Medicine

Question 1

Anaphylaxis acute management (4)

Answer 1

1. Adrenaline - IM dose of 300-500 mcg (0.3-0.5mL of 1:1000) while trying to gain IV access.
2. Nebulised salbutamol (5mg) with high flow oxygen
3. Fluid resuscitation with normal saline to treat hypotension
4. If no response to initial dose of adrenaline further doses can be given IV (either in 20-50mcg boluses or as a continuous infusion)

Question 2

What adjuvant treatment can be given in an anaphylaxis reaction? (3)

Answer 2

Anti-histamine (e.g. promethazine)
Histamine-2 receptor blockade (e.g. ranitidine)
Corticosteroid (e.g. 250mg IV hydrocortisone)

Question 3

What blood test can be used to help diagnose anaphylaxis?

Answer 3

Mast cell tryptase - serum protease specific to mast cells which reaches a peak one hour after an anaphylactic reaction and remains elevated for approx. 6 hours.

A NORMAL SERUM TRYPTASE DOES NOT EXCLUDE A POSSIBLE ANAPHYLACTIC REACTION

Question 4

What is the exception to serum tryptase elevation in anaphylaxis?

Answer 4

Elevation very rarely associated with food-induced prophylaxis

Question 5

Post-acute management of severe first-time anaphylaxis (4)

Answer 5

1. Requires observation in ED or in a short-stay ward for at least 10 hours
2. On discharge, should be prescribed and carefully educated in the use of an ‘EpiPen’ and referred to allergist for further testing (skin testing or serum antibody tests) and follow-up
3. Education regarding allergen advice
4. Place alert in medical record outlining suspected trigger and features of the reaction

Question 6

What is the dose of adrenaline in children with severe anaphylaxis?

Answer 6

0.1 mL/kg of 1:10000 IV (0.01 mg/kg)

Question 7

What is the risk of hyponatraemia vs rapid correction?

Answer 7

Hyponatraemia - cerebral oedema

Rapid correction can cause central pontine myelinolysis

Question 8

Define anaphylaxis.

Answer 8

Severe, life-threatening, generalised or systemic hypersensitivity reaction

Characterised by rapidly developing life-threatening airway (pharyngeal or laryngeal edema) and/or breathing (bronchospasm and tachypnea) and/or circulation (hypotension and tachycardia) problems usually associated with skin and mucosal changes (but not always!)

Question 9

Warfarin: What needs to happen if INR is greater than therapeutic range but less than 5.0 (no bleeding)? (2)

Answer 9

1. Lower dose or omit the next dose of warfarin

2. Resume therapy at lower dose when INR approaches therapeutic range

Question 10

Warfarin: what needs to happen if INR 5.0 - 9.0 with no bleeding? (5)

Answer 10

1. Cease warfarin
2. Consider reasons for elevated INR
3. If bleeding risk high, give vitamin K1 (1mg oral or IV)
4. repeat INR within 24 hours
5. Resume warfarin at lower dose once INR in therapeutic range

Question 11

Warfarin: what needs to happen if INR greater than 9.0 with no bleeding? (4)

Answer 11

1. cease warfarin
2. if low risk bleeding: vitamin K1 (2.5-5.0mg oral or 1mg IV)
3. if high risk: vitamin k1 1mg IV, consider prothrombinex-HT and FFP
4. Measure INR 6-12h and resume warfarin at lower dose once INR less than 5

Question 12

Warfarin: what needs to happen if there is any clinically significant bleeding with warfarin-induced coagulopathy? (3)

Answer 12

1. cease warfarin
2. give vit K1, prothrombinex, FFP
3. Assess patient continuously until INR less than 5 and bleeding stops

Question 13

What can anaphylaxis present as in those with known allergies?

Answer 13

Isolated hypotension

Question 14

What is contained in prothrombinex?

Answer 14

Vit K dependent factors - II, VII (small amounts only), IX and X

Question 15

What are the diagnostic criteria for DKA? (3)

Answer 15

1. BGL > 11.1
2. Venous pH less than 7.3 or bicarbonate less than 15
3. Presence of blood or urinary ketones

Question 16

What is the treatment of DKA? (5)

Answer 16

See BHS guidelines!

1. O2 if necessary, and IV access
2. Fluid resuscitation - 1L of 0.9% saline stat
3. Insulin - amount dependent on initial BGL - roughly 0.1u/kg/hr - aim to lower glucose by 1-2 mmol/l/hr
4. Once glucose below 15 provide 5% dextrose 100 mL/hr
5. Monitor for electrolyte abnormalities + may require ICU admission

Question 17

What happens in DKA?

Answer 17

No insulin = no glucose uptake = lipolysis = FFAs broken down into ketone bodies = metabolic acidosis = respiratory compensation leads to hyperventilation

Question 18

When should adults who have a wound get a booster dose of tetanus?

Answer 18

If it has been more than 5 years since the last one, and if the wound is ‘tetanus prone’

Question 19

When shoud IM tetanus immunoglobulin (TIG) be given?

Answer 19

TIG only used if wound is tetanus-prone and if person has had less than three doses or is uncertain of how many doses they’ve had.