Acute

Question 1

STEMI management

Answer 1

1. IV morphine + metoclopramide
2. 15L oxygen if low
3. Dual antiplatelet (high dose): aspirin 300mg, ticagrelor 180mg
4. Percutaneous coronary intervention if possible within 120 mins (or IV alteplase within 30 mins if PCI not ready by then)

Question 2

NSTEMI management

Answer 2

1. IV morphine + metoclopramide
2. 15L oxygen if low
3. Dual antiplatelet (high dose): aspirin 300mg, ticagrelor 180mg
4. Immediate coronary angiography (or fondaparinux if not immediate)

Question 3

Acute heart failure management

Answer 3

A-E
Sit upright
15L oxygen
IV furosemide
IV diamorphine
GTN spray SL

No response:
Repeat furosemide
Escalate to ITU
Non-invasive PPV
Nitrate

Question 4

PEFR in moderate, severe and life-threatening asthma

Answer 4

Moderate: 50-75%
Severe: 33-50%
Life-threatening: PEFR <33%

Question 5

Acute asthma management

Answer 5

A-E
Warn ICU
15L oxygen
Nebulised salbutamol
IV hydrocortisone (or PO prednisolone)

If responding: continue 4-6 hourly nebulised salbutamol + prednisolone for 1 week

Escalation:
Nebulised ipratropium bromide
IV magnesium sulphate
IV aminophylline
Intubation

Question 6

Acute exacerbation of COPD management and what to discharge with

Answer 6

A-E
15L oxygen (24% first venturi mask if CO2 retention)
Nebulised salbutamol
Nebulised ipratropium
IV hydrocortisone
IV antibiotics

Escalation to ICU:
Non-invasive PPV
(IV aminophylline - not used really anymore)
Intubation and ventilation

Discharge with prednisolone 7-14 days

Question 7

Primary pneumothorax management

Answer 7

> 2cm/breathless - aspirate (16-18G)
<2cm - review in 2-4 weeks

Question 8

Secondary pneumothorax management

Answer 8

> 2cm/breathless - chest drain
1-2cm - aspirate
<1cm - high flow O2, observe 24 hours

Question 9

Haemodynamically unstable pneumothorax management

Answer 9

Chest drain

Question 10

Bilateral pneumothorax management

Answer 10

Chest drain

Question 11

Tension pneumothorax management

Answer 11

Large-bore needle (14-16G) with syring with saline
Remove trapped air bubbling into syringe
Request CXR
Insert chest drain

Question 12

Pulmonary embolism management (Well’s score > 4) and haemodynamically stable

Answer 12

PE likely

A-E

CTPA (anticoagulate with DOAC e.g. apixiban if delayed)

If positive:
DOAC
Heparin if low eGFR

If negative:
Proximal leg vein USS

Question 13

Pulmonary embolism management (Well’s score > 4) and haemodynamically unstable

Answer 13

A-E
Heparin and alteplase

Question 14

Pulmonary embolism management (Well’s score 4 or less)

Answer 14

A-E
D dimer
Positive: CTPA
Negative: Consider alternative diagnosis

Question 15

Upper GI bleed management

Answer 15

A-E
Initiate major haemorrhage protocol if >5L
NBM
Stop anticoag/platelet

2 large-bore cannulae
IV crystalloid up to 1L
O-negative blood until crossmatch complete
Monitor urine output with catheter

Endscopy or mesenteric angiography

Sengstaken-Blakemore tube

SC ceftriaxone and terlipressin if variceal bleed
PPI if ulcer bleed

Question 16

Meningitis management

Answer 16

A-E

IV access:
Blood culture, blood glucose, HIV
LP unless rapidly deteriorating or raised ICP
IV cefoxatime (+ ampicillin > 50 years)
Consider IV dexamethasone

Question 17

Status epilepticus management

Answer 17

Start a clock
A-E
Open and secure airway
Call for help

15L oxygen and suction
IV access - bloods
IV lorazepam - repeat once after 10 mins if no response
(Thiamine if malnourishment
100ml 20% glucose if hypoglycaemia
Fluids if hypotension
Dexamethasone if tumour)
IV phenytoin (monitor BP and ECG)
ICU review

Question 18

When to CT head < 1 hour

Answer 18

Focal neurological deficit
Skull fracture
Seizure
Vomit 2+

Question 19

Raised ICP management

Answer 19

A-E
Urgent neurosurgery referral
Sit up 40 degrees
Hyperventilate if intubated (reduced CO2, cerebral vasoconstriction)
Mannitol
Dexamethasone (if tumour)
Fluid restriction

Question 20

DKA management

Answer 20

A-E
Call for help
Fluid bolus (500ml over 15 mins) then continue
Insulin - fixed-rate infusion until ketones <0.6
Potassium
10% dextrose when glucose <14

LMWH for VTE prophylaxis due to dehydration

Question 21

Myxoedema coma management

Answer 21

A-E
IV T3
IV hydrocortisone
Warming blanket

Question 22

Thyroid storm management

Answer 22

A-E
IV propranolol
PO carbimazole
IV hydrocortisone
IV fluids
Cooling
Treat precipitant

Lugol’s iodine for 10 days

Question 23

Carbon monoxide poisoning management

Answer 23

A-E
100% high-flow oxygen via tight-fitting non-rebreathe mask with inflated seal for 6 hours
SpO2 target 100%

Mannitol of cerebral oedema
Hyperbaric oxygen if severe (specialist)

Question 24

Hypothermia management

Answer 24

A-E
Warm-humified O2
Remove wet clothes
Rewarm +0.5C an hour - blankets, warm IV infusion
Abx cover for pneumonia

Question 25

Sepsis management

Answer 25

A-E
Administer O2 – aim >94%, or 88-92% if at risk of CO2 retention
Take blood cultures
Give broad-spectrum abx
IV fluid challenge – 500ml over 15 mins
Measure lactate
Measure hourly urine output

Question 26

Anaphylaxis management

Answer 26

A-E but straight to management if suspected
Call for help
Remove trigger

Lie flat and secure airway
IM adrenaline 1:1000 500ug
Repeat after 5 mins if no response

Still no response = refractory
Adrenaline infusion and continue IM doses
IV access and fluid challenge for hypotension
Alert ITU/CCOT/anaesthetics

Question 27

Anaphylaxis discharge plan

Answer 27

Allergy clinic visit
2x epipens - teach
MedicAlert bracelet with allergen name

Question 28

Stroke management

Answer 28

A-E

CT head: excluded haemorrhagic
- aspirin 300mg
- alteplase within 4.5 hours
- consider thrombectomy within 6 hours

If haemorrhagic, generally supportive care / surgical resection of haematomas.

Question 29

Secondary prevention anticoag/platelet for PE, MI, AF, stroke, TIA

Answer 29

PE
1) DOAC
2) heparin

MI
- aspirin
- clopidogrel

AF
1) DOAC
2) warfarin

Stroke
- aspirin
- clopidogrel
- dipyridamole

TIA
- clopidogrel