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OSCEStop Emergencies 2 Flashcards

1
Q

peritonitis summarise DDx, classic hx, classic exam, inv, management

A

DDx: perforated viscus
(peptic ulcer, tumour, diverticulum, gallbladder, appendix, spleen, AAA, ectopic)

severe generalised abdo pain

no movement with resp, guarding, firm abdo, rebound + percussion tenderness, severe pain on light palp

inv- standard acute abdo + erect CXR, urgent CT AP

standard acute abdo + urgent surgical repair + double cannulae

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2
Q

acute abdomen standard inv + management (obvs add specifics for diff causes)

A

FBC, U+E, LFT, CRP, INR, G+S, amylase

urine dip+culture
bHCG if female

IVF
catheter NGT
analgesi
VTE prophylaxis unless theatre within 2 hrs

if need surg:
check INR, G+S
stop anticaog/antiplatelets/ diabetic meds

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3
Q

ruptured AAA summarise DDx, classic hx, classic exam, inv, management

A

ddx - other peritonitism

elderly, severe generalised pain, back pain, reduced GCS

hypotensive, peritonitic, expansile mass

standard inv + bedsidde USS, CT angio

standard treat + double cannula, permissive hypotension, massive haemorrhage protocol, urgent open repair

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4
Q

renal colic summarise DDx, classic hx, classic exam, inv, management

A

ddx - pyelonephritis, biliary colic

spasms of loin to groin ppain, nausea + vom, can’t sit still

SNT abdo, renal angle tenderness

standard inv + CT KUB

standard treat + diclofenac, IV fluids, abx if necc

either tamsulosin + wait or surgical options

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5
Q

appendicits summarise DDx, classic hx, classic exam, inv, management

A

ddx: Meckel’s diverticulum, Chron’s, mesenteric adentitis, ovarian cyst, ovarian torsion,ectopic

young, periumbical pain localising to RIF, anorexic, nauseous, fever

tender RIF, McBurney tender
gurading
Rosving +Ve

standard inv + USS if gynae worry

general treat + urgent lap

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6
Q

gallstones summarise DDx, classic hx, classic exam, inv, management

A

biliary colic or cholecystitis or CBD stones or cholangitis

standard inv +a abdo USS, CT if req

standard treat + depends on condition
(either remove GB, ERCP or give abx)

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7
Q

acute pancreatitis summarise DDx, classic hx, classic exam, inv, management

A

ddx - gastritis, cholecystitis, pericarditis

severe epigastric / central pain
moves to back, relieved by sitting forwards, vom

epigastric tenderness, tachy, fever, shcok, GT+C signs

standard inv+ amylase /lipase, CT abdo if uncertain bloods
find cause with USS, triglycerides, Igs

standard treat + supportive, aggressive fluids, NBM, treat cause, consdier ITU

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8
Q

peptic ulcer summarise DDx, classic hx, classic exam, inv, management

A

ddx - pancreas, cholecystitis

epigastric pain linked to meals

tender epigastrium, SNT abdo

OGD+biospy

PPI, H pylori eradication

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9
Q

diverticulitis summarise DDx, classic hx, classic exam, inv, management

A

ddx - diverticular cyst, diverticulosis, mesenteric ischaemia, IBS, ovarian cyst/torsion

elderly LIF pain, pyerexia, diarrhoea

tender LIF
guarding
PR -ve

CT abdo if nec + standard inv

standard treat + clear fluids then build up
abx

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10
Q

bowel obstruction summarise DDx, classic hx, classic exam, inv, management

A

ddx - gastroenteritis

vomiting + abdo pain + non bowel or flatus motions

distended tender abdo
tinkling BS

standard inv + AXR then CT AP
gastrograffin if SBO

standard treat + NBM, wide bore NG on free drainage, lap if complte or non resolving

