ACT Emergency

Question 1

Description of anaphylaxis

Answer 1

Anaphylaxis is a life threatening Type 1 hypersensitivity reaction. There is IgE mediated release of histamine from mast cells in response to a presensitised allergen. The cascade release of inflammatory cytokines increases capillary permeability causing oedema.

Question 2

Aetiology of anaphylaxis

Answer 2

Exposure to an allergen such as a food or drug, presensitises individuals. When there is subsequent exposure, IgE activation of mast cells causes a type 1 hypersensitivity reaction.

Question 3

Complications of anaphylaxis

Answer 3

The resulting swelling can occlude the patients airway.

Fluid shift out of the intravascular space can cause a distributive shock.

Question 4

Assessment of suspected anaphylaxis

Answer 4

A to E approach - Full set of Observations
Dx- Acute onset, Life threatening ABC problem and/or skin changes
Check drug chart
Ask ward staff for recent medications

Question 5

Immediate management of anaphylaxis

Answer 5

Stop allergen exposure 
Call for Help 
Lie flat + Legs up
Adrenaline 1:1000 500micrograms IM
Establish airway + 15L non-rebreathe 
IV access  - Mast cell tryptase, FBC, U&Es
\+/- Fluid challenge 
Chlorphenamine 10mg slow IV
Hydrocortisone 200mg slow IV

Question 6

Investigations for anaphylaxis

Answer 6

Bloods: FBC, U&Es
Serum Mast cell tryptase x 3: up to 1 hr, at 3hr and 24 hrs
Diagnosis will show a peak then return to normal by 24hrs

Question 7

Explanation of anaphylaxis to patient

Answer 7

Anaphylaxis is a type of severe allergic reaction which occurs when the body comes into contact with something the immune system has become sensitive to.
It can be caused by many things including foods such as nuts and shellfish or drugs such as antibiotics
Symptoms can include a rash with itching and tingling, swelling of the lips and tongue and difficulty breathing.

Question 8

Long term management of anaphylaxis

Answer 8

Follow up appointment with immunologist for:
Patient education
Rx of Epipen and training

Question 9

Differential diagnosis for anaphylaxis

Answer 9

Carcinoid syndrome - paraneoplastic release of serotonin

Phaeochromocytoma - neuroendocrine tumour of adrenal medulla secreting catecholamines

Question 10

Description of septic shock

Answer 10

Sepsis with hypotension and a lactate > 2mmol/L despite adequate fluid resuscitation.
The patient needs vasopressors to maintain a mean arterial pressure of 65mmHg

Question 11

Aetiology of septic shock

Answer 11

There is loss of vascular tone following a systemic inflammatory response to pathogenic toxins.
Fluid shift out of the intravascular space causes a drop in blood pressure.

Question 12

Complications of shock

Answer 12

Hypo-perfusion of end organs can lead to schema and dysfunction. If prolonged can lead to multiple organ failure and death

Question 13

Management of septic shock

Answer 13

A to E - BUFALO
Call for senior help
Requires ICU Early Goal Directed Therapy
Vasopressors to maintain mean arterial pressure >65mmHg

Question 14

Description of cardiogenic shock

Answer 14

A state of end-organ hypoperfusion due to cardiac failure and the inability of the cardiovascular system to provide adequate blood flow to the extremities and vital organs

Question 15

Aetiology of cardiogenic shock

Answer 15

True cardiac - MI, arrhythmia, valve failure

Extracardiac - Obstructive
Prevent inflow- Tension pneumothorax, Tamponade
Prevent outflow - Pulmonary embolus

Question 16

Assessment and investigations for suspected cardiac shock

Answer 16

A to E
ABG, CXR,
Bloods - FBC, U&E, Glucose, clotting, crossmatch
ECG, Echocardiogram

Question 17

Management of cardiogenic shock

Answer 17

A to E
Treat the underlying cause eg. Revascularisation
Cautious fluid resuscitation - 250ml
Early ICU involvement - inotropes and vasopressors

Question 18

Description of hypovolemic shock

Answer 18

Insufficient circulating volume in the intravascular space to adequately perfuse end organs due to fluid loss

Question 19

Aetiology of hypovolemic shock

Answer 19

Haemorrhage - On the floor and 4 more
Chest, Abdomen, Pelvis, Long bones.

