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3B GH > A+E > Flashcards

A+E Flashcards

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
Q

what is cardiac tamponade

A

fluid in the pericardium builds up, resulting in compression of the heart.

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26
Q

what are the 6 life threatening chest injuries

A 
ATOMFC
Aorta/Airway obstruction
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Flail chest
Cardiac tamponade
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27
Q

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/?

A

pain relief

nerve block

pulses and neurology

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28
Q

what is the name of the rash typically ass. w/ allergy rn/ describe it

A

urticaria

wheals - raised pink circular with white centre

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29
Q

which systems can be affected in an allergy rn and what corresponding features should you look for on examination?

A

airway: stridor, swollen lips + tongue
lungs: wheeze, ^RR, cyanosis, low sats
skin: rash
circulatory: low BP, Pale, clammy
brain: reduced consciousness

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30
Q

what is the mechanism of anaphylactic rn.s

A

IgE, IgG, complement > mast cell degradation >histamine release
vasodilaiton
contraction of bronchial muscles

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31
Q

Tx for anaphylaxis

A 
ABCDE
o2
fluids
chlorphenamine [piriton]
adrenaline 0.5mg [0.5ml of 1 in 1000]
hydrocort
salb if wheeze
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32
Q

when is adrenaline indicated in anaphylaxis

A

extremes of each system: stridor/wheeze, hypoTN, drowsy

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33
Q

what can cause a delayed deterioration in anaphylaxis

A

digestion of food

delayed histamine response

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34
Q

best route for adrenaline in anaphylaxis

A

IM

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35
Q

risks of giving IV adrenaline

A

palpitations, SOB, N+V, MI, arrhythmia

36
Q

what is a biphasic rn in anaphylaxis?

A

not v common, recurrence of anaphylaxis after tx, several hrs later

37
Q

follow-up /discharge plan after anaphylaxis admission

A 
epipen [adrenaline]
3-5 days pred
PO antihistamine
salb inhlaer
R/V w/ allergist
38
Q

risks of someone else picking up epipen and accidental needle stick

A

finger ischaemia

[vasoconstrictor]

39
Q

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.

A

PE
MSK pain
LRTI
pneumothorax

40
Q

what examianation findings would be suggestive of MSK chest pain

A

tenderness on pressure

tender shoulder movements

41
Q

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

A 
CT pulmonary angiogram
D dimer
ABG
ECG
CXR
FBC
U+E
LFT
clotting
42
Q

what is a d-dimer

A

fibrin degradation product

43
Q

list 5 clinical findings suggestive of DVT

A 
dilated superficial veins
swollen >3cm
tender on back
pain
pitting
44
Q

scoring system for PE, + what factors it takes into account

A

wells

Clinical signs/Sx of DVT
Heart rate > 100
Immobilization [3 days] /surgery in last 4 weeks
Previous PE /DVT
Hemoptysis
Malignancy
45
Q

pt started on warfarin. What range should INR be?

A

2-3

46
Q

how long warfarin for PE?

A

3-6/12

if recurrent, lifelong

47
Q

Mx of large PE

A 
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
Q

Sx of PCM overdose

A

none/
vomiting
RUQ pain

later:
jaundice, encpehalopathy, AKI

49
Q

how long does it take for PCM toxicity to occur?

A

hepatic enzymes ^ at around 24 hrs,

then jaundice, hepatomegaly at around 48hrs

50
Q

why do you do bloods at 4hrs in PCM overdose if toxicity takes 24 hrs? why not sooner?

A

PCM levels, to predict future toxicity

time for digestion/absorption from GI tract

51
Q

liver is main site of PCM toxicity, what other organs are commonly affected in serious toxicity?

A

brain

kidney [AKI]

52
Q

which pt.s are at particular risk of liver damage in PCM overdose?

A 
malnutrition/ low BMI
alcohol
carbamaz
pre-existing liver disease
HIV [reduced hepatic glutathione]
53
Q

in PCM overdose, in what circumstances should you start the NAC as soon as poss, prior to seeing PCM levels?

A

8-24 hrs post ingestion
suspicion of large overdose
ingestion time unknown
staggered

54
Q

PCM overdose - important Qs to ask patients about the overdose and the events surrounding it, to assess risk of further overdose

A 
intention
previous overdoses
note/finances in order
any further plans
who rang the ambulance
55
Q

see pt 11 hrs after PCM overdose, what bloods should you take?

A 
U+E
LFT
PCM level
clotting/INR
glucose
56
Q

see pt 11 hrs after PCM overdose, should you give charcoal?

