3

Question 1

Can we use b-blocker in LVF?

Answer 1

No

Question 2

Management of STEMI

Answer 2

• ABC
• if hypoxic and no COPD: 15L O₂ via non-rebreather

Meds:

• Aspirin 300 mg PO
• Morphine 5-10 mg IV + Cyclizine 50mg IV
• GTN spray/tablet
• PCI or thrombolysis
• B-blocker (unless LVH/asthmatic) e.g. Bisoprolol 2.5 mg PO
• Transfer CCU

Question 3

Management of NSTEMI

Answer 3

• ABC
• if hypoxic and no COPD: 15L O₂ via non-rebreather

Meds:

• Aspirin 300 mg PO
• Morphine 5-10 mg IV + Cyclizine 50mg IV
• GTN spray/tablet
• Clopidogrel 300mg PO and either LMWH 0r Foundapatinux 2.5mg OD SC
• B-blocker (unless LVH/asthmatic) e.g. Bisoprolol 2.5 mg PO
• Transfer CCU

Question 4

The difference in the management of STEMI vs NSTEMI

Answer 4

• STEMI: Primary PCI or thrombolysis
• NSTEMI: Clopidogrel 300mg PO + LMWH/Foundaparinux 2.5mg OD SC

(all other steps are the same)

Question 5

Management of Acute LVF

Answer 5

• ABC
• if hypoxic and no COPD: 15L O₂ via non-rebreather

Meds:

• Sit patient up
• Morphine 5-10 mg IV + Cyclizine 50mg IV
• GTN spray/tablet
• Furosemide 40 - 80mg IV (repeat again as required/tolerated)
• If inadequate response Isosorbide dinitrate infusion +/- CPAP
• Transfer CCU

Question 6

Adverse features of tachycardia

Answer 6

• syncope
• shock
• MI
• HF

Question 7

Treatment of an unstable patient with tachycardia

Answer 7

(unstable/adverse features: syncope, MI, HF, shock)

• Synchronised DC shock (up to 3 attempts)
• Amiodarone 300 mg IV over 10-20 min + repeat shock
• then Amiodarone 900mg over 24 hours

Question 8

Treatment of tachycardia (with no adverse/unstable features) if QRS is narrow + rhythm is regular

Answer 8

• Vagal manoeuvers
• Adenosine 6 mg rapid IV bolus
• if unsuccessful give 12 mg Adenosine
• if unsuccessful, again 12 mg Adenosine

If sinus rhythm:

• restored -> probable re-entry paroxysmal SVT: record ECG, if recurs give adenosine again + consider anti-arrhythmic prophylaxis
• not restored: seek senior help + consider atrial flutter (control rate B-blocker)

Question 9

Management of tachycardia (with no adverse features) that is of narrow QRS complex and irregular

Answer 9

• probable AF
• control rate with B-blocker or diltiazem
• consider Digoxin or amiodarone if evidence of HF

Question 10

A stable patient with tachycardia and irregular rhythm + broad QRS

(3) possible diagnosis and management

Answer 10

Seek senior help!

Possibilities:

• AF with BBB: treat as narrow complex (control rate)
• Pre-excited AF: amiodarone
• Polymorphic VT (torsades de pointes): Magnessium 2g over 10 min

Question 11

Management of a stable patient with tachycardia + broad complex QRS + regular rhythm

(2 possibilities)

Answer 11

If ventricular tachycardia (or uncertain rhythm):

• Amiodarone 300 mg IV over 20-60 min + 900 mg Amiodarone over 24 hours

If previously confirmed SVT + BBB:

• give adenosine (6mg -> 12mg ->12mg)

Question 12

Is Domperidone safe to use in Parkinson’s?

Answer 12

Yes. Although Domperidone is a dopamine antagonist it doesn’t cross BBB, hence it’s safe in Parkinson’s

Question 13

Management of acute exacerbation of asthma

Answer 13

• ABC
• 100% O₂ by non-rebreather mask
• Salbutamol 5mg NEB
• Hydrocortisone 100 mg IV (if severe life-threatening)
• Prednisolone 40-50 mg PO (if moderate)
• Ipratropium 500 micrograms NEB
• Aminophylline (only if life-threatening)

Question 14

What type of pneumothorax always require treatment?

Answer 14

secondary i.e. patient has lung disease = always need treatment of pneumothorax

Question 15

Management of anapylaxis

Answer 15

• ABC + 15L non-rebreather mask oxygen if needed (and if no COPD)
• remove the cause
• Adrenaline 500 micrograms of 1:1000 IM
• Chlorphenamine 10 mg IV
• Hydrocortisone 200 mg IV

Question 16

When do we insert chest drain in secondary pneumothorax?

Answer 16

Chest drain if any of the following:

• SOB
• >50 y/o
• >2cm

(otherwise aspirate)

Question 17

Management of primary pneumothorax

Answer 17

Primary pneumothorax

• if <2cm rim on CXR and not SOB -> discharge with outpatient follow up in 4 weeks
• if >2 cm or SOB -> aspirate, if unsuccessful, aspirate again and if still unsuccessful, then chest drain

Question 18

Management of tension pneumothorax

Answer 18

emergency aspiration but will need chest drain quickly

Question 19

Management of pneumonia

Answer 19

• High flow oxygen
• antibiotics (depends on CURB-65 and CAP or HAP) e.g. Amoxicillin or Co-amoxiclav
• Paracetamol
• if low BP then IV fluids

Question 20

Management of PE

Answer 20

• High-flow oxygen
• Morphine 5-10 mg IV + Cyclizine 50mg IV
• LMWH treatment dose
• If low BP: fluid bolus + contact ITU + consider thrombolysis

Question 21

Management of GI bleed

Answer 21

• as usual: ABC and if needed oxygen
• cannulate x2 large bore
• catheter + strict fluid monitoring
• crystalloid bolus
• cross-match 6 units of blood
• correct clotting abnormalities
• Endoscopy
• STOP NSAIDs, aspirin, warfarin, heparin
• call surgeons - if severe

Question 22

How to correct clotting abnormalities in GI bleed?

Answer 22

• if PT/aPTT more than 1/5 times normal range -> give fresh frozen plasma (unless due to warfarin - then give prothrombin complex)
• if platlets <50 x 10⁹ / L + actively bleeding -> platlet transfusion

Question 23

Management of bacterial meningitis in a hospital

Answer 23

• ABC + oxygen if needed
• IV fluids
• 4-10 mg Dexamethasone IV (unless severly immunocompromised)
• LP +/- CT head
• 2g Cefotaxime IV

*if immunocompromised or >55 y/o add 2g ampicillin IV

Question 24

When to start drug management in a seizure?

Answer 24

If lasts more than 5 min

Question 25

Drug management in seizure

Answer 25

* **Lorazepam** 2-4 mg IV OR: diazepam 10 mg IV or midazolam 10mg buccal * If still fitting after 5 min -\> repeat benzodiazepine * Inform anaesthetist * If still fitting after further 5 min: **Phenytoin** 15-20 mg/kg IV * If still fitting after further 5 min: **Propofol** (intubate + ventilate)

Question 26

Management of ischaemic stroke

Answer 26

* ABC * CT to exclude haemorrhage * if onset \< 4.5 hours ago -\> **thrombolysis** In some centres thrombectomy may be available for certain patients if onset \<24 hours ago * **Aspirin 300 mg** oral or rectal (if unsafe to swallow) * Transfer to stroke unit