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11
Q

ectopic pregnancy summarise DDx, classic hx, classic exam, inv, management

A

ddx - appendicits, PID, Meckel’s diverticulum, Chron’s , mes adenitis, ovarian cyst / torsion

increasing iliac fossa / pelvic pain
6 weeks pregnant
spotting

tender RIF/LIF
guarding
adnexal tenderness
cervical excitation

standard inv + bHCG+trendline + TV USS

standard treat + double cannulae, lap salpingostomy /ectomy
methotrexate if uncomplicated

anti D PROPHYLAXIS if needed

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12
Q

initial approach to upper GI bleed pt

A 
ABCDE approach
IV fluid resus, permissive hypotension <100SBP
massive haemorrhage protocol 
transfuse if Hb <70/80
must be stable before OGD

o/e - look for signs of common causes, do PR for melaena
bloods - G+S, XM, FBC, U+Es (urea raised), LFTs, clotting, glucose
catheterise
CXR, AXR once stable
regular obs and r/v

keep NBM, correct any clotting abnoramilites, stop anticaog/antiplt, treat cause

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13
Q

acute variceal bleed management

A

terlipressin pre OGD
prophylactic abx IV
OGD - variceal band ligatoin, sclerotherapy, ballon tamponade Sengstaken tube

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14
Q

acute non variceal bleed management

A

peptic ulcer, MW tear, oesophagitis

adrenaline injection into ulcer
IV PPI post OGD

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15
Q

scoring systems for GI bleed

A

Blatchford score - pre OGD = likelihood pt will need intervention

Rockall score - post OGD, assesses mortality risk

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16
Q

preventing further GI bleeding from varices

A

propanolol
variceal banding
TIPSS (shunt)
liver transplant

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17
Q

preventing further GI bleeding from peptic ulcer

A

PPI
H pylori eradication therapy
avoid precipitants (check drug chart)

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18
Q

DKA management protocol

A
  1. ABCDE approach
  2. confirm diagnosis - VBG, all 3 of the name are present
  3. IV fluids aggressively (start with 1L over 1 hr, then add bags with potassium over next 2 2 4 4 6 6 hrs consecutively)
  4. Regular U+Es (K+)
  5. Fixed rate insulin infusion 0.1U/kg/hr from 50U Actrapid in 50mlm 0.9% normal saline (max rate 15U/hr)
  6. Once glucose <14, add 10% IV glucose at 125ml/hr in addition to saline, but reduced saline rate.
  7. Investigate cause
  8. Treat cause
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19
Q

investigating cause of DKA

A 
history
top to tail exam
bloods = FBC, UE,LFT, glucose, osmolality, CRP
blood culture
MSU
CXR
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20
Q

when to consider ITU with DKA

A 
if ketones 6+
bicarb <5
pH <7.1
GCS <12
SBP <90
sats <92%
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21
Q

follow up post acute phase DKA

A 
manage cause
continue daily long acting basal  bolus insulin
2 hrly VBGs
restart normal insulin regimen only when acid base corrected and able to eat and drink 
if not eating, VRII
VTE prophylaxis
NGT consider
educated and review meds
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22
Q

targets bicarb glucose ketones in DKA recovery

A

increase bicarb by 3 an hour
reduced glucose by 3 an hour
reduced ketones by 0.5 an hour

if not going that rate, increase insulin by 1U/hr

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23
Q

common causes of hyperglycaemia

A 
DKA
HHS
sepsis
steroids
missed insulin/meds
pancreatitis 
dehydration
meal/feeds
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24
Q

common causes of hypoglycaemia

A

not eating enough
vomiting

insulin/SU excess
dec renal function (So drug excess by proxy)
alcohol
abrupt steroid stoppage

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25
Q

Hyperosmolar Hyperglycaemic State what is it

A

slowly develops as a result of illness and dehydration
no acidosis / ketones

dx: 30+ sugars, osmolality 320+, hypovolaemic

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26
Q

management HHS

A

rehydrate aggressively, can be quicker than DKA as v v dehydrated
VTE prophylaxis - high risk
0.05U/kg/hr insulin if glucose not falling with fluids alone
look for cause

HOLD metformin until r/v

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27
Q

managing hypoglycaemia

A

unconsicous - 150ml 10% glucose IV stat, repeat as necc, glucagon IM 1mg if not IV access up to 2x max, recheck cap gluc

can’t swallow - glucose gel around teeth

can swallow - 12-30g fasta acting carb and long acting carbs too

correct cause and avoid omitting insulin/SU afterwards, just edit dose (ask pharmacist?)

