OSCEStop Emergencies 2 Flashcards

Question

Hyperosmolar Hyperglycaemic State what is it

Answer 1

slowly develops as a result of illness and dehydration no acidosis / ketones dx: 30+ sugars, osmolality 320+, hypovolaemic

Answer 2

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

Answer 3

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?)

Answer 4

precise onset when last well any progression risk factors (CVD) full neuro exm pulse, HS, carotids, bruising, bleeding signs of RFs

Answer 5

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 ```

Answer 6

no driving for 4 weeks | tell DVLA if HGV driver or still sympto after 4 weeks or any complications

Answer 7

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

Answer 8

``` 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? ```

Answer 9

``` 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

Answer 10

find cause - CT, EEG, LP treat cause refer to neuro driving advice

Answer 11

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

Answer 12

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

Answer 13

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 ```

Answer 14

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

Answer 15

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

Answer 16

lateral ligament

Answer 17

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

Answer 18

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

Answer 19

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

Answer 20

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)

Answer 21

forced flexion, hyperextension or rotation injury to extended knee knee collapses on weight bearing immediate pain can't walk really rapid haemarthrosis

Answer 22

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

Answer 23

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

Answer 24

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

Answer 25

rotational injury to flexed knee ``` immediate pain diff to weight bear slowly forming effusion clicking and locking locking limits extension of knee ```

Answer 26

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

Answer 27

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

Answer 28

Resuscitate Reduce if displaced Retain position for healing Rehabilitate

Answer 29

``` 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) ```

Answer 30

ATLS if life threatened | look for other injuries - don't get tunnel vision. may need to immobilise c spine

Answer 31

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

Answer 32

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

Answer 33

intramedullary - nails for long bones, K wires for small bones extramedullary - plates and screws (for comminuted # or compress)

Answer 34

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

Answer 35

acutely - splint or backslab allowing for swelling 1 week post injury - full circumferential cast callus takes 6 weeks to form on average

Answer 36

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

Answer 37

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

Answer 38

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

Answer 39

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

Answer 40

head of femur waist of scaphoid neck of talus

Answer 41

broad arm sling, polysling

Answer 42

collar and cuff

Answer 43

collar and cuff +brace/slab cast

Answer 44

above elbow backslab/cast

Answer 45

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

Answer 46

futuro splint +/- thumb extension/splint

Answer 47

displaced>60 yrs = total hip replacement / hemiarthro undisplaced/displaced<60 = cannulated screws

Answer 48

``` intertrochanteric = dynamic hip screw subtrochanteric = intramedullary nail ```

Answer 49

aircast boot with wt bearing

Answer 50

surgical fixation

Answer 51

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+

Answer 52

``` 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 ```

Answer 53

``` 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 ```

Answer 54

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

Answer 55

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

Answer 56

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

Answer 57

``` 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 ```

Answer 58

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

Answer 59

``` 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)

Answer 60

common bile duct injury / bile leak

Answer 61

``` CBD injury/bile leak CBD stricture anastomotic leak bleeding into bil tree (jaundice) pancreatitis ```

Answer 62

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

Answer 63

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

Answer 64

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

Answer 65

facial nerve damage

Answer 66

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

Answer 67

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

Answer 68

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

Answer 69

retroperitoneal bleed

Answer 70

lymphoedemea

Answer 71

cranial nerve damage - 11, 12

Answer 72

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

Answer 73

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

Answer 74

<2 days - atelectasis,pneumonia 2-4 days - UTI 5-7 days - wound infection, collections 8-10 days - VTE ANY time - transfusion/drug reactions

Answer 75

assess for cause and evidence of end organ dysfunction look at lactate ABG, UO catheter, confusion GCS cap refill, periphries, tachy

Answer 76

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

Answer 77

RT infections - pneumonia PE PO - at risk due to large fluid shifts, low albumin, cardiac dysfunction assess fluid status calves investigate infection

Answer 78

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

Answer 79

abx, gelofusine, NAC, IV contrast nuts, strawbs, eggs, shellfish wasps/bees latex

Answer 80

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

Answer 81

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

Answer 82

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!!!

Answer 83

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

Answer 84

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