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Yr 3/4emergency medicine > quesmed emergency med > Flashcards

quesmed emergency med Flashcards

1
Q

Management of PEA and Asystole
These rhythms are not compatible with life, and CPR should be commenced immediately with interruptions minimised.

how often do you give adrenaline and how much

A

Adrenaline 1mg IV is given in the first cycle, and, should a non-shockable rhythm persist, every other cycle (i.e. cycles 1, 3, 5 etc.).

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2
Q

describe VF

A

Ventricular tachycardia presents as a regular broad complex tachycardia on cardiac monitoring.

Ventricular fibrillation presents as as chaotic irregular deflections of varying amplitude

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3
Q

if shock has not bought someone back from VT and VF what can you do

A

rapid chaotic waves of varying amplitudes with no discernible P waves, QRS complexes or T waves. The carotid pulse is not palpable.

Defibrillation and CPR are the mainstays of treatment. However if persistent, Amiodarone 300mg IV (same dose used to treat monomorphic VT) and Adrenaline 1mg IV (1:10,000) can be given after the third shock has been delivered.

Amiodarone is given as a one-off dose. However Adrenaline may be repeated every other cycle following a shock (i.e. cycles 3, 5, 7 etc.)

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4
Q

doses of aspriin and clopidogrel in MI

A

300mg

later reduced to 75mg

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5
Q

features of hypoglycaemia

A

Shaking/trembling
Sweating
Palpitations
Hunger
Headache
Double vision and difficulty concentrating
Slurred speech
Confusion
Coma

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6
Q

causes of hypoglycaemia

A

Drugs
Insulin
Sulphonylureas
GLP-1 analogues
DPP-4 inhibitors
Beta-blockers
Alcohol
Acute liver failure
Sepsis
Adrenal insufficiency
Insulinoma
Glycogen storage disease

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7
Q

endogenous insulin

A

C-peptide is a more accurate test of islet cell function

Endogenous insulin refers to the insulin the pancreas makes, and exogenous insulin refers to the insulin people inject or infuse via an insulin pump.

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8
Q

elevated proinsulin means what

A

Elevated intact proinsulin seems to indicate an advanced stage of β-cell exhaustion and is a highly specific marker for insulin resistance.

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9
Q

High insulin AND high C-peptide and proinsulin

A

endogenous production

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10
Q

High insulin AND low C-peptide and proinsulin

A

Exogenous administration

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11
Q

Management of Mild Hypoglycaemia (Still Conscious)

what should you avoid - slows down how fast reaches blood stream

A

ABCDE
Eat/drink 15-20g fast acting carbohydrate such as glucose tablets, a small can of Coca-Cola, sweets or fruit juice.
AVOID chocolate
Eat some slower acting carbohydrate afterwards (e.g. toast)

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12
Q

Management of Severe Hypoglycaemia (eg. Seizures, Unconscious)

A

ABCDE
200ml 10% dextrose IV 0r 100ml of 20%
1mg/kg glucagon IM if no IV access (will not work if caused by acute alcohol because of its action in blocking gluconeogenesis)
Treat seizure if prolonged or repeated

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13
Q

Management of Severe Hypoglycaemia (eg. Seizures, Unconscious)

A

ABCDE
200ml 10% dextrose IV 0r 100ml of 20%
1mg/kg glucagon IM if no IV access (will not work if caused by acute alcohol because of its action in blocking gluconeogenesis)
Treat seizure if prolonged or repeated

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14
Q

glandular fever make what noise

A

stridor as tonsils swells
EBV - Paul Bunnell’ test will be positive if performed
advise against heavy lifting

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15
Q

Status epilepticus describes any seizure activity that lasts more than 5 minutes or if the patient experiences more than one seizure and does not fully regain consciousness between the two.

managemnet 1st line and so on

A
  1. IV lorazepam 4mg
  2. A second dose of lorazepam should be given if no response
    In the absence of IV access, PR diazepam or buccal midazolam can be administered. - can also be first line if no IV
    If the initial benzodiazepine fails, further anti-convulsants can be used:
  3. Leviteracetam, Phenytoin, Valproate
    If seizures continue to persist, intubation and general anaesthesia is necessary.
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16
Q

sx of pe

A

Symptoms

Sudden-onset shortness of breath, pleuritic chest pain, and haemoptysis (this is the ‘typical’ triad, although note that all three features are rarely present).

A massive pulmonary embolism may present with the above and syncope/shock.

A small pulmonary embolism may be asymptomatic.