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28
Q

history and examination of stroke and TIA

A

precise onset
when last well
any progression
risk factors (CVD)

full neuro exm
pulse, HS, carotids, bruising, bleeding
signs of RFs

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29
Q

management algorithm for stroke

A

Rosier score >1 - stroke likely

CT head within 1 hr
excluded intracran bleed

if<4.5 hrs give alteplase if no contraindications

otherwise: aspirin 300mg OD for 2 weeks, stat 300mg clopi then 75mg OD

consider clot retrieval
transfer to stroke ward

MDT:
SALT assessment
optimise nutrition
early mobilisation
treat infections, care for skin
rehab
consider carotid surgery
long term:
antihypertensives
clopidogrel 75mg OD 
anticoag if any AF
statin 48hrs+ post stroke
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30
Q

DVLA advice with stroke

A

no driving for 4 weeks

tell DVLA if HGV driver or still sympto after 4 weeks or any complications

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31
Q

TIA algorithm

A

ABCD2 score
give aspirin 300mg OD for 2 weeks
OR 300mg stat clopi then daily 75mg
treat any AF

specialist r/v within 24 hrs

carotid endartectomy if ipsilateral stenosis >50%

inv long term: ECG, 24 hr tape, echo+/- bubble study for PFO, screen vasculitis, screen coag disorders

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32
Q

initial seizure management and assessment

A 
recovery position
jaw thrust airway
consider NPA if doubts
15L o2 non rebreather
secure IV access 
obs + cardiac monitor 
cap glucose
VBG
FBC, UE, calcium
drug levels
clotting
ECG - prolonged QTc?
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33
Q

definitive seizure managemetn

A 
if 5 + minutes 
buccal midaz or rectal diazepam
repeat multiple times
if ongoing phenytoin IV
then ITU

give 20% glucose if hypo, give pabrinex if alc

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34
Q

post seizure managemetn

A

find cause - CT, EEG, LP

treat cause
refer to neuro
driving advice

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35
Q

common causes of seizures

A

neuro: epilepsy, SOL, meningitis, post stroke, head trauma
metabolic: low sugar, high uric acid, electro abnormal
drugs: OD, abuse, alc withdrawal, toxins
febrile convulsion
eclampsia if preg

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36
Q

assessing traumatic wound initially

A

hx - who, hand dominance
what happened, mechanism, forces involved
clean wound and examine for damage + contamination
check tendon and NV status
check tetanus status
x ray if FB risk

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37
Q

wound management

A

clean wound, LA, debride, pressure irrigation if dirty,
thorough + deep inspection
if any damage risk, surgical input

closure: if clean and fresh wound, immediate primary closure
delayed primary: left open for 48 hrs post clean (for old or contaminated wounds)
secondary intention: let wound to close by itself (ulcers, tissue loss so can’t align edges)
skin grafts - burns

other aspects:
abx
tetanus
rabies if bite
pain relief
rest ice elevation if swelling
dressing
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38
Q

wound follow up

A

give advice
rest ice elevate
arrange follow up if delayed primary closure, diabetic, icomp, burns

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39
Q

when to remove sutures

A

head / face - 5 days
upper limb/trunk/abdo - 7 days
lower limb /diabetic/icomp - 10 days

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40
Q

most common ankle ligament sprain

A

lateral ligament

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41
Q

rules used to decide who needs an ankle x ray

A

Ottowa rules

x ray if malleolar pain + any of: pain over posterior tip of lat malleolus / medial malleolus, inability to weight bear immediately after injury and continuously after

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42
Q

examining an injured ankle

A

palpate deltoid ligament medially and lateral ligament complex

palpate fibula up to knee (check for assoc head of fib #)

squeeze test (squeeze tib fib lower parts together = checks for #)

watch walking / wt bear

distal neurovasc exam

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43
Q

generic management of ankle injury

A

ice, crutches, pain relief, advice to RICE
then mobilise
weight bearing encouraged if no fractures (daily)

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44
Q

grading of ankle ligament injuries

A

1 - stretch and micro tear (compression bandage, heals in 4 weeks max)

2 - stretch with partial tear (stirrup splint for 4 weeks, heals in 12)

3- complete rupture (aircast boot 6 weeks, may need surg, 3-6 months healing)

45
Q

anterior cruciate ligament damage hx and symptoms

A

forced flexion, hyperextension or rotation injury to extended knee

knee collapses on weight bearing
immediate pain
can’t walk really
rapid haemarthrosis

