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Year 6 > Emergency med 2 > Flashcards

Emergency med 2 Flashcards

1
Q

Approach to head injury?

A

ABCDE assessment

Involve neurosurgeons at an early stage, especially with comatose patients, or if raised icp suspected.

  • Examine the cns - basic obs + pupils every 15min.
  • Assess anterograde amnesia and retrograde amnesia—its extent correlates with the severity of the injury.

After assessment consider CT head

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2
Q

when is CT head requiired in head injury?

A
  • gcs <13 at any time, or gcs 13 or 14 at 2h following injury
  • Focal neurological deficit
  • Suspected open or depressed skull fracture, or signs of basal skull fracture (haemotympanum, ‘panda’ eyes, csf leak through nose/ears, Battle’s sign)
  • Post-traumatic seizure
  • Vomiting >once
  • Loss of consciousness and any of the following:
  • Age ≥65
  • Coagulopathy
  • ‘Dangerous mechanism of injury’, eg car crash or fall from great height
  • Anterograde amnesia of >30min
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3
Q

On assessment of patient with head injury, which situations require immediate ventilation?

A
  • Coma ≤8 on Glasgow coma scale
  • PaO2 <9kPa in air (<13kPa in O2) or PaCO2 >6kPa
  • Spontaneous hyperventilation (PaCO2 <3.5kPa)
  • Respiratory irregularity
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4
Q

criteria for admission after head injury?

A
  • Difficult to assess (child; postictal; alcohol intoxication)
  • cns signs; severe headache or vomiting; fracture

• Brief loss of consciousness does not require admission if well and a responsible adult is in attendance

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5
Q

for a drowsy trauma patients (gcs 8-14) smelling of alcohol, how do we know if their signs a due to alcohol?

A
  1. Blood alcohol
    - Alcohol is an unlikely cause of coma if plasma alcohol <44mmol/L
  2. Osmolar gap
    - if blood alcohol ≈ 40mmol/L then osmolar gap ≈ 40mmol/L
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6
Q

List complications of a head injury?

A

Early:
Extradural/subdural haemorrhage, seizures.

Late:
Subdural haemorrhage,
Diabetes insipidus,
Parkinsonism, dementia.

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7
Q

What is the mx of increased ICP?

A
  1. IV Mannitol:
    - short term use, lest rebound ICP occurs

1b. Corticosteroids
- if effusion around tumour

  1. Fluid restriction
    - to less than 1.5L a day
  2. Monitor carefully
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8
Q

which brain herniation presents as;

causing a dilated ipsilateral pupil (3rd nerve palsy),
then ophthalmoplegia.
This may be followed (quickly) by contralateral hemiparesis

A

uncal herniation

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9
Q

which brain stem herniation presents as;

Ataxia, vith nerve palsies, and upgoing plantar reflexes occur first, then loss of consciousness, irregular breathing, and apnoea

A

Cerebellar tonsil herniation

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10
Q

which brain stem herniation presents as;

may be silent unless the anterior cerebral artery is compressed and causes a stroke—eg contralateral leg weakness ± abulia (lack of decision-making).

A

subfalcine herniation

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11
Q

complications of MI?

A

DARTH VADE

Death
Arrhythmias
Myocardial rupture  
Tamponade
Heart failure

Valve disease
Aneurysm
Dressler syndrome - Pericarditis 2nd or 3rd day
Embolism

others:
Recurrent ischaemia
Infarct extension/expansion causing;
Mural thrombus
Cardiogenic shock
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12
Q

How do we approach a suspected STEMI?

A
  1. ABCDE
  2. Circulation:
    A. 12 lead ECG
    B. IV access: Blood tests on admission: u&e, troponin, cardiac enzymes, glucose, cholesterol, fbc.
  3. Take brief history, do a quick physical examination eg CCF signs, JVP
    3b. Imaging; CXR
  4. Dual antiplatelets; Aspirin 300mg +
    - 2021: Followed by another anti-platelet; Ticagrelor 180mg
    - Use prasugrel if getting PCI
  5. IV Morphine 5-10mg + IV Metoclopramide (a-emetic) 10mg
  6. PCI - if presenting within 12h of sx onset and pci can be done within 2 hrs
  7. Fibrinolysis if PCI not around in 120 mins (2 hours)
    • and if no contraindications
    • IV alteplase
    • afterwards give aspirin + ticagrelor

• Oxygen is recommended if patients have SaO2 <95%, are breathless or in acute lvf.

