Acute Care Station

Question 1

STEMI

Answer 1

“ECG, glucose
Bloods: U&E, FBC, Troponin, Glucose, Lipids
CXR
MONA
Primary PCI / Streptokinase 1.5 million U in 100ml saline over 1h
BB + DVT prophylaxis”

Question 2

NSTEMI

Answer 2

"ECG, glucose
Bloods: U&E, FBC, Troponin, Glucose, Lipids
CXR
MONAC (DAT 12 months)
LMWH + BB
Consider angiography"

Question 3

Pulmonary oedema

Answer 3

"Note COPD / asthma / pneumonia / pulmonary oedema can coexist
O2 100%, Morphine 10mg + Metoclopramide
GTN spray + Furosemide 40-80mg IV
CXR, ECG
U&E, Troponin, BNP, ABG
If BP >100; can start nitrate infusion
If no response, NIV
If BP <100 = cardiogenic shock = ITU 
Once stable --> daily weights, obs, CXR, change to oral, ?treat HF "

Question 4

Broad complex tachycardia

Answer 4

“ECG: HR>100; QRS>120ms; LAD (VT)
Ddx: VT/TDP, SVT with aberrant conduction, AV re-entry tachcardia with WPW
Blood: Esp low K, Mg
Mx: Help, cardiac monitor, O2, Defib, iv access
Unstable: Synchronised DC, KCL & MgSO4, amiodarone 300mg/60min
Stable: KCL & MgSO4, amiodarone 300mg IV/60min, if fails DC shock
After: establish cause, maintenance antiarrythmic
Torsades des pointes: Stop predisposing drugs, KCL & MgSO4. Overdrive pacing or isoprenaline may be needed “

Question 5

Narrow complex tachycardia

Answer 5

“DDx –> AF, A flutter, WPW reentry tachycardia
O2 + IV access
Rhythm regular? (If not, treat as AF)
Continuous ECG trace
Vagal manoeuvres
Adenosine 6mg bolus (+2 12mg boluses if necessary)
Unstable –> Sedation + synchronised cardioversion + amiodarone 300mg / 60min
Stable –> Amiodarone 300mg IV / 60 min OR verapamil OR digoxin”

Question 6

Coma

Answer 6

“Ddx: Drugs, poisoning (CO, %, TCA), Sugar (hypo, DKA, HONKC), O2, CO2 (COPD), infection, hypothermia, addison’s, myxoedema, encephalopathy (renal/liver). Neuro (meningitis, encephalitis, tumour, vasc TIA/CVA
ABCDEFG
ABG, FBC, U&E, LFT, ESR, CRP, ethanol, toxic screen, drug levels, cultures, CXR, CT head
Treat underlying cause”

Question 7

HHS

Answer 7

“TIIDM, dehydration and hyperglycaemia, high osmolality and acidosis
Aggressive rehydration over 48h. Saline, replace K when urine begins to flow.
Avoid rapid changes to electrolytes (central pontine myelinolysis)
Think about insulin
“

Question 8

Addisonian crisis

Answer 8

“DDx TB, trauma, abrupt stopping of long term corticosteroids, AI
Blood: cortisol + ACTH
Hydrocortisone 100mg IV stat
Fluids: 0.9% saline
Monitor glucose - this is the danger; may need IV glucose
Senior: may need fludrocortisone, gluide steroid replacement”

Question 9

Phaeochromocytoma

Answer 9

“Hypertensive crisis: pallor, pulsating headache, HTN, impending doom, pyrexia, ST elevation, VT, cardiogenic shock
Senior + ITU
A block + B block + surgery
Phentolamine 2-5mg IV, repeated to maintain BP normal
When ok, phenoxybenzamine 10mg/24h, titrating dose untiil BP normal
BB
Surgery elective @ 4-6wks”