46
Q

posterior cruciate ligament damage hx and symptoms

A

tibia forced backwards e.g. fall on object or against dashboard of car, may hear popping sound

knee collapses on weight bearing
immediate pain
can’t walk really
rapid haemarthrosis

47
Q

medial collateral ligament injury hx and symptoms

A

blow to lateral side of knee

pain on inner/outer knee
immediate pain
diff to weight bear
instability symptoms if high grade injury

48
Q

lateral collateral ligament injury hx and symptoms (uncommon)

A

blow to medial side of knee - check peroneal nerve

pain on inner/outer knee
immediate pain
diff to weight bear
instability symptoms if high grade injury

49
Q

meniscus tear injury hx and signs

A

rotational injury to flexed knee

immediate pain
diff to weight bear
slowly forming effusion
clicking and locking
locking limits extension of knee
50
Q

general management of acute knee injury

A

Ottowa rules decide on x ray needs = age >55, can’t weight bear, patellar tenderness, head of fib tender, can’t flex to 90

full exam after a week - often too painful at first

crutches, analgesia, RICE advice, NSAIDs, mobilise and weight bear if no trauma found

51
Q

specific knee ligament injury management

A

lig stretch with micro tear - stable knee - bandage for 2 weeks

stretch + partial tear = lax but stable - 4 week knee brace

complete lig rupture - unstable joint - brace for 6-12 weeks if collaterals, cast and surgery if cruciates

meniscal damage - arthroscopic repair if locked knee or no improv in 2 weeks

52
Q

4 stages of fracture management

A

Resuscitate
Reduce if displaced
Retain position for healing
Rehabilitate

53
Q

general # hx and exam

A 
age, job, hobbies, hand dominance
what happened, mechanism, force
when/where/why it happened
examine for other injuries
check NV status 
screen complications 
check SH and smoking (delays healing)
54
Q

resuscitation of a fracture

A

ATLS if life threatened

look for other injuries - don’t get tunnel vision. may need to immobilise c spine

55
Q

reduction of a fracture

A

if displaced

open reduction -> for if intra-articular # or assoc NV damage

closed manipulation -> for extra-articular # where acceptable reduction can be achieved with sedation

traction

56
Q

retaining a fracture

A

to maintain the reduced position

external fixation - contaminated wound, severe open fractures, severe assoc ST injury

internal fixation - comminuted or displaced #, intra-articular #, bones that can’t be reduced otherwise, joint damage

conservative immobilsation - splint, cast, brace, traction

57
Q

methods of internal fixation

A

intramedullary - nails for long bones, K wires for small bones

extramedullary - plates and screws (for comminuted # or compress)

58
Q

femur and tib/fib #

A

if extra-articular can usually be cons management but often given IM nailing to reduced non weight bearing time

59
Q

using splint / case

A

acutely - splint or backslab allowing for swelling

1 week post injury - full circumferential cast

callus takes 6 weeks to form on average

60
Q

other tips aside from 4 Rs for # management

A 
RIcE
smoking cessation - slows
analagesia (not NSAIDs)
abx proph if open 
VTE proph
treat cause
61
Q

immediate/early/late # complictions

A

imm- bleed, local damage, fat embolus,compartment syndrome

early - (weeks) - local infection, loss of position, clots, chest infection,

late - (months-years) - malunion / non union, OA, AVN

62
Q

define compartment syndorme

A

a rise in pressure in a myofascial compartement - pain out of proportion to injury. exarcerbated by passive stretching of muscles

fasciotomy

63
Q

timings of healing of bones and imaging

A

callus at 6 weeks - same time as removal of temporary fixation (wires,cast)

full healing at 12 weeks

upper limb bones heal twice as quickly as lower limb, kids heal twice as quickly as adults

repeat x rays at post op and after cast application

64
Q

3 fractures with avascular necrosis risk

A

head of femur
waist of scaphoid
neck of talus

65
Q

clavicle#

A

broad arm sling, polysling

66
Q

prox humerus #

A

collar and cuff

67
Q

mid humerus #

A

collar and cuff +brace/slab cast

68
Q

distal humerus #

A

above elbow backslab/cast

69
Q

Colle’s #

A

closed manipulation under haematoma blok then below elbow backslab + cast with wrist flexed and ulnar deviation