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13
Q

when would GTN be indicated in STEMI?

A

if hypertensive

or acute LVF

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14
Q

what does PCI involve?

A

2021 - NICE

Done in the cathlab

Angiography done first before PCI

anticoagulation is given as part of this;
Bivalirudin is preferred, if not available use enoxaparin ± a gp iib/iiia blocker.

Also give Prasugrel (unless high bleeding risk then give ticagrelor)

Radial access should be considered in preference to Femoral access which is what is usually used.

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15
Q

contraindications to thrombolysis?

A
  • Previous intracranial haemorrhage
  • Ischaemic stroke <6months
  • Cerebral malignancy or avm
  • Recent major trauma/surgery/head injury (<3wks)
  • gi bleeding (<1 month)
  • Known bleeding disorder
  • Aortic dissection
  • Non-compressible punctures <24h eg liver biopsy, lumbar puncture
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16
Q

ECG signs of NSTEMI?

A

ecg: st depression; flat or inverted t waves; or normal.

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17
Q

Mx of NSTEMI?

A
  1. Admit to CCU

O2 if sats <90%

6drugs:
IV Morphine 5-10mg + IV Metoclopramide 10mg (antiemetic)

GTN spray or sublingual

300mg Aspirin + Clopidogrel 300mg (or another P2Y12i)

Fondoparinux 2.5mg SC PO (or lmwh) - inject on abdomen

  1. IV nitrate (GTN 50mg in 50ml saline 0.9%)

before discharge;
aspirin + clopidogrel 75mg - may need clop for 12m

PO Beta-blocker (atenolol) unless contraindicated

start of ACEi + Statin. Make sure troponin has normalised

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18
Q

what meds should someone be on after an MI (ongoing care) ?

A

5 drugs

Dual antiplatelet therapy:
A. Aspirin - 300mg loading then 75mg
B. Clopidogrel - 300mg loading then 75mg
(or prasugrel or ticagrelor)

Ramipril 2.5mg BD

Atorvastatin

Spirinolactone - if signs of heart failure (K sparing diuretic - or epleronone)

(may also be given BBlocker and SGLT2i - dapagliflozin (if lvef<40)

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19
Q

What is the mx for when symptoms recur in an NSTEMI

A

refer to cardiologist for urgent;

Imaging; angiography

Rx; pci or cabg.

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20
Q

iivx findings in STEMI and NSTEMI?

A

see y3 folder

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21
Q

list some differentials for Broad complex tachycardias?

A

Regular complexes:
• Ventricular tachycardia (VT) - most common

• Ventricular fibrillation—chaotic, no pattern

Irregular complexes;
• SVT - eg AF but only IF with bundle branch block it becomes broad complex
• Polymorphic VT - including torsades de pointes.
—–
• Pre-excitation tachycardias,
AVRT with underlying wpw

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22
Q

summary of broad complex tachycardia mx?

A

If haemodynamically stable;

  1. correct electrolyte disturbance - low K,Mg,Ca
  2. Below

Regular;
Amiodarone 300mg IV over > 20mins

Irregular;
if SVT - IV adenosine 6mg

Torsades - IV Mg2+

  • If haemodyn unstable;*
    1. Call for specialist input
    2. Synchronised DC shocks
    3. steps above
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23
Q

after correction of VT / BCT whats next?

A

Oral anti-arrhythmic agent; Sotalol

If BCT happened after MI, continue Amiodarone infuson for 12-24h

Might need implantable cardioverter defibrillator (icd)

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24
Q

what is the difference ini managing ventricular fibrillation?

A

Use NON-synchronised shocks

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25
Q

what are the commonest post-mi arrhythmia?

A

ventricular ectopics

26
Q

what are the commonest post-mi arrhythmia?

A

ventricular ectopics

patients describe palpitations, a thumping sensation, or their heart ‘missing a beat’.

On ecg, ventricular ectopics are broad qrs complexes; they may be single or occur in patterns.