Question 10

IECOPD

Answer 10

“Investigations: PEF, ABG, CXR, ECG, FBC/U&E/CRP, MCS
Controlled O2 - venturi 24-28%, ABG monitoring. Aim PaO2>8 with rise in PaCO2<1.5
Nebs: Sal + Iptratropium
Roids: IV hydrocortisone 200mg / Pred 40 (7-14 days)
Abx: Local protocol (e.g. doxycycline)
No response: Repeat nebs ± IV aminophylline
No response: NIPPV
No response: Inquire about ITU (unlikely)
Post –> Pulm rehab, stop smoking, LTOT”

Question 11

Asthma

Answer 11

“Sit up 100% O2, PEF
ABG + IV access + bloods
Salbutamol 5mg + Tiotropium 0.5mg neb + Hydrocortisone 100mg IV
CXR for ? pneumothrax; repeat PEF to monitor response
If life threatening features = ITU informed ASAP; MgSO4 2g IVI / 20 min Salbutamol every 15min (monitor ECG)
If improving = O2 titrate >92% Sat; Prednisolone 40mg OD 5days; neb Sal every 4h; monitor PEF
If not improving 15-30min = Sal every 15min, ipratropium every 4-6h
If still no improvement = As for life threatening, ±aminophylline loading dose “

Question 12

Pneumonia

Answer 12

“CXR, ABG, FBC/U&E/LFT/CRP, MCS, aspirate, CURB65
O2 + Fluids + Abx + Analgesia
Escalation: ITU with ventilatory support”

Question 13

PE / DVT

Answer 13

"Assess risk factors in Hx
Wells Score 
100% O2
Morphine + Metoclopramide
*If critical illness immediate thrombolysis (50mg alteplase)
IV access + LMWH (trust guidelines)
BP: if low rapid colloid infusion (x2 500ml bolus / 15min)
If BP ok warfarin loading
CTPA to confirm"

Question 14

Pneumothorax

Answer 14

“DDx idiopathic, asthma, COPD, TB, pneumonia, Ca, CF, IPF, Sarcoid, Marfans, Ehler’s Danlos, trauma, iatrogenic (SVC insertion)
Tension: Neddle decompression + Drain
Non tension: CXR
Rim or air > 2cm - aspirate. If failure, drain. For smaller observe and consider discharge”

Question 15

Acute GI bleed

Answer 15

“DDx PUD, MW tear, erosions, oesophagitis, varisces
Rockall scoring system for acute GI bleed
O2
NBM + 2 cannulae + urinary catheter
U&E, FBC, LFTs, glucose, clotting, XM 6u
Rapid IV crystalloid, 1L (or 2x 500ml); consider O-ve blood
Transfusion, use Hb as guide
Correct clotting (vit K, FFP)
Monitor + endoscopy ± surgery”

Question 16

AKI / dialysis

Answer 16

"DDx pre-renal / renal / post renal
Catheterise + fluid balance chart
Stop nephrotoxic drugs
Assess hydration 
Cardiac monitor (K)
Fluid challenge (250-500ml /15 min)
If suspicious of sepsis - sepsis 6"

Question 17

Hyperkalaemia

Answer 17

Recheck - sample may have clotted, use ECG/clinical to guide. Tented T waves, flat P waves, prolonged PR interval; wide QRS. 10ml 10% Ca Glucuronate IV/2min (repeat as necessary); Neb Salbutamol 2.5mg; 10U actarapid in 50ml 50% glucose /30min. If refractory dialysis

Question 18

Hypernatraemia

Answer 18

Usually fluid loss w/o replacement, DI, Addison’s. Ideally oral hydration, IV 5% dextrose guided by UO and plasma Na. Saline replacement can be considered if hypovolaemic, as this causes smaller fluid shifts.