70
Q

scaphoid #

A

futuro splint +/- thumb extension/splint

71
Q

NOF intracapsular

A

displaced>60 yrs = total hip replacement / hemiarthro

undisplaced/displaced<60 = cannulated screws

72
Q

NOF extracapsular

A 
intertrochanteric = dynamic hip screw
subtrochanteric = intramedullary nail
73
Q

femur/tib shaft #

A

IM nail

74
Q

lateral malleolus #

A

aircast boot with wt bearing

75
Q

malleolus # disrupting syndesmosis

A

surgical fixation

76
Q

identifying a patient with sepsis

A

consider if any suspicion of infection
systemic response evident

risk factors - extremes of age, recent trauma or surgery last 6 weeks, imparied immunity, indweling lines, IVDU, skin broken

lactate correlates with severity, severe = 4+

77
Q

assessing a pt with sepsis

A 
obs
cap refill, skin temp, pulse o/e 
look for SOURCE - exam all major systems ABCDE approach, check all wounds + lines
inv - FBC, CRP, platelets, INR, bili + VBG lactate
blood cultures
cap glucose
urine dip and culture 
culture any lines/drains
CXR
consider CT abdo if ?surgical collection
78
Q

high risk of severe illness/death from sepsis parameters

A 
alterted mental state
RR 25+ or new oxygen req
HR 130+
systolic 40 below normal 
urine output less than 0.5ml/kg/hr or none in 18hrs
cyanotic
mottled, ashen
non blanching rash
79
Q

end organ dysfunction with sepsis by system

resp
cardio
renal
liver
coag
CNS
A

resp- ARDS - infiltrates on CXR, obs off = mech ventil

cardio - heart failure, hypovol and shock, SBP v low = inotropes, vasopress

renal - AKI, UO <0.5ml/kg/hr (should be body wt in mls/hr+) - consider dialysis

liver - BR>35, doubled ALP/ALT

coag - DIC - low platelets, prolonged PT, low fibrinogen - blood products

CNS - encephalopathy - new confusion, low GCS

80
Q

sepsis six

A

occurs WITHIN ONE HOUR

3 in:
oxygen
abx
fluids

3 out:
lactate
blood cultures + other bloods esp FBC
urine output - catheter

ABCDE approach
consider source and any need for sugery
consider need for organ support + ITU
if still hypotensive after 30ml/kg resus then need vasopressors

81
Q

post - op complications - immediate

A

anaesthetic complications - arrhythmia, BP off, hyperthermia, resp probs, MI/stroke, allergy, teeth/lip/tongue damage)

bleeds - often not bovious externally - monitor drains, obs, FBC/Hct

82
Q

early post op complications

A 
fluid depletion
electrolyte deviation
local infection (wound or site)/ systemic infection (chest/UTI/sepsis)
fluid collections
atelectasis
DVT/PE
wound break down
anastamotic break down 
bed sores
83
Q

gastrectomy complications

A 
dumping syndrome
malabs
anastomotic ulcer
peptic ulcer/gastric ca
small int bacterial overgrowth
abdo fullness/bloat
84
Q

small and large bowel ops complications

A 
ileus 
anastomotic leaks 
adhesions
obstruction
damage to local structures
intra abdo collections
stoma retraction
pre sacral plexus damage

(leaks present 5-10 days post op, but can be upto 21 days)

85
Q

cholecystectomy complications

A

common bile duct injury / bile leak

86
Q

biliary surgery complications

A 
CBD injury/bile leak
CBD stricture
anastomotic leak
bleeding into bil tree (jaundice)
pancreatitis
87
Q

CABG/stenting complications

A

reperfusion arrhythmias
post op ACS
inotropes post op may cause organ injury elsewhere

88
Q

grafts/stents/bypass complications

A 
failure of graft/stent
bleed/clot
infection
rethrombosis
limb/organ ischaemia
AV fistula
cholestrol embolism 
arteriopaths (stroke/MI/PE)
contrast complications - anaphylaxis, AKI
89
Q

thyroidectomy complications

A

airway obstruction secondary to bleed - urgent
hypocalc (damaged PT)
recurrent laryngeal n dam

90
Q

parotidectomy complications

A

facial nerve damage

91
Q

any ortho op complications

A 
infection of prosthesis
loss of position/failed fixation
non union/malunion/delayed
NV injury 
compartment syndrome
92
Q

total hip arthroplasty complications

A

sciatic nerve damage, disloc, leg length difference, loosening, wear, need for revision