27
Q

how do we mx torsades de pointes with long-qt syndromes (usually found together)

A

stop all predisposing drugs,

correct hypokalaemia, and give magnesium sulfate (2g iv over 10min).

Alternatives include: overdrive pacing

Torsades is VT, so amiodarone etc

28
Q

list the causes of pulmonary oedema

A
  • Cardiovascular, usually left ventricular failure (post-mi or ischaemic heart disease). Also valvular heart disease, arrhythmias, and malignant hypertension.
  • ARDS from any cause, eg trauma, malaria, drugs. Look for predisposing factors, eg trauma, post-op, sepsis. Is aspirin overdose or glue-sniffing/drug abuse likely? Ask friends/relatives.
  • Fluid overload.
  • Neurogenic, eg head injury.
29
Q

list signs / sx off pulmonary oedema?

A

Dyspnoea, orthopnoea (eg paroxysmal), pink frothy sputum. nb: note drugs recently given and other illnesses (recent mi/copd or pneumonia).

Signs;

Distressed, pale, sweaty, ↑pulse, tachypnoea,
pink frothy sputum, pulsus alternans,

↑jvp, fine lung crackles, triple/gallop rhythm, wheeze (cardiac asthma).

Usually sitting up and leaning forward.

30
Q

ivx for pulmonary oedema?

A

• cxr:
cardiomegaly, signs of pulmonary oedema: look for shadowing (usually bilateral), small effusions at costophrenic angles, fluid in the lung fissures, and Kerley b lines (septal linear opacities).

  • ecg: signs of mi, dysrhythmias.
  • u&e, troponin, abg.
  • Consider echo.
  • bnp - may be helpful if diagnosis in question (high negative predictive value).
31
Q

list the causes of cardiogenic shock?

A
  • Myocardial infarction.
  • Arrhythmias.
  • Pulmonary embolus.
  • Tension pneumothorax.
  • Cardiac tamponade
  • Myocarditis; myocardial depression (drugs, hypoxia, acidosis, sepsis) .
  • Valve destruction.
  • Aortic dissection
32
Q

Mx of DKA - ketoacidosis?

A

see paeds DKA cards

33
Q

How do we manage Hyperglycaemic hyperosmolar state?

A
  1. Rehydrate slowly (according to deficit) with 0.9% saline IVI over 48h
  2. Replace K+ when urine starts to flow
    - Only use insulin if blood glucose not falling by 5mmol/L/h with rehydration or if ketonaemia
34
Q

complications of taking metformin?

A

Lactic acidosis

A rare but serious complication of dm with metformin use or septicaemia. Blood lactate: >5mmol/L

35
Q

how shall we ivx an acute asthma attack?

A

PEF—but may be too ill; abg if saturations <92% or life-threatening features

CXR (if suspicion of pneumothorax, infection or life-threatening attack)

FBC & u&e

36
Q

side effects of salbutamol?

A

(β‎2-agonist)

tachycardia, arrhythmias, tremor, ↓K+.

37
Q

differentials for acute asthma

A

pulmonary oedema,
upper respiratory tract obstruction, pulmonary embolus,
anaphylaxis
inifective exacerbation of cold

38
Q

how do we ivx infective exacerbation of copd?

A
  • abg
  • cxr to exclude pneumothorax and infection.
  • fbc; u&e; crp. Theophylline level if patient on therapy at home.
  • ecg.
  • Send sputum for culture if purulent.
  • Blood cultures if pyrexial.
39
Q

causes of upper GI bleeding?

A
  • Peptic ulcer disease (pud) 35–50%.
  • Gastroduodenal erosions 8–15%.
  • Oesophagitis 5–15%.
  • Mallory–Weiss tear 15%.
  • Varices 5–10%.
  • Other: upper gi malignancy, vascular malformations
40
Q

signs and sx of upper GI bleed?

A

depends on cause really:

Haematemesis, or melaena, dizziness (especially postural), fainting,

abdominal pain, dysphagia? Hypotension (in young may be postural only), tachycardia (not if on β‎-blocker),

↓jvp, ↓urine output, cool and clammy, signs of chronic liver disease (p[link]), eg telangiectasia, purpura, jaundice. nb: ask about previous gi problems, drug use, alcohol.