Question 19

Hyponatraemia

Answer 19

Euvolaemia / Hypovolaemia / Hypervolaemia. Correct underlying cause. Too rapid correction causes central pontine myelinolysis - lethargy, confusion, pseudobulbar palsy, paresis, locked in syndrome

Question 20

Anaphylaxis

Answer 20

"Secure Airway + 100%O2
Remove cause
Adrenaline 0.5ml 1:1000 IM every 5min PRN (BP, HR, RR - until improved)
Chlorphenamine 10mg IV
Hydrocortisone 200mg IV
Fluids: Saline 500ml / 15 min (BP, HR)
Wheeze? Treat for asthma
No improvement = ITU + IVI adrenaline 
Post: Education, EpiPen, Atopy testing"

Question 21

Cardiogenic shock

Answer 21

“O2
Morphine + Metoclopramide
Arrythmias / Electrolyte abnormalities / Acid/Base
Measure pulmonary capillary wedge pressure. If >15 Ionotrpic support if <15 plasma expander
Consider dopamine, intraaortic balloon pump”

Question 22

Hypovalaemic shock

Answer 22

Saline or colloid, titrate against BP/CVP/UO. Group O-ve blood, XM asap, correct acidosis, contact surgery if bleeding suspected. XM, clotting, FBC, ABG, glucose, CRP, lactate, blood and urine cultures, ECG, CXR. Consider arterial line, catheterise

Question 23

Septic Shock

Answer 23

ABCDE, Abx within 1h (right after cultures), 500ml bolus / 15min. Unresponsive - may need inotrope support in ITU

Question 24

Salicylate poisoning

Answer 24

“Dose related effects. Levels >700mg/L fatal
N&V, dehydration, tinnitus, vertigo, sweating, seizures, coma.
ABG - initially resp alkylosis –> metabolic acidosis with wide anion gap
Activated charcoal <1h
ToxBase
Bloods: U&E, FBC, LFTs, INR, glucose, paracetamol & salycilate levels
ABG, ECG, UO, glucose monitoring
?HCO3 to correct acidosis
If level >500mg/L consider alkalisation of urine with HCO3 and K infusions
Dyalisis may be required “

Question 25

Paracetamol poisoning

Answer 25

"150mg/kg or 12g in adults potentially fatal. Initially asymptomatic, vomiting + RUQ pain, jaundice + liver failure + encephalopathy + ARF Lavage / Charcoal if <1h Plasma concentration graph - NAC 150mg/kg in 200ml 5% dex over 15 min initially Blood: INR, FBC, U&E, LFTs, Specialist unit: Encephalopathy / ICP+, INR high, ARF, pH persistently low Liver Tx"

Question 26

Bradycardia

Answer 26

``` "Bradycardia HR<40 Atropine - 500microg Then more atrpoine up to 3mg Transcutaneous pacing Isoprenaline 5mcg Adrenaline 2-10 Alternative drugs - Aminophylline, dopamine, glucagon" ```

Question 27

IE

Answer 27

"Infective endocarditis 2 if own valve Fluclox and Gent 3 if prosthetic Vanc, gent, rifampicin Sepsis 6 3 out - Urine, 1 million blood culture, Lactate 3 IN - O2, Fluid, ABX If septic 2 cultures within 1 hour from 2 seperate sites ABX for 4 weeks Dukes Criteria Major - Blood, ECHO evidence Minor - Predisposition, Shit cultures, Fever, Immune phenomena, Embolic phenomena"

Question 28

Thyrotoxic storm

Answer 28

``` "Increased Temp, sweat, agitation, confusion, coma, Tachy, AF, Acute abdo, HF Precipitants --> Recent thyroid surgery or radioiodine Infection; MI; Trauma Fluid resus, and NGT Bblocker Carbimazole Lugol’s Iodine Hydrocortisone Treat cause" ```

