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Presentations Flashcards

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1
Q

What is more important in a case of poisoning/overdose - the drug history, or the clinical assessment?

A

The clinical assessment - a drug history may be uunreliable as the pt may not be able to give a history, and if they truly meant to overdose, they will lie.

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2
Q

What are the main toxindromes that we can recognise in poisoning situations?

A

Sympathomimetics
Anticholinergics
Cholinergic
Opioid/sedative syndromes

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3
Q

What does the sympathomimetic toxindrome mimic?

A

The flight or fight reaction.

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4
Q

What drugs can cause the sympathomimetic toxindrome?

A 
Adrenaline/NA
Caffeine
Methmphetamines (LSD/ritaline)
Theophylline
Ecstasy
SSRIs
Alcohol withdrawal
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5
Q

A patient comes in with an overdose. They are hypertensive, tachycardic, agitated, and hyperthermic. What other symptoms are common in this toxindrome?

A 
Arrythmias
Mydriasis
Convulsions
Rhabdomyolysis
ACS/CVA/Mesenteric ischaemia
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6
Q

A patient comes in with an overdose. They are hypertensive, tachycardic, agitated, and hyperthermic. Which toxindrome is this?

A

Sympathomimetic toxindrome.

Could also be antocholinergic toxindrome.

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7
Q

How should sympathimimetic toxindrome be managed?

A

Symptomatically - cooling, sedation, hydration

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8
Q

What can be used to sedate a pt with sympathomimetic toxindrome?

A

Benzodiazepines

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9
Q

What are the classic symptoms of alcohol withdrawal?

A

Pyrexia

Tactile hallucinations, classically insects on skin

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10
Q

What can be given for pyrexia in sympathomimetic toxindrome?

A

Paracetamol

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11
Q

What can be given for tachycardia in sympathomimetic toxindrome?

A

You don’t! Benzos can sedate the patient, but DO NOT give beta blockers!

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12
Q

A patient comes in with overdose symptoms. They are agitated, tachycardic, dry skin, hyperthermic, in urinary retention, and complaining for palpitations. What toxindrome does this sound like?

A

Anticholinergic toxindrome

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13
Q

Which arrythmias are associated with anticholinergic toxindrome?

A

Long QT

Torsades de Pointes

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14
Q

Which drugs cause anticholinergic toxindrome in overdose?

A 
TCAs
Other antidepressants
Class 1A antiarrhythmics (quinodine)
Antihistamines
Antipsychotics
Antispasmodics
Mydriatics
Carbamazepine
Atropine
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15
Q

What is found on examination of a patient with antocholinergic toxindrome? (not observations)

A

Dilated pupils
Urinary retention
Dry, flushed skin
Bowel sounds reduced

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16
Q

What bloods need to be done in an overdose?

A

Routine Bloods
VBG
Drug levels in the blood (depending on hospital capbility)

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17
Q

A patient comes in with overdose symptoms. They are agitated, tachycardic, dry skin, hyperthermic, in urinary retention, and complaining for palpitations. What is the management for this toxindrome?

A

Anticholinergic toxindrome:

  • Magnesium sulphate for metabolic acidosis
  • Bicarbonate for acidosis

-Physostigmine in ITU setting (can cause seizures and agitation)

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18
Q

A patient comes in with overdose symptoms. They are sweating, salivating, have watering eyes, and incontinence. What other signs would you expect from this toxindrome?

A 
N&V
Increased bronchial secretions
Myosis
Bradycardia
Convulsions
Respiratory depression
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19
Q

A patient comes in with overdose symptoms. They are sweating, salivating, have watering eyes, and incontinence. Which toxindrome is this?

A

Cholinergic toxindrome

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20
Q

How should cholinergic toxindrome be managed?

A

Atropine

Pralidoxyme

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21
Q

Why is atropine used to counteract cholinergic toxindrome?

A

It is a vagolytic

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22
Q

What drugs cause cholinergic toxindrome?

A

Pesticides
Organophosphates
Some mushrooms

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23
Q

When dealing with a pesticide/organophosphate overdose, why is PPE important?

A

Skin to skin transfer and inhalation from the patient to the HCP can occur.