41
Q

Gastro-oesophogeal varices may be secondary to increased portal pressures. list causes of oncreased portal pressures?

A

Causes of portal hypertension
Pre-hepatic:
Thrombosis (portal or splenic vein).

Intra-hepatic:
Cirrhosis (80% in uk); schistosomiasis (commonest worldwide); sarcoid; myeloproliferative diseases; congenital hepatic fibrosis.

Post-hepatic:
Budd–Chiari syndrome ; right heart failure; constrictive pericarditis; veno-occlusive disease

42
Q

what are the causes of stroke?

A
  • Small vessel occlusion/cerebral microangiopathy or thrombosis in situ.
  • Atherothromboembolism (eg from carotids).
  • CNS bleeds (↑bp, trauma, aneurysm rupture, anticoagulation, thrombolysis).
  • Cardiac emboli - >30% of cases
    • Atrial fibrillation
    • Cardioversion - why we anticoag 1st
    • Prosthetic valves
    • Acute myocardial infarct with large left ventricular wall motion abnormalities on echocardiography.
    • Patent foramen ovale/septal defects.
  • Cardiac surgery.
  • Infective endocarditis (gives rise to septic emboli;
43
Q

How do we mitigate stroke in some1 with AF - atrial fibrillation?

A

Cha2ds2vasc score can be used to calculate risk of STROKE in patients with af.

Offer anticoagulation in patients with a score of 2 or above.

Take bleeding risk into account: calculate the risk of major bleeding using the HAS-BLED score.

Caution and regular review of oral anticoagulants are required if the HAS-BLED score >3.

Do not offer stroke prevention therapy in patients with af if <65y and cha2ds2vasc score is 0 for men or 1 for women.

Offer anticoagulation with a direct‑acting oral anticoagulant to people with atrial fibrillation and a CHA2DS2‑VASc score of 2 or above, taking into account the risk of bleeding. Apixaban, dabigatran, edoxaban

44
Q

Mx of stroke?

A

Summarised:

300mg Aspirin
Admit to specialised stroke unit
CT head to rule out haemorrhage

IV Alteplase - if no haemorrhage or CI to thrombolysis

Ongoing:

  1. 300mg aspirin 2 weeks after stroke - if not haemorrhagic
  2. Switch to long term Clopidogrel (or dipyridamole)

Haemorrhagic;
1a. If GCS score ≤8 - Consider endotracheal intubation and maintain sats above 94%
1b. admit to acute or hypera-acute stroke unit
2. neurosurgeon input
3. reduce BP (if no cx or upcoming surgery)
4. reverse anticoagulation
(warfarin: prothrombinase complex + vitamin k)
(Fxa inhibitors: prothrombinase complex)

Neurosurgery may want to evacuate haematoma

Monitor:
Basic obs, Conscious level, Glucose, ECG

45
Q

complications of stroke?

A
  1. Complications related to immobility such as pressure sores, aspiration pneumonia, constipation, and contractures
  2. Mental health - depression in them + carer
  3. Significant morbidity - reduced indepence in ADLs (try to mobilise them asap after treatment)
46
Q

how may cerebral infarcts present (signs)?

A

Depending on site there may be contralateral sensory loss or hemiplegia—initially flaccid (floppy limb, falls like a dead weight when lifted), becoming spastic (umn); dysphasia; homonymous hemianopia; visuo-spatial deficit.

47
Q

what are the scoring systems for patietns with acute coronary syndromes? their meaning?

A

They both predict mortality;

GRACE score - for ACS
- also used to decide if someone with NSTEMI should have PCI immediately or just medical management.

TIMI score - for NSTEMI and UA.

48
Q

how to tell difference between NSTEMI and unstable angina?

A

troponin is increased in NSTEMI because cardiac myosite death.

49
Q

Which medications are known to cause falls?

A

The most common drug causes are:

  • Benzodiazepines and other hypnotics
  • Antidepressants (tricyclics and selective serotonin reuptake inhibitors (SSRIs)
  • Antipsychotics
  • Opiates
  • Diuretics
  • Antihypertensives, especially ACE inhibitors and α‎-blockers
  • Antiarrhythmics
  • Anticonvulsants
  • Skeletal muscle relaxants, e.g. baclofen, tizanidine
  • Hypoglycaemics, especially long-acting oral drugs and insulin
50
Q

What are the differentials for falls?

