Acute Station

Question 1

Acute Pneumonia

Answer 1

• ABCDE
• Severe Pneumonia = IV co-amoxiclav
• HAP = piperacillin + tazobactam
• CAP = amoxicillin

Question 2

PE

Answer 2

• ABCDE
• LMWH
• Haemodynamically unstable = alteplase thrombolysis
• Persistant low BP = noradrenaline or dobutamine vasopressors (aim for systolic > 90)

Question 3

STEMI

Answer 3

• MONAS RAB
• S = clopidegrol
• R = repercussion (primary PCI or thrombolysis)
• A = anti-coagulation (enoxaparin - LMWH)
• B = B-Blockers

Question 4

NSTEMI

Answer 4

• MONA Fuck Stop Now Before I Die (high risk patients)
• A = aspirin
• F = fondaparinux
• S = clopidegrol (prasugrel for PCI)
• N = nitrate infusion
• B = b-blockers
• I = intervention (PCI if GRACE score > 140)
• N.B. No chest pain or normal ECG or normal Troponin = low risk patient = can use conservative approaches

Question 5

AKI (presentation + management)

Answer 5

ABCDE

Presentation

• creatinine + urea high
• fall in eGFR
• low urine output + dehydration
• confusion, fatigue, drowsiness

Management

• largely supportive
• careful fluid balance
• stop nephrotoxic drugs + diuretics, metformin and anti-hypertensives
• (loop diuretics only if significant fluid overload)
• hyperkalaemia = stabilise cardiac membrane

Question 6

Sepsis

Answer 6

• ABCDE
• Sepsis 6
• Culture EVERYTHING = sputum, lines, poo, CSF
• Urosepsis = may have AKI

Question 7

DKA

Answer 7

• ABCDE
• Fluids (1 L over an 1 hour x 2, 1L over 2 hours)
• Insulin (0.1 units/kg/hr)
• Potassium (NOT in the 1st bag = 40 mmol KCL)
• Glucose (when BM <14)

Question 8

Major Haemorrhage

Answer 8

• ABCDE
• 2222 = major haemorrhage protocol
• Blood Transfusion
  
  • Systolic < 90
  • Hb < 70

Question 9

Major GI Bleed

Answer 9

• ABCDE
• Varices = terlipressin —> emergency endoscopic band ligation OR Sengstaken-Blakemore Tube insertion
• Ulcer = endoscopy within 2 hours BEFORE PPIs

Question 10

Anaphylaxis

Answer 10

• ABCDE
• IM adrenaline 1:1000 0.5mls
• 10mg chlorphenamine
• 200mg IV hydrocortisone

Question 11

Pneumothorax

Answer 11

• ABCDE
• Tension:
  
  • ​needle thoracocentesis = 2nd ICS mid-clavicular line
  • chest drain = safe triangle - 4/5th intercostal space anterior to mid-axillary line, lateral to pectoralis major
• Primary:
  
  • ​< 2 cm = home
  • > 2 cm = needle thoracocentesis
• Secondary:
  
  • ​= COPD bullae OR underlying lung disease
  • < 1 cm = 24 hour observation + oxygen
  • 1-2cm = needle thoracocentesis + 24 hour observation w oxygen
    
    • ​unsuccessful = chest drain
  • > 2 cm OR SOB = chest drain

Question 12

Thyroid Storm (symptoms + management)

Answer 12

Symptoms

• fever > 38.5
• tachycardia
• confusion/agitation
• N&V
• HTN
• heart failure
• LFTs abnormal

Management

• symptomatic (paracetamol)
• treat precipitating event
• propanolol
• anti-thyroid = propylthiouracil
• lugol’s iodine
• dexamethasone

Question 13

Arrhythmias

Answer 13

• ABCDE
• DC cardioversion => haemodynamically unstable (syncope, heart failure, low blood pressure, chest pain/signs of ischaemia)

1. Atrial (narrow QRS) = Adenosine
2. Bradycardia = Atropine
   
   • causes = b-blockers, verapamil, digoxin, heart block
3. Ventricular = Amiodarone

(ADBTVA)

Question 14

Status Epilepticus

Answer 14

• ABCDE
• buccal midazolam + rectal diazepam
• IV lorazepam (x2)
• IV phenytoin (phenobarbital)
• Call anaesthetist
• Intubate

Question 15

Addisonian Crisis (symptoms + management)

Answer 15

Symptoms

• fatigue
• weight loss
• low BP
• low BM
• N&V + D&V
• abdominal pain

Management

• IV fluid bolus
• IV hydrocortisone
• Monitor U&Es for hyperkalemia
  
  • treat w calcium gluconate, insulin and salbutamol nebs
• Monitor hypoglycaemia (50ml 50% glucose)

Question 16

Burns

Answer 16

• ABCDE
• secure airway (consider early intubation + dexamethasone to reduce inflammation)
• oxygen + ABG
• manage fluid loss (2 large bore cannula + 2L warm hartmanns immediately)
• prevent infection (prophylactic anti-pseudomonal)
• morphine analgesia
• partial thickness burns
  
  • dress them
  • biological = cadaveric skin
  • synthetic
  • cream = flamazine
• full thickness burns
  
  • excision debridement
  • split-thickness skin grafts
• Wallace Rule of 9s
  
  • ​torso and legs = 18
  • head and neck = 9
  • arms = 9 each
  • perineum = 1
  • palm = 1

Question 17

Peripheral Oedema

Answer 17

• ABCDE
• Diamorphine
• GTN
• Isosorbide Dinitrate Infusion
• Frusemide

Question 18

Cardiac Arrest

Answer 18

• 30:2 compressions
• Assess rhythm:
  
  • VF or pulseless VT = SHOCK
  • PEA or asystole = do not shock
• Continue CPR for 2 minutes
• Reassess
• Adrenaline = every 3-5 minutes
• Amiodarone = after 3rd shock

Reversible Causes

• 4 H’s = hypovolaemia, hypoglycaemia (calcaemia, kalaemia), hypothermia, hypoxia
• 4 T’s = toxins, tamponade, thrombosis (PE or MI), tension pneumothorax