Emergency medicine

Question 1

what is the zero point survey?

Answer 1

ZERO POINT SURVEY
Pre-resus
Self – physical readiness ‘I’m safe’, cognitive readiness: breath, talk, see focus
Team – leader identified, roles allocated, briefing
Environment – danger, space, light, noise, crowd control
Resus commenced
Patient – primary survey – ABCDE
Update – share mental model of patient status
Priorities – identify team goals and set mission trajectory

Question 2

why might you have difficulty maintaining an airway of someone who is have a seizure?

Answer 2

• Seizure may cause upper airway obstruction and respiratory depression
• Also the gag reflex is suppressed during a seizure and patient may aspirate if they vomit
• The patients upper airway may also be obstructed by their relaxed tongue
• Difficult to inspect airway- because of the jaw clench – often you cannot move the jaw if this happened - you could give nasopharyngeal airway as you won’t be able to put and oropharyngeal airway in. Also the nasopharyngeal airway is more tolerable.

Question 3

if you are struggling to get IV access of someone who is having a seizure what medication could you give?

what should you check prior to giving it

Answer 3

• Buccal midazolam 10 mg
• Rectal lorazepam 10 mg
• Has she already be given any drugs – is she already epileptic and taken medication for the seizure, have the paramedics given her this – this is because you don’t want to overdose on a certain drug or if they have already been given two doses now you would want to escalate the treatment.
• Have they got any allergies, You would want to check that she had not taken any opioids, as risk of respiratory depression and other CNS depressant effects

Question 4

if you gain Iv access in someone who is seizing what could you give?

what is the side effect you are most concerned about?

Answer 4

• IV lorazepam 4mg ( this can be given following one dose of buccal or rectal benzo)
• resp depression

Question 5

Why is lorazepam now used in preference to diazepam?

Answer 5

• Has a much longer duration and reduced cardio-respiratory side effects
• Lorazepam has much less respiratory depression effect but has a much longer anti-epileptic effect

Question 6

if they are still fitting after the diazepam what would you try next?

Answer 6

• Phenytoin infusion at a dose of 15-18mg/kg at a rate of 50 mg/minute

Question 7

what should you monitor whilst phenytoin is being infused?

Answer 7

therapeutic drug monitoring

monitor ECG and BP

Question 8

if phenytoin is contradicted when treating seizures what could you give instead?

Answer 8

• Levetiracetam – Keppra – this is probably going to become this first choice second line drugs rather than phenytoin because it is just as effective and has less side effects
• Phenobarbital
• Sodium valproate

Question 9

what are the problems with using long acting paralytic agents in patients who are having seizures?

Answer 9

they could still be fitting just you can’t see it, so they brain will still be having a seizure which can be detrimental to the brain. This is why a short acting paralytic agent is used. Because you have to be sure you have stopped them fitting and not just stopped them moving.
- You could perform an EEG to see if they are still fitting when under GA.

Question 10

causes of status epilepticus?

Answer 10

• People with epilepsy – drug withdrawal due to poor adherence to their medication – likely
• Hypoxia – unlikely
• Stroke – possible – would be a haemorrhagic stroke – get CT – give stroke treatment
• Metabolic abnormalities, low sodium, can also happen with low calcium - possible, U&E’s, correct electrolyte abnormalities
• Alcohol intoxication or withdrawal – possible cause – so she could have delirium tremens, suggestive IV pabrinex and benzos
• Infection -possible, check temp, start broad spec antibiotics or antivirals
• Brain trauma -possible – get CT
• Tumour - possible, CT head, dexamethasone
• Hypoglycaemia – possible – check BM’s give dextrose, give glucagon
• Drug withdrawal
• Eclampsia, give magnesium sulphate and deliver baby
• Acute alcohol intoxification

Question 11

medical complications of status epilepticus?

Answer 11

• Pulmonary oedema
• Cardiac arrhythmias
• Hyperthermia
• Aspiration pneumonias

Later on complications

• Focal neurological deficit
• Cognitive dysfunction – most likely memory deficits
• Behavioural problems

Question 12

features of alcohol withdrawal?

Answer 12

Tremors, sweating, tachycardia, anxiety

Question 13

how do you treat alcohol withdrawal?

Answer 13

chlordiazepoxide

Question 14

features of delirium tremens?

Answer 14

Coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Question 15

how is delirium tremens managed?

Answer 15

benzo - IV lorazepam

thiamine