93
Q

cystoscopy/TURP complications

A 
high UTI risk
TURP syndrome (absorb irrigation fluid causing hyponatraemia)
impotence
retrograde ejac
external sphincter damage (incontinence)
urethral stricture
94
Q

endovascular surgery complication

A

retroperitoneal bleed

95
Q

lymph node dissection complications

A

lymphoedemea

96
Q

neck dissection of a lump compolication

A

cranial nerve damage - 11, 12

97
Q

assessing unwell post op patient

A

use ABCDE approach
consider op, pre op fitness and post op progress
think about specific and general op risks
special review of op site, newly placed drains + their contents

98
Q

assessing pyrexial post op patient

A

assess all obs
consider sepsis but operative intervention cause low grade fever anyway
pay particular attention to chest infection and UTI

99
Q

5 causes of post op fever by timing

A

<2 days - atelectasis,pneumonia

2-4 days - UTI

5-7 days - wound infection, collections

8-10 days - VTE

ANY time - transfusion/drug reactions

100
Q

2 aims when assessing hypotension

A

assess for cause and evidence of end organ dysfunction

look at lactate ABG, UO catheter, confusion GCS
cap refill, periphries, tachy

101
Q

causes of post op hypotension

A

sepsis + anaphylaxis

decreased volume - long op + evap, third space losses, bleeds, poor intake

pump failure - surgical stress inc risk of MI around 48hrs post op, consider fluid overload +HF

sympathetic shock - if epiderual analgesia and high block (T5 and above), assess using cold sprays

102
Q

causes of resp difficulty post op

A

RT infections - pneumonia
PE
PO - at risk due to large fluid shifts, low albumin, cardiac dysfunction

assess fluid status
calves
investigate infection

103
Q

low urine output post op

A

must be 0.5ml/kg/hr +++

consider causes
pre renal - volume depletion or cardiac probs
renal - nephrotoxics
post renal - BPH, raised IAP compressing

fluid status incl drains and third spaces (bowel, tissues), DH review, catheter exam + bladder scan

104
Q

common causes of anaphylaxis

A

abx, gelofusine, NAC, IV contrast

nuts, strawbs, eggs, shellfish

wasps/bees

latex

105
Q

anaphylaxis, what now/

A

call for help, call 2222 and remove allergen!

A - secure

then give 0.5ml of 1 in 1000 IM, repeated at 5 min intervals (inj come as 1ml so discard 1/2 ml first)

B - attach 15L non rebreather, give 5mg salbutamol nebs if wheeze

C - secure double IV access, give stat 500ml fluid challenges

hydrocortisone 200mg IV
chloramphenamine 10mg IV
3 lead cardiac monitor

106
Q

short term and long term management post anaphylaxis attack

A

short term - seek ITU input if still not improving on intervention
admit for 6 hrs obs post adrenaline (biphasic reactions risk)
continue 30mg pred daily for 5 days post event
Piriton 4mg QDS if itchy
monitor ECG
IVfluids PRN
document fully
mast cell tryptase confirms
update records, red bracelet

long term - educate, teach epipen, medic alert bracelet, allergy clinic + skin prick testing, clinical incident form if caused by known abx allergy

107
Q

what do you do if a patient is agitated and a risk to self or others?

A

try to calm them + move them to a safe place / remove other pt and staff

call security for backup

1 - turn on the lights, offer hearing aid/glasses
2-explain where they are, the time, ask their concerns
3 - see if a relative can come or has advice
4- rapid tranq is last resort!!!

108
Q

rapid tranquilisation protocol

A

only if at risk to themselves or others

lorazepam 1-2mg PO/IM

or haloperiodol 2-5mg PO/IM

offer oral route if possible
give half doses if elderly or in renal failure

109
Q

follow up after rapid tranq agitated patient

A

offer oral route if possible
give half doses if elderly or in renal failure
NO HALOPERIDOL if Parkinson’s, LBD, alcohol, heart probs (check prev ECG)
ensure you have procyclidine to counteract any dystonia from haloperidol

REPEAT doses - only if needed, at 30-60 min intervals, 3x maximum
oral therapy needs 45mins to an hour to work

obs every 30 mins in light sedation, 15 mins if deep

clearly DOCUMENT WHY NEEDED POST EVENT

AS / OS Paces RT (11 decks)

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