Salt or fluid loss - Vomiting, Diarrhoea

Third spacing - Ascities

Question 20

Assessment and investigation of suspected hypovolemic shock

Answer 20

A to E 
ABG - ?DKA ?Pancreatitis
CXR - ?Haemothorax
Bloods - FBC, U&E, LFT, Amylase, Coag, X-match
ECG - ischaemia 
FAST Scan - ruptured AAA
Pelvic x-ray - fractures 

Urine Osmolality - Diabetes insipidus
Stool MC&S

Question 21

Management of hypovolemic shock

Answer 21

A to E 
Fluid resuscitation with 0.9% NaCl
Treat the underlying cause  
Correct electrolyte disturbances 
?Massive Haemorrhage protocol

Question 22

Description of acute respiratory failure

Answer 22

Type 1 respiratory failure is a Pa02 <8kPa caused by a ventilation-perfusion mismatch

Type 2 respiratory failure is a Pa02 <8kPa with hypercapnia PaCO2 >6kPa caused by failure of ventilation

Question 23

Aetiology of Type 1 respiratory failure

Answer 23

The 4 Ps + Asthma
Pulmonary embolus 
Pulmonary oedema 
Pneumothorax
Pneumonia

Question 24

Aetiology of Type 2 respiratory failure

Answer 24

Respiratory - COPD, Life threatening Asthma

Neurological - Drugs, MND, Guillian-Barre

MSK - Myasthenia gravis, obesity, kyphoscolioisis

Question 25

Complications of Type 1 respiratory failure

Answer 25

Prolonged hypoxia Invasive ventilation and the risks associated with it. Multiorgaan failure and death

Question 26

Complications of Type 2 respiratory failure

Answer 26

Prolonged hypoxia Prolonged hypercapnia Multiorgan failure and death

Question 27

Assessment and investigation of suspected Type 1 respiratory failure

Answer 27

``` A to E assessment Peak Expiratory Flow ABG - pa02 <8kPa CXR - pneumonia, pneumothorax ECG - Pulmonary embolus ```

Question 28

Assessment and investigation of suspected Type 2 respiratory failure

Answer 28

A to E assessment ABG - pa02 <8kPa, PaCo2 >6kPa CXR Send sputum

Question 29

Management of Type 1 respiratory failure

Answer 29

``` Treat the cause - 15L Non rebreathe - Continuous Positive Airway Pressure - Invasive Ventilation Monitor for progression to type 2 ```

Question 30

Management of Type 2 respiratory failure

Answer 30

Treat the cause COPD - Controlled 02, aim sats 88-92% White Venturi 28% to start Consider non invasive ventilation with bilevel positive airway pressure

Question 31

Reversible causes of cardiac arrest

Answer 31

Hypoxia Hypovolaemia Hypo/perkaleamia Hypothermia Thrombosis Tension pneumothorax Tamponade Toxins

Question 32

Shockable and non shockable rhythms during cardiac arrest

Answer 32

Ventricular Fibrillation pulseless Ventricular tachycardia Pulseless electrical activity and asystole

Question 33

When are drugs given during advanced life support

Answer 33

Give adrenaline 1mg 1:10,000 IV every 3-5 minutes | Give amiodarone 300mg IV after 3 shocks

Question 34

Aetiology of falls in the elderly

Answer 34

B - Hypoxia, PE C - MI, dysrhythmia, Sepsis, Shock D - Hypoglycaemia, Seziures, CVI Mechanical Ataxia Syncope - postural hypotension, vasovagal, situational

Question 35

Hx taking for falls in the elderly

Answer 35

Before - events, symptoms, speed of onset During - LOC? Head injury? Incontinence? Time on the floor? After - Speed of recovery? Helped up? Previous falls + ICE PMH - Cardiac, DM, Neuro DH - New? antihypertensives? hypoglycemics? Anticoagulants SH - Circumstances, Mobility, vision?

