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3B GH > A+E > Flashcards

A+E Flashcards

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1
Q

what biochemical test would you want to know the result of in the 1st few minutes after the arrival in A +E of any unconscious or semi-conscious patient?

A

BM
[DKA or hypo]
treatable, + life-threatening/ brain damage

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2
Q

Pt found unconscious in stairwell of a block of flats. Airway patent, RR 12, sats 100% on O2, pulse 92, BP 120/90, slight response to pain, pupils equal + reacting. What further examination points are relavant?

A

GCS
exposure - needlesticks/ injuries
examine head for injury
neuro exam

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3
Q

Pt found unconscious in stairwell of a block of flats. Airway patent, RR 12, sats 100% on O2, pulse 92, BP 120/90, slight response to pain, pupils equal + reacting. What other basic observation is important and why?

A

temp
hypothermia [found outside]
or pyrexia - sepsis - LOC from reduced organ perfusion

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4
Q

WHY DONT you use GCS in stroke

A

may not be able to speak/slurred, arm weakness etc.

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5
Q

Patient is opening eyes to painful stimuli only, pulling his arm away when painful stimuli is applied to his hand and making a groaning noise. What’s his GCS?

A

2 + 4 + 2 = 8/15

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6
Q

GCS

A

motor /6

  1. normal
  2. localizes
  3. withdraws
  4. flex
  5. extends
  6. none

eyes/4

  1. open spont
  2. opens to voice
  3. open to pain
  4. none

voice/5

  1. normal
  2. confused
  3. words
  4. incomprehensible sounds
  5. none
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7
Q

methods for applying painful stimuli to assess GCS

A

supraorbital pressure
jaw thrust
nail bed pressure

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8
Q

list possible pathological/clinical categories for the causes of a patient’s decreased level of conciousness + a few examples for each

A
  1. cardiac [hypovol, arrhythmia, MI]
  2. neuro [meningitis, epilepsy, stroke, head injury]
  3. sepsis
  4. metabolic: [hypo/DKA, hypo/pernatraemia, hypercalc, myxoedema, uraemia]
  5. other: overdose, CO, ^CO2, alcohol, NEA
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9
Q

Pt found unconscious in stairwell of a block of flats. Airway patent, RR 12, sats 100% on O2, pulse 92, BP 120/90, slight response to pain, pupils equal + reacting.
5 most important investigations:

A 
BM
CT head
ABG/VBG
ECG
urine drugs screen
FBC
U+E
CRP
LP
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10
Q

Pt found unconscious in stairwell of a block of flats. His resps have now become shalower and RR = 8. He has pinpoint pupils. Diagnosis? + differential for pinpoint pupils

A

heroin overdose [/opoids/antipsychotics/ mirtaz]

pons haemorrhage

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11
Q

how do you manage heroin overdose?

A

ABCDE

naloxone

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12
Q

examination findings that might alert you to the posibility of heroin overdose

A

shallow slow resps
pinpoint pupils
myoclonic jerks
track marks

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13
Q

what GCS needs intubation/ventilation

A

<8 [can’t protect own airway]

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14
Q

A+E pt with base of skull fracture and large subdural haematoma. How do you prepare the Pt for transfer to another hospital/

A 
O2, fluids
defib paddles
emergency drugs
anaesthetist + ODP
paperwork, handover
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15
Q

signs of base of skull fracture

A

racoon/panda eyes [periorbital bruising]
mastoid bruising
CSF rhinorrhoea/otorrhoea
haemotypanum [blood adjacent to tympanic membrane]

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16
Q

what prophylaxis do you need to give base of skull fracture pt

A

pneumococcal and meningococcal vaccines

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17
Q

how does the ABCDE approach for assessing the patient change in major trauma

A

CABCDE
catastrophic haemorrhage
+ C-spine

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18
Q

what is the pathological process behind tension pneumothorax?

A

air between visceral and parietal pleura

one way valve means the pneumothorax increases every time you breath in

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19
Q

major trauma patient in RTC, suddenly deteriorates, says he cant breathe, pulse 130 ,sats 89% on high flow, BP 93/59. What’s happened?

A

massive haemothorax/ tension pneumothorax

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20
Q

Mx of tension pneumothorax

A

immediate decompression with largebore cannula in 2nd intercostal space mid clavicular line

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21
Q

massive haemothorax Mx

A

large bore chest drain

IV fluid/blood replacement

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22
Q

becks triad of cardiac tamponade

A

rising JVP
falling BP
muffled HS
[+/-pulsus parodoxus]