Signs

Classically tachypnoea, tachycardia and hypoxia is present. There may be low-grade pyrexia. Tachycardia may be the only presenting sign.

Note that a small pulmonary embolism may result in a normal examination.

A massive pulmonary embolism may present with hypotension, cyanosis, and signs of right heart strain (such as a raised JVP, parasternal heave, and loud P2).

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17
Q

V/Q scan prefeered in

A

renal impairment, contrast allergy or is pregnant.

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18
Q

medical managemnt of pe if no obviosu RF

A

DOAC for 6 months

A provoked PE (identifiable risk factors e.g. surgery, peri-partum) should be treated for 3 months. An unprovoked PE should be treated for 6 months. If there is an ongoing cause (e.g. a thrombophilia) the patient should be treated for life.

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19
Q

provoked PE post surgery how long on anticoagulation

A

3 months

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20
Q

how could ramipril worsen aki

A

Ramipril may worsen pre-renal AKI by selectively reducing glomerular pressure. ACE inhibitors inhibit bradykinin, thereby constricting the afferent arterioles, causing increased resistance and reduced renal perfusion. It is therefore imperative to stop it.

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21
Q

5 points for managing aki

A

Management of Acute Kidney Injury is based around the following:

  1. Find and treat causes (e.g. sepsis, drugs, obstruction)
    Bloods - FBC, U+Es, CRP, consider antibody screen if autoimmune cause suspected
    Urine dip and microscopy
    Bladder scan - if retention suspected
    Ultrasound renal tract - if obstruction suspected
    ECG - looking for hyperkalaemia/pericarditis
  2. Stop renotoxic drugs
    ACE-I/ARBs
    Spironolactone
    Diuretics
    Gentamicin - may need dose adjustment if necessary for treatment
    NSAIDs
  3. Give IV fluid - aggressiveness depends on severity of AKI and comorbidities
  4. Treat complications (e.g. hyperkalaemia, acidosis)
  5. Give dialysis if:
    Persistently high potassium that is refractory to medical treatment
    Severe acidosis (pH<7.2)
    Refractory pulmonary oedema
    Symptomatic uraemia (pericarditis, encephalopathy)
    Drug overdose (e.g. aspirin)
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22
Q

1st line treatment of thyroid storm

A

Propylthiouracil (PTU)

This patient presents with thyroid storm which is a life-threatening complication of untreated hyperthyroidism. The very low TSH level and elevated T4 and T3 levels indicate primary hyperthyroidism

Treatment consists of conservative measures (e.g. fluids, cooling) and the triad of PTU, propranolol & steroids

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23
Q

sx of thyroid storm

A

storm include palpitations, restlessness, tremor, hyperthermia, hypertension and confusion.

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24
Q

why is PTU preferred to carbimazole in a thyroid storm

A

Propylthiouracil (PTU) is preferred to carbimazole in the treatment of thyroid storm as, in addition to inhibiting the production of thyroid hormone, it also inhibits the conversion of T4 to the active T3 form in the periphery. Steroids also prevent this peripheral conversion and hence they are recommended along with propranolol for symptomatic relief

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25
Q

PTU or carbimazole CI in preg

A

carbimazole

propnaolol symptomatic relief

26
Q

how does propanolol provide symptomatic relief in a thyroid storm

A

Symptomatic relief can achieved by Beta-blockers, especially propranolol, which blocks beta-adrenoreceptors (which thyroid hormones upregulate) as well as reduces the conversion of T4 to T3.

27
Q

He is sweaty and there are fine inspiratory crepitations throughout the lung fields. what thinking H?

A

pulmonary oedema - sit them up and then order investigation

28
Q

what is a strokes adam attack

A

cardiac syncope to bradycardia

29
Q

suspected sepsis with symtpoms of pyrexia, tachycarida and hypotension what shoudl also treat with in mind

A

The likely diagnosis is a thyrotoxic storm with classic findings of pyrexia, tachycardia, hypotension and general malaise. Initial treatment after the sepsis six protocol is initiated is to promptly treat the tachycardia with a beta-blocker, or diltiazem if beta-blockers are contraindicated. It is important to treat immediately on a clinical diagnosis without waiting for thyroid-function results.