Question 36

Assessment and investigations for fall in the elderly

Answer 36

``` Full set of observations + CPG Check for head injury and C spine tenderness Cardiovascular and Neurological exam Lying and standing BP Hourly neuro obs for 4 hours ``` Ix: ECG at bedside Bloods - FBC, U&Es, CRP, BM, Troponin? CT head - if criteria Radiograph - if suspicious of fracture

Question 37

CT head guidelines for adults following head injury within 1 hour

Answer 37

``` GCS < 13 on initial assessment GCS < 15 at 2 hours after injury Focal neurological deficit More than one episode of vomiting Suspected skull fracture Any sign of Basal soul fracture Post traumatic seizures ```

Question 38

CT head guidelines for adults following head injury within 8 hour

Answer 38

Always if anti-coagulated LOC or amnesia following injury + - 65yrs or older - Previous bleeding/clotting disorder - Dangerous mechanism - > 30mins retrograde amnesia of before injury

Question 39

Hx taking and risk assessment following overdose

Answer 39

``` Drugs taken + Dose + Number? Time taken + Staggered? With alcohol? Symptoms - vomiting, tinitus, dizziness Before - Events, trigger, planned, note writing During - who, what, where, intent After - how discovered? Guilt? RISK - Feeling now? Plans? Protective? Previous attempts + Psych Hx Social Hx + Current stressors ```

Question 40

Pathophysiology of paracetamol overdose

Answer 40

Normal pathways of conjugation with the sulfate and glucuronide become saturated, so more paracetamol is shunted to the cytochrome P450 system to produce NAPQI. Hepatocellular supplies of glutathione become depleted and NAPQI remains in its toxic form in the liver. NAPQI damages cellular membranes resulting in widespread hepatocyte damage and death, leading to acute liver necrosis

Question 41

Investigations of paracetamol overdose

Answer 41

Paracetamol levels after 4 hours Bloods: FBC, U&E, LFTs, Clotting, Bicarbonate If Bicarbonate abnormal then do ABG

Question 42

Management of paracetamol overdose

Answer 42

Single OD above treatment line (>150mg/kg) Staggered overdose Paracetamol levels not known at 8hrs N-acetyl-cysteine in 5% Dextrose Bag 1 = 150mg/kg in 200ml over 1h Bag 2 = 50mg/kg in 500ml over 4h Bag 3 = 100mg/kg in 1000ml over 16h. If anaphylactoid reaction - Chlorphenamine + slow IV Psychiatric assessment If liver failure, discuss with hepatologist

Question 43

Presentation of salicylate overdose

Answer 43

Tinnitus or hearing impairment Vomiting, Sweating, Fever, Drowsiness, Dizziness, Blurred vision Hyperventilation - due to direct stimulation of respiratory centre, causes respiratory alkalosis

Question 44

Assessment and investigation of suspected Salicylate overdose

Answer 44

``` ABG - respiratory alkalosis Progresses to metabolic acidosis U&Es - decreased K+, deranged Na+ BM - Deranged due to uncoupling of oxidative phosphorylation Salicylate levels raised Paracetamol levels incase mixed ```

Question 45

Management of salicylate poisoning

Answer 45

IV rehydration and potassium replacement If severe then consider: Urinary alkalisation with IV sodium bicarbonate Heamodialysis

Question 46

Presentation of Tricyclic overdose

Answer 46

Anticholinergic features Dsyrhythmia +/- hypotension Mycolonic jerking, Reduced GCS

Question 47

Assessment and investigation of tricyclic overdose

Answer 47

ABG - Metabolic acidosis | ECG - Prolonged PR, QRS widening

Question 48

Management of tricyclic overdose

Answer 48

Cardiac monitoring or serial ECGs Alkalisation with sodium bicarbonate IV glucagon or vasopressors for hypotension Control seizures with benzodiazepines

Question 49

Presentation of iron overload

Answer 49

``` First stage - GI irritation Nausea, vomiting, diarrhoea Second stage - 24 -48 hrs after OD Dehydration, Metabolic acidosis Liver failure ```

Question 50

Investigation of iron overload

Answer 50

ABG - ?metabolic acidosis Bloods: FBC, Serum iron, Glucose AXR - tablets can be counted

Question 51

Management of iron overload

Answer 51

Desferrioxamine IV infusion