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23
Q

how would you diagnose cardiac tamponade in acute setting

A

US - black stripe around heart indicates fluid

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24
Q

Mx of cardiac tamponade

A

emergency pericardiocentesis

thoracotomy + pericardotomy

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25
what is cardiac tamponade
fluid in the pericardium builds up, resulting in compression of the heart.
26
what are the 6 life threatening chest injuries
``` ATOMFC Aorta/Airway obstruction Tension pneumothorax Open pneumothorax Massive haemothorax Flail chest Cardiac tamponade ```
27
benefits of splinting a suspected fractured femur? how can you make the procedure more comfortable for the patient? what should you check before and after splinting/?
pain relief nerve block pulses and neurology
28
what is the name of the rash typically ass. w/ allergy rn/ describe it
urticaria | wheals - raised pink circular with white centre
29
which systems can be affected in an allergy rn and what corresponding features should you look for on examination?
airway: stridor, swollen lips + tongue lungs: wheeze, ^RR, cyanosis, low sats skin: rash circulatory: low BP, Pale, clammy brain: reduced consciousness
30
what is the mechanism of anaphylactic rn.s
IgE, IgG, complement > mast cell degradation >histamine release vasodilaiton contraction of bronchial muscles
31
Tx for anaphylaxis
``` ABCDE o2 fluids chlorphenamine [piriton] adrenaline 0.5mg [0.5ml of 1 in 1000] hydrocort salb if wheeze ```
32
when is adrenaline indicated in anaphylaxis
extremes of each system: stridor/wheeze, hypoTN, drowsy
33
what can cause a delayed deterioration in anaphylaxis
digestion of food | delayed histamine response
34
best route for adrenaline in anaphylaxis
IM
35
risks of giving IV adrenaline
palpitations, SOB, N+V, MI, arrhythmia
36
what is a biphasic rn in anaphylaxis?
not v common, recurrence of anaphylaxis after tx, several hrs later
37
follow-up /discharge plan after anaphylaxis admission
``` epipen [adrenaline] 3-5 days pred PO antihistamine salb inhlaer R/V w/ allergist ```
38
risks of someone else picking up epipen and accidental needle stick
finger ischaemia | [vasoconstrictor]
39
32 yr old female presents with 3 day history of L side CP, worse on inspiration + cough, sharp at times, feels SOB, occasional dry cough. Only DH is marvelon. Smokes 20/day, drinks 20-30 units/week. Give 4 differentials.
PE MSK pain LRTI pneumothorax
40
what examianation findings would be suggestive of MSK chest pain
tenderness on pressure | tender shoulder movements
41
32 yr old female presents with 3 day history of L side CP, worse on inspiration + cough, sharp at times, feels SOB, occasional dry cough. Only DH is marvelon. Smokes 20/day, drinks 20-30 units/week. List 4 useful tests
``` CT pulmonary angiogram D dimer ABG ECG CXR FBC U+E LFT clotting ```
42
what is a d-dimer
fibrin degradation product
43
list 5 clinical findings suggestive of DVT
``` dilated superficial veins swollen >3cm tender on back pain pitting ```
44
scoring system for PE, + what factors it takes into account
wells ``` Clinical signs/Sx of DVT Heart rate > 100 Immobilization [3 days] /surgery in last 4 weeks Previous PE /DVT Hemoptysis Malignancy ```
45
pt started on warfarin. What range should INR be?
2-3
46
how long warfarin for PE?
3-6/12 | if recurrent, lifelong
47
Mx of large PE
``` O2 if hypoxic morphine w/ antiemetic LMWH/fondaparinux fluid bolus if low BP consistent low BP -> noradrenaline/dobutamine IV thrombolysis [alteplase] long term anticoag ```
48
Sx of PCM overdose
none/ vomiting RUQ pain later: jaundice, encpehalopathy, AKI
49
how long does it take for PCM toxicity to occur?
hepatic enzymes ^ at around 24 hrs, | then jaundice, hepatomegaly at around 48hrs
50
why do you do bloods at 4hrs in PCM overdose if toxicity takes 24 hrs? why not sooner?
PCM levels, to predict future toxicity time for digestion/absorption from GI tract
51
liver is main site of PCM toxicity, what other organs are commonly affected in serious toxicity?
brain | kidney [AKI]
52
which pt.s are at particular risk of liver damage in PCM overdose?
``` malnutrition/ low BMI alcohol carbamaz pre-existing liver disease HIV [reduced hepatic glutathione] ```
53
in PCM overdose, in what circumstances should you start the NAC as soon as poss, prior to seeing PCM levels?
8-24 hrs post ingestion suspicion of large overdose ingestion time unknown staggered
54
PCM overdose - important Qs to ask patients about the overdose and the events surrounding it, to assess risk of further overdose
``` intention previous overdoses note/finances in order any further plans who rang the ambulance ```
55
see pt 11 hrs after PCM overdose, what bloods should you take?
``` U+E LFT PCM level clotting/INR glucose ```
56
see pt 11 hrs after PCM overdose, should you give charcoal?
no, give if presenting <4 hrs since overdose
57
see pt 11 hrs after PCM overdose, when should you start NAC?
immediately >8hrs since ingestion
58
Pt receiving NAC for PCM overdose, flushed and vomited. Obs normal. what should you do?
