bradycardia - also sweating and nausea

Question 24

24. Rx for autonomic dysreflexia:

Answer 24

• Confirm previous SCI at T6 or above with severe headache and/or SBP>160
• Identify and Rx possible causes: distended bladder, ensure IDC not kinked, Mx pain
• If SBP still >160, GTN 300mcg (no prev admin) or 600mcg, repeat 10/60 until symptoms resolve, side effects or BP<160

Question 25

25. What are the steps for assessment and mx of a suspected stroke?

Answer 25

Determine onset time, consider mimics, consider co-morbidities, perform MASS (if +ve <24hrs perform ACT-FAST), assess ECG for possible AF: - #1 MASS +ve ≥12hrs and ACT-FAST -ve or suspected TIA: Tx to closest thrombolysing stroke centre - #2 MASS +ve <12hrs and ACT-FAST -ve: IV 18G in large vein, Tx to nearest thrombo centre, consider R/V with MSU, notify hospital with details/name/DOB - #3 MASS +ve <24hrs and ACT-FAST +ve: ECR eligible, IV 18G large vein, consider R/V with MSU, pre-notify

Question 26

26. What is the eligibility criteria for ACT-FAST? 4

Answer 26

1. Deficits are new or significantly worse 2. Known onset of symptoms <24hrs 3. Living at home independently with at most minor assistance 4. No evidence of mimics: not comatose, no seizure, BGL>2.8, no definitely known malignant brain cancer

Question 27

27. Stroke mimics: SMITH MISSES

Answer 27

``` Seizures Migraine Intoxication Tumour - Brain Hypo/Hyperglycaemia ``` ``` Multiple sclerosis Inner ear disorder (vertigo) Sepsis Syncope Electrolyte disturbance Subdural Haematoma ```

Question 28

28. When is an ischaemic stroke or ICH more likely? And Tx options?

Answer 28

- Rapid deterioration in conscious state and GCS<8 - Severe headache - N/V - Bradycardia/hypertension Tx: awake - nearest stroke hospital comatose - neurosurgical centre - RMH, SVH, Austin, Alfred or MMC

Question 29

29. What is the Rx for Palliative care pts?

Answer 29

Community palliative care service unavailable - cross check calculations with partner/clinician - Rx N/V as per CPG - Rx pain, agitation caused by pain or dyspnoea with Morphine max (20mg) subcutaneously - Treat mild agitation not caused by pain with Midazolam 2.5 mg S/C Morphine and Midazolam should not be administered to same pt unless under direction of community palliative care service to due risk of resp depression

Question 30

30. What needs to be considered for TBI when using Agitation CPG?

Answer 30

- Agitation in traumatic/hypoxic brain injury must be managed with judicious analgesia - Hypotensive effects of midaz can be detrimental to pt outcomes - Mild-moderate acute TBI (GCS 10-14) - sedation can only be given after consultation with clinician

Question 31

31. Considerations for paed and adolescent pt for Agitation CPGs:

Answer 31

- <16yrs: RCH (or MCH) must be consulted prior to any sedation - 16 + 17yrs: consult with clinician for most appropriate hospital