Question 29

Decomp CLD

Answer 29

"Jaundice, Asterixis, Ascites + SBP Invx --> FBC, PT/INR, Diagnostic paracentesis (MC+S,SAAG >1.1 - portal HTN; <1.1 - Cancer) Amylase, U&E, LFTs, Blood cultures. CT/USS, chest abdo xray Mnx -->Analgesia, Antiemetics, ABX (Taz/cefotaxime, cipro Long term prophylaxis), Therapeutic paracentesis, IV albumin Complications --> Hypoalbuminaemia, Bleedin, Hypoglycaemia, Hepatorenal syndrome (Iv albumin, terlipressin, haemodialysis Liver transplant Encephalopathy --> Lactulose, Phosphate enemas, get rid of nitrogen-forming bowel bacteria. Appropriate nursing, Avoid sedatives"

Question 30

IBD

Answer 30

"Supportive --> NBM, Parenteral nutrition, Dietician input (elemental diet in crohns) Medical Acute Flare Up --> IV Hydrocortisone Surgical --> If toxic megacolon, perf, haemorrhage, not responding to medicines. Subtotal/total colectomy - end ileostomy/ileorectal anastomoses. Panproctocolectomy - Ileoanal pouch. Hartmanns crohns Induction of remission --> UC (5 ASA PR/PO, Prednisolone PR/PO) vs Crohns (Pred, 5 ASA) Maintenance --> UC (5ASA, azathioprine, biologics, surgery), Crohn’s (Azathioprine, Methorexate, Biologics)"

Question 31

Alcohol detox ± delirium tremens

Answer 31

``` "Alcohol detoxication e.g. delirium tremens Pabrinex (B12, vitamin C, Thiamine) Chlordiazepoxide (2wk Tappering regime) Acamprosate/baclofen - decrease cravings Disulpharam - Aversion therapy" ```

Question 32

Meningitis

Answer 32

``` "Septicaemic - IV Ceftriaxone 2g BD Meningitic - LP first within 1 hour Ceftriaxone 10mg Dexamethasone IV (swelling) Old/young - Ampicillin" ```

Question 33

Encephalitis

Answer 33

As meningitis Plus IV acyclovir 10mgs/kg TDS

Question 34

Status epilepticus

Answer 34

"Seizing continous or repeatedly for 30 mins 10mg IV Diazepam (Lorazepam 0.1mg/kg)/ buccal midaz 10mg repeat after 10 mins 10mg/kg iv phenobarbitol 100mg/minutes OR Phenytoin 18mg/kg at 50mgs/min ESCALATE! RSI"

Question 35

Raised ICP

Answer 35

``` "Sit up Neuroprotective hyperventilation - High o2 low co2 IV Mannitol/hypertonic saline Scan head and Treat cause Burr holes/craniotomy; coiling if SAH Keep BP above 160 CT, LP 12 hours later xanthochromia Nimodipine - prevents vasospasm Platinum coiling Coning - Tonsilar - brain stem death " ```

Question 36

DKA

Answer 36

"Acidosis <7.3, ketones >3mM, glucose >11.1mM 0.9% NS BP<90 1L stat; BP>90 1L over 1 hour; 1L/2*2, 1L/4h*2, 1L/6hrs Start Potassium in 2nd bag --> >5.5mM - Nil; 3.5-5.5mM - 40mM/L; <3.5 Senior review Fixed rate Insulin - Actrapid 0.1u/kg/h Continue giving them their basal insulin regimen too of their long acting to prevent rebound hyperglycaemia. Swap to dextrose once blood sugar gets below 15 It takes longer to turn off ketogenesis than it does to bring the blood sugar down. So Insulin Must be continued in order to stop ketone production Resolution when: pH above 7.3; Ketones less than .3 If you can eat and drink then you can go on your basal bolus regime "

Question 37

Hypoglycaemia

Answer 37

"Alert and orientated - Oral Carbs: Rapid acting - Lucozade Long Acting - Sandwich Drowsy/confused, swallow intact - Hypostop/ Glucogel; Consider IV access Unconscious: 100mls 20% glucose Insulin induced/no access: 1mg Glucagon "