rash is common SE - continue, chlorphenamine + antiemetics, observe. Can reduce to 1/2 rate. Dont stop unless anaphylaxis w/ shock [BP here is normal].
59
Mx of acute stemi incl. Ix.s
``` ECG 12 lead cannulate + take blood for trop, FBC, glucose, lipids, U+E O2 IF LOW SATS CXR aspirin ticagrelor morphine [+metoclop] BIVALIRUDIN BB PCI [within 120mins] TPA thrombolyiss ```
60
contraindications to IV TPA thrombolysis post-MI [if you cant get them to PCI within 120 mins]
``` prev intracranial haemorrhage ischaemic stroke <6/12 cerebral malig AV malf recent major trauma/surg/head injury recent GI bleed bleeding disorder A dissection liver biopsy/LP <24hrs ```
61
what do you give a pt with STEMI who present >12hrs after Sx onset?
fondaparinux
62
causes of cardiogenic shock
``` MI arrhythmia PE tension pneumo tamponade myocarditis endocarditis aortic dissection ```
63
Mx of broad complex tachycardia
``` O2 sedate and DC shock correct electrolytes amiodarone if known SVT/BBB: adenosine torsades -give Mg2+ ```
64
mx of narrow-complex/ supraventricular tachycardia
O2 [if sats<90] unstable - sedate + DCCV correct electrolytes amiod stable + regular -vagal manoevres adenosine [verapamil]
65
mx of bradycardia
``` O2 if hypoxic correct electrolytes unstable:atropine transcutaneous pacing Isoprenaline adrenaline ```
66
mx of acute asthma
``` O2 salb neb ipratropium neb hydrcort iv/ pred PO MgSO4 IV ``` ICU: aminophylline, ventilation, IV salb,
67
what Ix.s do you want to do in acute asthma
PEF ECG for arrhythmias ABG
68
Mx of acute COPD
``` salb neb ipratropium neb controlled O2 IV hydrocort + PO pred amoxi/clarith/doxy if infection physio aid sputum ``` Iv aminophylline CPAP resp stimulant doxapram intubate/ventilate
69
mx of large PE
``` O2 if hypoxic morphine [w/ antiemetic] fondaparinux/ LMWH fluids/ vasopressors if hypovol consider alteplase long term anticoag ```
70
for a pt with acute upper GI bleed who is shocked, what drug can you add to your management if you suspect oesophageal varices to be the cause? [e.g. known liver disease]
terlipressin
71
acute Mx of convulsive status epilepticus and what Ix.s would you take alongside your management?
ABCDE open and secure airway +/- adjuncts O2 suction bloods: FBC, U+E, LFT, glucose, Ca2+, tox screen, anticonvulsant levels LORAZ, + repeat [buccal midaz/ rectal diaz] THIAMINE [alc/malnourished] GLUCOSE fluids PHENYTOIN infusion ECG after 1 hr, anaesthetist RSI, intubate + vent
72
Mx of raised ICP
correct hypotn elevate bed head if intubated, hyperventilate to achieve low CO2 [leads to cerebral vasoconstriction] mannitol if oedematous tumour -dex
73
in a fitting patient , what is another possible cause other than epilepsy in a female patient?
eclampsia
74
you give IV loraz to fitting pt, what SE are you most worried about?
resp arrest
75
what is the risk of phenytoin infusion in fitting pt and when would you not give it?
brady | brady or heart block
76
what are the causes if status epilepticus
``` epilepsy eclampsia hypoglyc alcohol drugs CNS infection/ lesion HTNive enceph ```
77
medical complications of status epilepticus
``` brain damage arrhythmia tachy resp failure aspiration asystole vomiting hyperkalaemia apnoea HTN ```
78
ecg criteria for thrombolysis in MI
ST elevation in adjacent leads LBBB post changes [ST dep, tall R waves V1-3]
79
in head injury, primary traumatic brain injury occurs at the time of impact. What neurophysiological/ anatomical consequences cause secondary injury mins-days later?
``` ^ICP cerebral oedema expanding haematomas seizures infection ```
80
assessing a patient using ABCDE, what aspects should be paid particular attention to if the patient has sustained a head injury?
GCS [and changes to this] pupils C-spine protection neuro examination
81
in a trauma patient, low BP together with inappropriately low pulse rate indicates injury to what aspect + what level of the spinal cord?
sympathetic | cervical
82
patient presenting with head injury and reduced GCS. What imaging do you need to arrange within 1st hour of injury?
CT head
83
following head injury, what aspects of your patient's presentation might warrant an urgent CT head?
``` reduced GCS open /depressed /basal skull fracture focal CNS deficit fit [post-injury] >1 vomit ``` LOC + coagulopathy
84
when would you add cervical spine CT to head CT in head injury patient?
``` intubated [?could exacerbate C-spine injury] GCS <13 dangerous mechanism of injury focal CNS deficit upper/lower limb parasthesia ```
85
elderly patient presents with unwitnessed fall + poor history. Doesnt know if she banged head. Takes warfarin. GCS 15, no focal neuro deficits. What Ix does she need?
CT head within 1 hour
86
risk of ICH is higher for patients on warfarin or clopidogrel?
clopidogrel
87
give 3 aspects of medical management of head injury
avoid hypoTN [syst >90] dont overload [cerebral oedema] dont use glucose [damages brain tissue] avoid hypoxia/hypercapnia > hypervent opiates mannitol IV loraz/buccal midaz for seizure raise head avoid ^glycaemia/ pyrexia

3B GH (16 decks)

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