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24
Q

A pt comes in with an overdose. They are barely breathing, have constricted pupils, reduced GCS, and are bradycardic and hypothermic. What drug overdose is likely?

A

Opiate or sedative overdose.

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25
Q

Which drugs can cause opiate/sedative oerdose?

A 
Morphine
Heroin
Codeine
Tramadol
Hydromorphine
Fentanyl
Methadone
Alfentanyl
Hydrocodone
Oxycodone
Benzos
Barbiturates
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26
Q

What is the antidote for opiate overdose?

A

Naloxone

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27
Q

What is important to remember about naloxone?

A

It has a short half life so will work for a little while before needing another dose.

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28
Q

What is the antidote for benzo overdose?

A

Flumazenil

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29
Q

What can be screened for toxins?

A

Blood and urine

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30
Q

Other than direct antidotes, what management can be used for overdoses?

A
  • Supportive
  • Prevention of absorption
  • Dialysis
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31
Q

What can be done to prevent absorption in drug overdoses?

A
  • Gastric lavage (not v. popular)

- Activated charcoal

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32
Q

Which drugs are absorbed by activated charcoal?

A 
Theophylline
Aspirin
Paracetamol
Phenobarbitol
Modified release drugs
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33
Q

Which overdose most commonly requires dialysis?

A

Ethylene glycol (anti-freeze)

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34
Q

How common is chest pain as a presentation to A&E?

A

5% of A&E visits as well as 40% of admissions to hospital

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35
Q

What causes of chest pain are there (by system)?

A
  • Cardiac - ischaemic and non-ischaemic
  • Respiratory
  • MSK
  • GI
  • Breast disease
  • Skin disease
  • Psychiatric
  • Sickle cell
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36
Q

What ischaemic cardiac causes of chest pain are there?

A 
Angina
ACS
Coronary vasospasm
Cardiomyopathy
Aortic stenosis
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37
Q

What non-ischaemic cardiac causes of chest pain are there?

A

Arrythmias
Aortic dissection
Pericarditis
Mitral valve disease

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38
Q

What are the acute respiratory causes of chest pain?

A 
Pneumothorax
PE
Pneumonia
Pleuritis
Lung cancer (not acute, but can cause acute pain)
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39
Q

What are the MSK causes of acute chest pain?

A 
Costochondritis
Trauma
Rib pain
Radicular pain
Fibromyalgia
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40
Q

What are the GI causes of acute chest pain?

A 
GORD
Oesophageal rupture/spasm
Peptic ulcer disease
Cholecystitis
Pancreatitis
Gastritis
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41
Q

What old results are useful for acute chest pain assessment?

A

Old ECGs

Old chest x-rays

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42
Q

Describe the typical chest pain for ACS.

A 
Central, crushing/stabbing.
Radiates to jaw/arm
Assoc. with sweating, N&V
\+/- SoB
Timing - 15 minutes plus
GTN spray helped (if used)
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43
Q

What is the difference between a STEMI and NSTEMI/unstable angina?

A

STEMI causes cardiac muscle death -> ST elevation on ECG.

NSTEMI/unstable angina -> cardiac muscle damage

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44
Q

What is the classic presentation of chest pain for pericarditis?

A 
Positional pain - wrose on leaning forwrad.
Sharp, central, retrosternal
Worsens on deep inspiration
Low grade fever
Pressing on oesophagus -> reflux
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45
Q

How do pericarditis and myocarditis differ in presentation?

A

They are very similar, but myocarditis may also have symptoms of LVHF.

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46
Q

What are the symptoms of cardiogenic pulmonary oedema?

A

Chest pain
SoB
Tachycardia
Arrythmias

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47
Q

A pt presents with pleuritic chest pain and SoB, with haemoptysis. What is the top differential?

A

Pulmonary embolism

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48
Q

A pt with pleuritic chest pain and SoB has an episode of syncope and is cyanosed. What is the top differential?

A

A Massive PE

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49
Q

What can we use to determine assessment and management of a PE?

A

Wells score

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50
Q

What are the elements of the wells score?