IV propanolol

30
Q

need O2 how much through what

A

Apply 15L/min oxygen via non-rebreathe facemask

31
Q

WPW management

A

Management of WPW
Radiofrequency ablation of the accessory pathway
Drug treatment (such as amiodarone or sotalol) to avoid further tachyarrhthmias. CI - structural heart disease.
Surgical (open heart) ablation - complex case only

Contraindications in WPW
Digoxin and NDP-CCBs (e.g. verapamil) are contraindicated for long term use because they may precipitate ventricular fibrillation.

supraventricular tachycardia
Unstable patients - direct current (DC) cardioversion.
stable patients - managed according to the rhythm-

In patients with an orthodromic AV reciprocating tachycardia (narrow QRS complex with short PR interval) management is with vagal manoeuvres (carotid sinus massage or Valsalva manoeuvre) in the first instance.
If this fails IV adenosine should be administered.
Note that in orthodromic AV reciprocating tachycardias one limb of the aberrant circuit involves the AV node so slowing conduction through the AV node helps terminate the tachycardia.
In patients with antidromic AV reciprocating tachycardia (wide QRS complex), atrial fibrillation, or atrial flutter intravenous anti-arrhythmics (such as procainamide or flecainide) help prevent rapid conduction through the accessory pathway.
DC cardioversion may be used if symptoms persist.

32
Q

what sedative best in asaethesia for seizure

A

Propofol or thiopental is an appropriate agent to use in the management of refractory status epilepticus. It is controversial whether one is superior to the other, as historically barbiturates (like thiopental) have been used as a first-line agent. Thiopental has a lower rate of treatment failure and breakthrough seizures, but a prolonged hospital stay and recovery. In younger people, there is concern relating to the use of high-dose propofol, as they are risk of propofol infusion syndrome.

33
Q

addisonian crisis treatment - It is an example of a medical cause of the ‘acute abdomen’. Patients with an Addisonian crisis can present variably such as with shock, abdominal pain or hypoglycaemia. It can be accompanied by mild hyponatraemia and hyperkalaemia

A

Hydrocortisone 100mg IM

34
Q

young man with abdomen pain what should you also check

A

testicles - torsion

35
Q

A 35-year old East Asian lady presents to the A&E department complaining of a headache, which came on quite suddenly last evening. She also feels very nauseous and noticed the vision in her left eye is blurry and it has also become quite red.

Apart from having migraines as a teenager, she is otherwise fit and healthy with no significant past medical history. She recently started taking amitriptyline as she had trouble sleeping. She has no drug allergies.

Her basic observations are as follows:

HR 100, RR 20, T 37.0, BP 130/80, SO2 98%

Given her underlying diagnosis, which of the following is the best initial treatment for her?

A

acute angle closure glaucoma
This lady has acute angle closure glaucoma. Risk factors include being female, Asian and the use of certain medications including those with antimuscarinic properties, such as amitriptyline. Patients with acute angle closure glaucoma complain of a sudden headache, nausea and loss of vision. Symptoms may worsen at night. The initial management includes administering IV Acetazolamide and a topical beta-blocker such as Timolol. An urgent Ophthalmology referral should be made

36
Q

both intial and definitve treatment for acute angle glaucoma

A

The initial management includes muscarinic agonists such as pilocarpine eye drops; oral acetazolamide and a topical beta-blocker such as Timolol. An urgent Ophthalmology referral should be made.

The definitive management for this condition is a peripheral iridotomy to relief the intraocular pressure.

37
Q

This patient likely has ……… …….. …….due to the symptoms of shortness of breath, sweatiness and nausea, the positive fluid balance and the findings on auscultation. Widespread coarse crackles on auscultation

what is it

A

acute pulmonary oedema

need to give IV furosemide

38
Q

severe acute pulmonary odema management

A

Oxygen, Morphine, Metoclopramide, IV Furosemide

39
Q

emergency managemnt of phaecytochromotma

A

Phentolamine

This is the ideal initial management of a symptomatic phaeochromocytoma because it blocks mainly alpha adrenergic receptors leading to vasodilation and reduction in blood pressure

The definitive treatment is surgical to resect the tumour.
Pre-operatively, alpha blockade with phenoxybenzamine is started first followed by consideration of beta blockade to expand blood volume and prevent hypertensive crises.

