acute and emergency

Question 1

presenting symptoms of aspirin overdose

Answer 1

may be initially asymptomatic

early symptoms:

• flushed
• fever
• sweating
• hyperventilation
• dizziness
• tinnitus
• deafness
• vomiting

later symptoms:

• lethargy
• confusion
• convulsions
• drowsiness
• respiratory depression
• coma

Question 2

key questions in aspirin overdose case

Answer 2

how much was taken

when was it taken

were any other drugs taken

any alcohol

Question 3

pathophysiology of aspirin overdose

Answer 3

aspirin is a weak acid with poor water solubility

increases RR and depth buy stimulating respiratory centre and causes resp. alkalosis

increased urinary bicarb and potassium excretion causes dehydration and hypokalaemia

loss of bicarb, uncouples oxidative phosphorylation, and lactic acid build up can cause metabolic acidosis

CNS depression and resp failure in severe cases

Question 4

toxicity levels of aspirin

Answer 4

150mg/kg = mild

250mg/kg = moderrate

>500mg/kg = severe

>700mg/kg = potentially fatal

Question 5

physical examination findings in aspirin overdose

Answer 5

fever
tachycardia
hyperventilation
epigastric tenderness

rare:
reduced GCS
seizures
hypotension
heart block
pulmonary oedema
hyperthermia

Question 6

investigations for aspirin overdose

Answer 6

bloods:
- salicylate/other drug levels
- FBC
- U&E (hypokalaemia)
- LFT (high AST/ALT)
- clotting screen (high PT)
- ABG

ECG: signs of hypokalaemia

• flattened/inverted T waves
• U waves
• prolonged PR interval
• ST depression

Question 7

management of aspirin

Answer 7

sodium bicarbonate

Question 8

define anaphylaxis

Answer 8

acute life-threatening multi system syndrome

caused by sudden release of mast cell and basophil derived mediators

type 1 IgE mediated hypersensitivity

Question 9

aetiology of anaphylaxis

Answer 9

immunogenic:
- IgE mediated
- immune complex/complement-mediated

non-immunogenic:
- anaphylactoid reaction
- mast cell/basophil degranulation
* without involvement of antibodies

Question 10

pathophysiology of anaphylaxis

Answer 10

inflammatory mediators released causing:

• bronchospasm
• increased capillary permeability
• reduced vascular tone

tissue oedema affecting:

• larynx
• lids
• tongue
• lips

Question 11

common allergens in anaphylaxis

Answer 11

drugs
latex
peanuts
shellfish
eggs
strawberries
semen

* repeated blood products in patients with selective IgA deficiency

Question 12

presenting symptoms of anaphylaxis

Answer 12

wheeze
SoB
choking sensation

sweating
palpitations

pruritus
rash

diarrhoea and vomiting

Question 13

physical examination findings in anaphylaxis

Answer 13

tachypnoea
hypotension
tachycardia

wheeze
swollen upper airways and eyes

cyanosis
urticarial rash
erythema

rhinitis
conjunctival infection

Question 14

investigations for anaphylaxis

Answer 14

requires clinical dx

supporting investigations:

• serum tryptase
• histamine/urinary metabolites of histamine

Question 15

investigations following an anaphylactic attack

Answer 15

allergen skin testing

IgE immunoassay (identifies food specific IgE)

Question 16

immediate management for anaphylaxis

Answer 16

ABCDE
stop suspected cause

100% O2 +/- intubation if respiratory obstruction imminent

0.5mg adrenaline IM
10mg chlorpheniramine IV
100mg hydrocortisone IV

salbutamol +/- ipratropium (bronchospasm)

maintain fluids
if patient remains hypotensive:
- transfer to ICU
- IV adrenaline +/- aminophylline
- nebuliser salbutamol

pulse oximetry
ECG
BP

Question 17

post-attack management of anaphylaxis

Answer 17

ward admittance
monitor ECG

mast cell tryptase monitoring 1-6hrs after

continue chlorpheniramine

MedicAlert bracelet
self-injected adrenaline education
skin prick tests

Question 18

complications of anaphylaxis

Answer 18

shock
organ damage resulting from shock

Question 19

prognosis of anaphylaxis

Answer 19

good with prompt treatment

Question 20

what is a stroke?