A 
S/S of DVT
PE likely diagnosis
HR >100
Immobilisation or recent surgery
PMH of dvt/pe
Haemoptysis
Malignancy
51
Q

A pt presents with chest pain. They describe it as a tearing pain that radiates to the back, and they had an episode of syncope when it first started. What is the most important differential?

A

Aortic dissection

52
Q

A pt with HTN in their PMHx has sudden onset back pain and a postural drop. What is the top differential?

A

AAA

53
Q

How can MSK be distinguished from other types of chest pain?

A

It is reproducible on palpation, and most often follows physical activity

54
Q

What are the classic symptoms of pneumonia?

A

Chest pain
SoB
Increased work of breathing
Fever

55
Q

When a young pt has an MI, what do we need to think about?

A

Cocaine use

56
Q

What are the acute causes of cardiac shortness of breath?

A 
Pulmonary oedema
Acute MI
Cardiac arrythmia
Pericarditis
Pericardial effusion
57
Q

What are the acute causes of respiratory shortness of breath?

A 
Pneumonia
Pneumothorax
PE
Asthma
Acute exaccerbation of COPD
ARDS
Large airway obstruction
58
Q

Other than cardiac and respiratory causes of SoB, what can cause shortness of breath acutely?

A 
Pain
DKA
Drugs e.g. aspirin overdose
Trauma
Anxiety
Thyrotoxicosis
Sepsis
59
Q

What is a primary pneumothorax?

A

A pneumothorax that occurs where there is no underlying lung disease.

60
Q

Who are primary pneumothoraces most common in?

A

Young (teen), tall males.

61
Q

What is a secondary pneumothorax?

A

A pneumothorax that occurs in the presence of underlying lung disease.

62
Q

What is the classic sign of a tension pneumothorax?

A

Deviated trachea

63
Q

Where should the needle be inserted to decompress a tension pneumothorax?

A

2nd intercostal space, midclavicular line

Use a large bore cannula.

After decompression, further management is needed to resolve the problem.

64
Q

What bloods should be done to investigate chest pain and shortness of breath?

A 
FBC
U&Es
LFTs
CRP
Clotting
Cultures
A/VBG
Troponins as appropriate
D-dimers as appropriate
65
Q

Why is analgesia so good for both chest pain and shortness of breath?

A

It prevents pain (duh), decreases anxiety, relaxes patient, causes vasodilation which can reduce symptoms depending on the cause.

66
Q

A child comes in with breathing difficulties. What respiratory symptoms might they be exhibiting?

A

SoB
Cough
Stridor/wheeze
Chest pain

67
Q

A child comes in with breathing difficulties. What non-respiratory symptoms might they be exhibiting?

A

Poor feeding
Abdo pain
Hypotonia
Change in colour of LoC

68
Q

How can respiratory effort be assessed in a child?

A
  • RR
  • Recessions
  • Noises
  • Grunting
  • Accessory muscle use
  • Nostril flaring
  • Gasping
69
Q

Where can recessions be seen on a child who has increased respiratory effort?

A

Intercostal
Subcostal
Sternal
Suprasternal

70
Q

How can respiratory efficacy be assessed in a child?

A
  • Chest expansion
  • Auscultation
  • Pulse oximetry
  • ABG
71
Q

Why do children in respiratory distress become hypotonic?

A

Hypoxic cerebral depression

72
Q

How should a child with respiratory distress be managed in A&E?

A

ABCDE

Airway manoeuvres, adjuncts, and oxygen.

Find the possible cause and start to treat accordingly.

73
Q

Pathology in which areas can cause respiratory distress in a child?

A
  • Upper airway
  • Lower airway
  • Lungs
  • Area around the lungs
  • Respiratory muscles
  • Below the diaphragm
  • Changes to respiratory drive
74
Q

What common upper airway pathologies can cause respiratory distress in a child?

A
  • Croup
  • Epiglottitis
  • FB
75
Q

What common lower airway pathologies can cause respiratory distress in a child?

A
  • Tracheitis
  • Asthma/viral wheeze
  • Bronchiolitis
76
Q

What common lung pathologies can cause respiratory distress in a child?

A
  • Pneumonia

- Pulmonary oedema

77
Q

What common pathologies affecting the areas around the lungs can cause respiratory distress in a child?

