RCEM Guidelines

Question 1

Cannabinoid hyperemesis Tx

Answer 1

Anti emetic
IVF
Haloperidol IM 0.05mg/kg (max 5mg)
- post ECG
Capsaicin cream to abdomen

Question 2

ABD Tx

Answer 2

Ketamine 4mg/kg IM
Droperidol 5-10mg IM
Midazolam 5-10mg IM
Lorazepam 4mg IM
Or
Haloperidol 5mg IM +/- 2mg lorazepam IM

Question 3

Taser management

Answer 3

Vital signs
ECG if CP or PPM
Pull out taser, assess for injury or retained FB

Question 4

magnet ingestion management

Answer 4

CXR, abdo Xr AP +- lateral
Discharge
- asymptomatic single magnet ingestion
- super strong magnets repeat XR in 6-12h
PIL - no metallic clothing

Question 5

Packers
Vs
Stuffers
Vs
Parachuting
Vs
pushers

Answer 5

Packers; mules
- swallow well wrapped packages
Stuffers
- concealed wrapped drugs eg cling film
Parachuting
- recreational drugs wrapped in something
pushers
- in rectum or vagina often in kinder eggs

Question 6

Packer management

Answer 6

Symptomatic
- surgical referral
- toxbase guidance
- Ct scan (contrast)
Asymptomatic
- CT scan (low dose)
- positive; admit for observation
- no consent for CT -> discharge with advice

Question 7

Stuffer management

Answer 7

Symptomatic
- toxbase
- LDCT if consents
- admit and observe
Asymptomatic
- observe for 8h post ingestion
- consider LDCT if consents

Question 8

Pusher management

Answer 8

Symptomatic
- toxbase
- LDCT after consent
- remove packages
Asymptomatic
- LDCT after consent
- no scan observe for 8 hours
- discharge with advice

Question 9

Common law doctrine of necessity

Answer 9

Lack of autonomy suspected but not confirmed
Eg capacity assement not completed
Common law can be used to protect life
Only employed if significant risk
and restraint is proportionate

Question 10

Homeless people responsibility

Answer 10

Statutory duty to refer to relevant housing authority the homeless and those at risk of homelessness (within 56 days)

Question 11

Indications; Ketamine sedation in children

Answer 11

Over 1 year old
Appropriate procedure
Does not need to go to theatre immediately

Question 12

Contraindications; Ketamine sedation in children

Answer 12

Less than 1 year old
Risk of laryngospasm; resp infection, active asthma
Abnormal airway
Severe comorbidity
Cognitive or behavioural disorder
Intracranial or pulmonary HTN
Prior adverse reaction
Intoxication

Question 13

Side effects; Ketamine sedation in children

Answer 13

All 5-20%
Agitation
Salivation and lacrimation
Involuntary movements
Vomiting in recovery
Transient rash

Question 14

Complications; Ketamine sedation in children

Answer 14

Apnea; if rapid bolus, does not happen if over 60s
Laryngospasm; 0.3%, transient
Emergence phenomena; more common the older you get under 10 uncommon adult 1 in 3

Question 15

Discharge criteria; Ketamine sedation in children

Answer 15

Awake and responsive
Normal obs
Mobilise as usual
Pain addressed

Question 16

Dosing; Ketamine sedation in children

Answer 16

Initial dose
- 1mg/kg over 60s
Supplementary dose
- 0.5mg/kg over 60s

Question 17

Management complications; Ketamine sedation in children

Answer 17

Emergence reactions;
- 0.1mg/kg midazolam
Vomiting
- 0.1mg/kg ondansetron
Laryngospasm
- airway repositioning, gentle suction
- normal Sats can continue procedure
- dropping Sats give O2 via BVM, apply PEEP and prepare RSI
- paediatric periarrest call

Question 18

Frequent attenders; types

Answer 18

Complex conditions
Chronic pain
Medically unexplained symptoms
Mental health

Question 19

Frequent attenders plan

Answer 19

1) ED care plan; patient and other specialities should be involved in developing care plan
2) MDT conference
- d/w other teams; GP, psych, social, housing
3) Psychological therapy for patients with medically unexplained symptoms

Question 20

Sexual assault and rape management

Answer 20

Can remain anonymous
Referral to SARC - cannot deal with acute injuries, will do everything else
Offer police
Emergency contraception
Post exposure prophylaxis ; Hep B, HIV and prophylactic Abx
Safeguarding; social services, victim support, community safety unit