40
Q

complications of addesonian crisis

A

Low blood pressure
Vomiting and diarrhoea
Dehydration
Shock
Coma
Death

41
Q

management of adesonian crisis

A

Management includes:

Fluid resuscitation is hypotensive.
IV hydrocortisone 100mg (Stat and then continue regularly)
IV glucose if hypoglycaemic
Swap back to their oral steroids after 3 days
Consider fludrocortisone if there is adrenal disease

42
Q

DKA management

A

alert and not dehydrated - oral intake and SC insulin
If patient is vomiting, confused, or significantly dehydrated –> give IV fluids (initial bolus of 10ml/kg 0.9% NaCl then discuss with a senior) and insulin infusion at 0.1 units/kg/hour 1hr after starting IV fluids. If there is evidence of shock, the initial bolus should be 20ml/kg.
If patient is shocked or comatose –> ABCDE approach for emergency resuscitation

43
Q

mx of tension p

A

high flow 02
needle decompression 16guage

44
Q

mx primary p

A

If the patient is NOT short of breath AND the pneumothorax is <2 cm on a chest x-ray conservative management is sufficient. The patient can be discharged and reviewed in the outpatient department in 2-4 weeks.

If the patient IS short of breath OR the pneumothorax is >2 cm the pneumothorax should be aspirated with a 16-18G cannula under local anaesthetic.

if under 1cm and symtpomatic can discharge
If this is successful the patient can be discharged. If this fails an intercostal drain is necessary (and the patient must be admitted).

aspiration

45
Q

secondary p

A

If the patient is NOT short of breath AND the pneumothorax is <1 cm on the chest x-ray they do not require further invasive intervention but should be admitted for observation for 24 hours and administered oxygen as required.

If the patient is NOT short of breath and the pneumothorax is 1-2 cm on the chest x-ray aspiration is required. If this is successful the patient can be admitted for 24 hours of observation. If this is unsuccessful and intercostal drain is necessary.

If the patient IS short of breath OR the pneumothorax is >2 cm on the chest x-ray an intercostal drain is necessary (and the patient should be admitted).

46
Q

IV furosemide has not worked what next

A

IV dobutamine

Intravenous inotropes (e.g. dobutamine, milrinone) may sometimes be necessary in managing patients with a severely reduced LV systolic function. These measures are done to maintain systemic perfusion to the end-organs

47
Q

is potassium added in the first bag when treating DKA

A

no

insulin started 1 hour after fluids given - insulin drives potassium into cells which is hwy monitor otassium

hypovaolaemia sevre as DKA caue osmotic diuressi - increased urine result in volume depletion so need to replace

48
Q

recent history of viral illness and raised troponin

A

myocarditis

49
Q

cherry red lips

A

carbon monozide posioning

need 15l oxygen via non-rebreathe mask

50
Q

He has an ECG which shows ST depression, broad R waves, and upright T waves in leads V1-3.

what ix next

A

ECG with leads V7-9 on the back

The ECG changes are typical of those which appear in a posterior myocardial infarction. If a STEMI occurs then in the posterior area of the heart then reciprocal changes are seen in the anterior and septal leads of V1-3. In order to investigate the posterior aspect of the heart directly leads must be placed on the back - these are leads V7-9

NSTEMI suspect post

51
Q

AKI most improtnt thing

A

IV fluid resus

52
Q

necrotising fascitis seen in

A

diabetes
need surgical debridement and wash out
can use CT and MRI to confirm if needed

53
Q

when is GTN contrindicated

A

in patients with systolic BP less than 90

54
Q

ABG shows that carboxyhaemoglobin level increased.

A

CO poisoning

55
Q

Kernig and Brudzinski signs.

A

menignitis tests

56
Q

encepahltiis tx

A

The empirical treatment for suspected encephalitis includes IV acyclovir and IV ceftriaxone to cover for bacterial infections.

57
Q

another name for shockable ryhtms

A

usynchronsied DC cardioversion - ireggular broad complex tachy( assumed to be VF)

synchronised is for unstabel tachys

58
Q

mx of upper gi bleed

A

Initial management involves an A-E assessment, focussing on IV fluid resuscitation and blood transfusion (if Hb <7) with or without platelets and fresh frozen plasma (every 4th unit of blood).
Recent evidence suggests that overtransfusion increases mortality therefore patients should not be transfused to a normal haemoglobin.
The patient should be NBM and supplemental oxygen given.
IV PPI may also be initiated.
In variceal bleeding, IV terlipressin and antibiotics are used.
Once stable, upper GI endoscopy is carried out to locate the source of the bleeding and attempt to stop further bleeding through various mechanisms, such as adrenaline injection and ulcer clipping.

59
Q

severe vomiting and haematemesis

A

mallory weiss

60
Q

epigastic pain radiating to back na relieved by leaving forward
nausea

A

acute pancreatitis

Yr 3/4emergency medicine (10 decks)

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