Answer 20

focal/neurological disturbance to the brain lasting >24hrs

Question 21

Types of stroke

Answer 21

1. ischaemic (85%)- neurological disturbance caused by ischaemia causing brain/ spinal chord death due to vessel occlusion/ stenosis (larger extracranial carotid/ vertebral arteries, intracranial arteries, smaller lacunar arteries)
2. Haemorrhagic (15%)- caused by blood collection due to ruptured blood vessel in brain
3. Silent strokes- pathological infarction without neuroloical

Question 22

causes of ischaemic stroke

Answer 22

• thrombus (also in prothrombotic state - dehydration/ pregnancy/malignancy)
• embolus of fatty deposit from larger arteries cause occlusion (from carotid dissection/ atherosclerosis/ venous blood clots pass through VSD)
• hypotension
• vasculitis
• cocaine (arterial spasm)

Question 23

causes of haemorrhagic stroke

Answer 23

• intracerebral haemorrhage (usually due to hypertension)
• subarachnoid haemorrhage (bleeding into subarachnoid space from cerebral vessels, burst aneurysm, vascular malformations)

Question 24

What is a silent stroke?

Answer 24

pathological sign of infarction without neurological disturbance

Question 25

presenting symptoms of stroke

Answer 25

- SUDDEN ONSET \*(motor, sensation, speech, balance, vision) - impaired fine motor co-ordination and gait - weakness - confusion - sensory loss (numbness/ parathesia) - visual impairment (loss/ diplopia) - headache - face + neck pain - dizziness/ vertigo/ loss of balance - speech problems (dysarthria) - nausea/ vomiting

Question 26

examination findings of a stroke

Answer 26

- FASt (facial weakness, arm weakness, slurred speech) Neurological examination * Specific cranial nerve deficits such as unilateral tongue weakness or Horner’s syndrome (miosis, ptosis, and facial anhidrosis) * sensory/ visual/ cognitive impairment * impaired fine motor coordination + gait -

Question 27

investigations + findings for stroke

Answer 27

- Blood pressure + pulse (check for AF/ hypertension) - Bloods: Clotting profile (check for thrombophillia) + blood glucose - ECG (check for arrythmias) - Echocardiogram (check for cardiac thrombus/ endocarditis/ emboli source) - Doppler ultrasound (check for carotid artery disease-atherosclerosis) - CT brain (check for haemorrhages) - MRI brain (check for infarction - less available) - CT cerebral Angiogram (look for carotid dissection/ stenosis)

Question 28

management for suspected acute stroke:

Answer 28

- maintain homestasis (control blood glucose 4-11mmol/L) - Nil by mouth until swallowing assessment - CT/MRI \<1hr- exclude haemorrhage so can start on thrombolysis 1. anti-platelets- ASPIRIN 300mg for 2 weeks, then long term antithrombotics 2. thrombolysis (ALTEPLASE) 3. thrombectomy - for large artery occlusion in proximal anterior circulation

Question 29

secondary prevention for future stroke

Answer 29

lifestyle (reduce CVD risk): stop smoking, improve diet (less salt/sat fat), exercise, reduce alcohol drugs: anti-platelets (**_clopidogrel_**), statin (atorvostatin), anti-hypertensives (thiazide-like diuretic/ CCBs) \*persistant AF =\> warfarin anti-coagulation

Question 30

prognosis for stroke

Answer 30

10% mortality 50% of survivors after stroke dependant 10% risk of recurrence haemorrhagic worse than ischaemic

Question 31

What scoring system is used to identify sepsis?

Answer 31

NEWS2 * score \>5 * score \>3 in one parameter

Question 32

Presenting symptoms + signs of sepsis

Answer 32

ABCDE approach to assess + manage * B- tachypnoea- raised RR \>20 * C- tachycardia (raised HR) * D-altered mental status/ confusion * E- raised temp, rigors (sudden fever + chills) Infection cause specific: Lung - cough, sputum, chest pain Genitourinary- dysuria, discharge abdo pain Skin- rashes, join pain, erythema CVS- headaches, photophobia GI- vomiting, diarrhoea, abdo pain, jaundice

Question 33

Investigations for sepsis

Answer 33

First-line * blood cultures * raised serum lactate- due to increased aerobic glycolysis causing imbalanced O2 delivery/use * hourly Urine output (reduced = poor perfusion/ cardiac output) * Bloods- FBC, U&Es, CRP, glucose * clotting * ECG Second line * urinalysis * CXR * lumbar puncture- analyse CSF for infection * CT/ MRI

Question 34

Management of sepsis

Answer 34

Give: 1. IV antibiotics 2. IV fluids- 500ml saline max 30ml/kg 3. oxygen (maintain \>94%) for CELLULAR HYPOXIA Take 1. blood cultures- identify pathogen 2. lactate level- sign of severe sepsis 3. urine output Further: * increase bp (catecolamine vasopressors - NA/ metariminol) * reduced cardiac function (inotropes- Adrenaline)