A
  • Pneumothorax
  • Pleural effusion/empyema
  • Rib fractures
78
Q

What group of disorders may cause respiratory distress due to their effect on the respiratory muscles?

A

Neuromuscular disorders

79
Q

What pathologies can cause increased respiratory drive in children?

A

DKA
Shock
Poisoning
Anxiety

80
Q

What pathologies can cause decreased respiratory drive in children?

A

Coma
Convulsions
RICP
Poisoning

81
Q

What is the most common cause of stridor in children in the UK?

A

Croup!!

82
Q

How can the severity of croup be assessed?

A

CROUPRHL (catchy innit?)

Cyanosis
Recessions
O2 sats
UPper airway obstruction
RR
HR
LoC
83
Q

What management is used for croup in A&E?

A

According to croup pathway:

  • Dexamethasone 0.15mg/kg PO or IV as appropriate
  • Nebulised budesonide 2mg
  • Nebulised adrenaline 0.5ml/kg

Call for senior help, get ITU involved as necessary.

84
Q

What management is used for asthma in A&E?

A

Via guidelines based on severity of attack:

  • Salbutamol (inhaler/ nebulised/IV as appropriate)
  • Prednisolone/Hydrocortisone (PO/IV as appropriate)
  • Ipatropium bromide
  • MgSO4 IV
  • Aminophylline IV

Call for help/ITU involvement as appropriate

85
Q

What is shock?

A

A state of acute cellular oxygen deficiency

86
Q

What are the 3 stages of shock?

A
  • Compensated
  • Uncompensated
  • Irreversible
87
Q

What are the 5 classes of causes of shock?

A
  1. Hypovolaemic
  2. Distributive
  3. Obstructive
  4. Cardiogenic
  5. Dissociative
88
Q

What is a burn?

A

An injury caused by thermal, chemical, electrical, or radiation energy.

89
Q

Who are burns most common in?

A

Those under 5 and over 75.

90
Q

What is the most common mechanism of injury for burns?

A

Burns or scalding related to the kitchen/cooking.

91
Q

Why are toddlers at higher risk of burns and scalds?

A

They pull hot beverages/pans over themselves, and are more likely to touch hot irons/hair straighteners/hobs as they don’t realise the danger yet.

92
Q

How should a burn be assessed?

A

As per primary survery - ABCDE, with prevention of hypothermia, and appropriate fluid resus.

Assess for other injuries at the same time as per trauma primary survery.

93
Q

If a burn has occured in an enclosed space, what other kind of injury should be considered?

A

Inhalation injury

94
Q

How can the surface area of a burn be measured?

A

By the rule of nines.

95
Q

What is the rule of nines?

A

Each anatomical area on the adult body is 9% of surface area, or a multiple of this:

  • 9% each for each upper limb, and head.
  • 18% of each lower limb, front of trunk, and back of trunk.
  • Genitalia is 1%
96
Q

What surface area does the size of the hand represent?

A

Roughly 1% of total body surface area

97
Q

How can the depth of a burn be described?

A

By degree - first, second, and third OR

  • Epidermal
  • Superficial dermal
  • Deep dermal
  • Full thickness (third degree)
  • Fourth degree (inc. subcut tissues)
98
Q

What additional assessment needs to be made if a burn is circumferential?

A

Status of distal circulation:

  • cyanosis
  • pulses
  • cap refil
  • neurological signs
99
Q

What bloods are important to ask for during primary survery of a burn pt?

A
  • FBC
  • G&S/crossmatch
  • Carboxyhaemoglobin (ABG)
  • Glucose
  • U&Es
100
Q

What monitoring can show if a burn pt is becoming hypoxic or has a metabolic derrangement?

A

ECG - an arrythmia may be the first sign of an abnormality

101
Q

How can we stop the burning process?

A
  • Remove clothing
  • Brush dry chemical powders from wound
  • Rinse involved areas with tap water
102
Q

How can a minor burn be managed?