A

1 • Frailty and unsteadiness

2 • Syncope (if LOC)

  • Reflex; vasovagal
  • Cardiac;
    a. arrhythmia; SVT, VT, bradycardia, fast AF, heart block, bradycardia etc
    b. structural (aortic stenosis, HOCM)
  • Orthostatic:
    a. drugs, dehydration, sepsis (vasodilation = intravascular volume loss)
  • Cerebrovascular
    a. aortic dissection, subclavian steel

3 • Neurological problems
epileptic seizures,
psycogenic seizures
Head truama, narcolepsy

  1. Metabolic
    - hypoglycaemia
    - intoxication; alcohol
51
Q

How to treat postural hypotension?

A
  • Treat the cause. Stop, reduce, or substitute drugs incrementally
  • Reduce consequences of falls (e.g. pendant alarms)
  • Modify behaviour—stand slowly and stepwise; lie down at prodrome
  • If still salt- or water-deplete, supplement with:
  • Sodium (liberal salting at table or sodium chloride (NaCl) tablets)
  • Water (oral or intravenous fluids)
  • Consider starting drugs if non-drug measures fail:
  • Fludrocortisone (0.1–0.2mg/day)
  • α‎-agonists, contraindicated in vascular disease
52
Q

management of hyperkalaemia?

A

Treat if K+ >6.5mmol/L or any with ecg changes (ecg for all K+ >6.0mmol/L):

  1. 10mL of 10% calcium chloride iv via a big vein over 5–10min, repeated if necessary and if ecg changes persist.

This is cardioprotective (for 30–60min) but does not treat K+ level.
If no ECG changes go to step 2:

  1. Intravenous insulin (10u soluble insulin) in 25g glucose (50mL of 50%). Insulin stimulates intracellular uptake of K+,

Monitor hourly for hypoglycaemia (in 11–75% of treated patients) which may be delayed in renal impairment (up to 6 hours after infusion).

  1. Salbutamol - (10–20mg via nebulizer) tachycardia can limit use. don’t use in fast arrhythmias

4 Definitive treatment requires K+ removal. If the underlying pathology cannot be corrected renal replacement - dialysis - may be indicated. Safe transfer to an offsite renal unit requires K+ <6.5mmol/L—discuss with renal team and critical care.

Key monitoring; potassiuim and glucose

53
Q

how does hyperkalaemia present? complications?

A

Abdominal pain and diarrhea.
Chest pain.
Heart palpitations or arrhythmia (irregular, fast or fluttering heartbeat).

Muscle weakness or numbness in limbs.
Nausea and vomiting.

complications:
cardiac arrest
arrhythmias and sudden cardiac death
severe muscle weakness/paralysis

54
Q

careful not to confuse sine waves for ?

A

Ventricular tachycardia

55
Q

what are the 5 principles of hyperkalaemia mx?

A

Protect the heart; if ecg changes -> Ca gluconate

Shift K+ into cells

Remove K+ from body; in life threatneing hyperkalaemia; sodium zirconium

Monitor K+ and Glucose

Prevention

56
Q

Whereare my p edema mx cards?

A

And af mx

57
Q

Glucose is one of the blood tests, what about ketones?

A

Is it vbg? Urine? Bottle?

58
Q

Mx of pulmonary oedema?

A 
PODMAN:
Position
Oxygen
Diuretics IV
Morphine IV, Anti-emetic; metoclopramide IV, Nitrates: GTN

if worsening:
call anaesthetics
CPAP

59
Q

Driving cut off times after an MI?

A

LVEF <40% : cant drive ffor 4 weeks after

normal LVEF afterr PCI: cant drive for 1 week.

60
Q

which statins to give if intolerant to statin (MI)?

A

PCKS9 inhibitor eg evolocumab

61
Q

in dka after first lines of treatment, how might you try to increase ph iff it hasnt resolved itself?

A

IV 1.26% bicarbonate is given - a very small amount

given by specialists
given REALLY SLOWLY

or might cause intracerebral acidosis what is called “Paradoxical acidosis”

Year 6 (17 decks)

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