A

no, give if presenting <4 hrs since overdose

57
Q

see pt 11 hrs after PCM overdose, when should you start NAC?

A

immediately >8hrs since ingestion

58
Q

Pt receiving NAC for PCM overdose, flushed and vomited. Obs normal. what should you do?

A

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
Q

Mx of acute stemi incl. Ix.s

A 
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
Q

contraindications to IV TPA thrombolysis post-MI [if you cant get them to PCI within 120 mins]

A 
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
Q

what do you give a pt with STEMI who present >12hrs after Sx onset?

A

fondaparinux

62
Q

causes of cardiogenic shock

A 
MI
arrhythmia
PE
tension pneumo
tamponade
myocarditis
endocarditis
aortic dissection
63
Q

Mx of broad complex tachycardia

A 
O2
sedate and DC shock
correct electrolytes
amiodarone
if known SVT/BBB: adenosine
torsades -give Mg2+
64
Q

mx of narrow-complex/ supraventricular tachycardia

A

O2 [if sats<90]
unstable - sedate + DCCV
correct electrolytes
amiod

stable + regular -vagal manoevres
adenosine
[verapamil]

65
Q

mx of bradycardia

A 
O2 if hypoxic
correct electrolytes
unstable:atropine
transcutaneous pacing
Isoprenaline
adrenaline
66
Q

mx of acute asthma

A 
O2
salb neb
ipratropium neb
hydrcort iv/ pred PO
MgSO4 IV

ICU: aminophylline, ventilation, IV salb,

67
Q

what Ix.s do you want to do in acute asthma

A

PEF
ECG for arrhythmias
ABG

68
Q

Mx of acute COPD

A 
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
Q

mx of large PE

A 
O2 if hypoxic
morphine [w/ antiemetic]
fondaparinux/ LMWH
fluids/ vasopressors if hypovol
consider alteplase
long term anticoag
70
Q

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]

A

terlipressin

71
Q

acute Mx of convulsive status epilepticus

and what Ix.s would you take alongside your management?

A

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
Q

Mx of raised ICP

A

correct hypotn
elevate bed head
if intubated, hyperventilate to achieve low CO2 [leads to cerebral vasoconstriction]

mannitol

if oedematous tumour -dex

73
Q

in a fitting patient , what is another possible cause other than epilepsy in a female patient?

A

eclampsia

74
Q

you give IV loraz to fitting pt, what SE are you most worried about?

A

resp arrest

75
Q

what is the risk of phenytoin infusion in fitting pt and when would you not give it?

A

brady

brady or heart block

76
Q

what are the causes if status epilepticus

A 
epilepsy
eclampsia
hypoglyc
alcohol
drugs
CNS infection/ lesion
HTNive enceph
77
Q

medical complications of status epilepticus

A 
brain damage
arrhythmia
tachy
resp failure
aspiration
asystole
vomiting
hyperkalaemia
apnoea
HTN
78
Q

ecg criteria for thrombolysis in MI

A

ST elevation in adjacent leads
LBBB
post changes [ST dep, tall R waves V1-3]

79
Q

in head injury, primary traumatic brain injury occurs at the time of impact. What neurophysiological/ anatomical consequences cause secondary injury mins-days later?

A 
^ICP
cerebral oedema
expanding haematomas
seizures
infection
80
Q

assessing a patient using ABCDE, what aspects should be paid particular attention to if the patient has sustained a head injury?

A

GCS [and changes to this]
pupils
C-spine protection
neuro examination

81
Q

in a trauma patient, low BP together with inappropriately low pulse rate indicates injury to what aspect + what level of the spinal cord?

A

sympathetic

cervical

82
Q

patient presenting with head injury and reduced GCS. What imaging do you need to arrange within 1st hour of injury?

A

CT head

83
Q

following head injury, what aspects of your patient’s presentation might warrant an urgent CT head?

A 
reduced GCS
open /depressed /basal skull fracture
focal CNS deficit
fit [post-injury]
>1 vomit

LOC + coagulopathy

84
Q

when would you add cervical spine CT to head CT in head injury patient?

A 
intubated [?could exacerbate C-spine injury]
GCS <13
dangerous mechanism of injury
focal CNS deficit
upper/lower limb parasthesia
85
Q

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?

A

CT head within 1 hour

86
Q

risk of ICH is higher for patients on warfarin or clopidogrel?

A

clopidogrel

87
Q

give 3 aspects of medical management of head injury

A

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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