A
  • Run under cold fresh water for 20 minutes
  • Debride wound
  • Leave small blisters in tact, aspirate larger/awkwardly placed blisters.
  • Non adhesive dressing, or biological dressing.
  • Re-examine after 48 hours

Ensure adequate analgesia

103
Q

How should an acute inhalation injury be managed?

A

May need endotraceal intubation and mechanical ventilation.

Transfer to burn centre once stable.

104
Q

What a burn from flames, what might need to be considered on the B of ABCDE?

A

Breathing in CO -> give 100% oxygen until baseline carboxyhemoglobin is obtained

105
Q

What is the formula used for fluid replacement in burns?

A

The Parkland formula for the total fluid requirement in 24 hours is as follows: 4ml x TBSA (%) x body weight (kg).

50% given in first eight hours; 50% given in next 16 hours

106
Q

What urine output is aimed for in burned pts who are:

a) adults
b) children

A

a) 0.5-1 ml/kg/hour

b) 1-2 ml/kg/hour

107
Q

What 2 things are very important to remember when managing a burns patient?

A

Analgesia and preventing hypothermia

108
Q

What specific complication can occur secondary to electrical burns?

A

Rhabdomyolysis

109
Q

What is the primary survery?

A

Initial assessment and management of a trauma patient, performed to detect and treat imminent life threats and prevent complicaitons.

110
Q

How does a primary survery compare to standard ABCDE?

A

Major haemorrhage comes first
A - includes C spine control
B - Full expose, percuss, ascultate, palpate!! Basically do everything more thoroughly but quickly.
C
D - GCS, pupils, blood glucose as per.
E - palpate everything|! Log roll for full assessment

Very important to reassess as you go along.

111
Q

How should Cspine be protected?

A

Immobilise with hands initially, then place collar and blocks to prevent pt from mobilising C spine.

112
Q

What immediately life threatnening things might be found on primary survery on the B section?

A
  • Tension pneumothorax
  • Massive haemothorax
  • Open pneumothorax
  • Flail chest
  • Ruptured diaphragm
113
Q

If IV cannula insertion isn’t an option e.g. on a shocked pt, what is a good alternative for access?

A

Inserting an intraosseous line

114
Q

How should fluids be given to a trauma patient?

A

They should be warmed before administration

115
Q

Who is head trauma more common in?

a) men or women?
b) children under 15 or adults 15-75?

A

a) men

b) children under 15

116
Q

What is the most common common factor in adult head injuries?

A

Alcohol

117
Q

Other than alcohol, what risk factors are common in head injuries?

A

Falls, assaults, and RTCs.

118
Q

How should a pt with GCS of 14/15 be assessed following head injury?

A
  • Hx and obs
  • Neurological examination
  • Examine for other injuries
  • CT head if indicated by guidelines
119
Q

How should a pt with GCS of 13 or less be assessed following head injury?

A

Resus and get them scanned within an hour (CT head)

120
Q

What are the indications for a CT head following head injury in adults?

A
  • GCS less than 13 at first assessment or less than 15 2 hours after injury
  • Suspected open or depressed skull fracture
  • ?Basal skull fracture
  • Post-traumatic seizure
  • > 1 discrete episode of vomiting
  • Focal neurological deficit
  • Amnesia
  • Anticoagulation or coagulopathy
121
Q

What are the signs of a basal skull fracture?

A
  • Panda eyes
  • Battle sign
  • CSF otto/rhinorrhoea
  • Haemotympanum
122
Q

How do the guidelines for CT head following injury differ for children compared to adults?

A

Includes:

  • ?NAI
  • Tense fontanelle
  • Aged <1 withbruise, swelling, or laceration >5cm on head.
  • Witnessed LoC
  • Dangerous mechanism of injury
  • Abnormal drowsiness

Differences:

  • GCS <14 initially
  • 3+ episodes of discrete vomiting
123
Q

How should a suspected C-spine injury be investiagted?

A
  • C spine x ray

- CT C spine if xray not adequate

124
Q

What are the possible complications of head injury?

A
  • Amnesia
  • RICP
  • Cerebral herniation
  • CSF leak
  • Meningitis
  • Intracranial haemorrhage
  • Skull fracture
  • Seizures
  • Concussion

Emergency Medicine Assistantship (12 decks)

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