Emergencies

Question 1

metabolic causes of coma?

Answer 1

Drugs e.g. CO poisoning, alcohol, tricyclics
Hyper/hyperglycaemia
Hypoxia
Septicaemia
Myoxedema/Addisonian crisis
Hepatic/uraemic encephalopathy

Question 2

neurological causes of coma?

Answer 2

Trauma
Infection- meningitis, encephalitis, malaria
Tumour
Vascular- stroke, SAH/SDH, hypertensive encephalopathy
Epilepsy

Question 3

immediate mx of coma?

Answer 3

ABC
Check BG- give 50ml 20% glucose IV stat if needed
IV thiamine if suggestion of wernicke’s encephalopathy
IV naloxone for opiate intoxication

Question 4

Ix of coma?

Answer 4

ABG
FBC, U&E, LFT, ESR, CRP
Ethanol
Toxic screen
Drug levels
Blood cultures
Urine culture
CXR
CT head

Question 5

signs of shock?

Answer 5

low GCS/agitation
pallor
cool peripheries
tachycardia
slow capp refill
tachypnoea
oliguria
lactate
reduced BP

Question 6

2 physiological causes of shock?

Answer 6

MAP = CO x SVR

reduced CO or reduced SVR

Question 7

causes of inadequate CO?

Answer 7

1. hypovolaemia- bleeding or fluid loss

2. pump failure- cardiogenic shock, PE, tension pneumothorax, cardiac tamponade

Question 8

causes of peripheral circulatory failure?

Answer 8

1. sepsis
2. anaphylactic
3. neurogenic e.g. spinal cord injury
4. endocrine failure
5. drugs e.g. antihypertensives

Question 9

signs and symptoms of anaphylaxis?

Answer 9

• itching, sweating, D&V, erythema, urticaria, oedema
• wheeze, laryngeal obstruction, cyanosis
• tachycardia, hypotension

Question 10

mx of anaphylaxis?

Answer 10

• secure airway
• give 15L O2 non-rebreathe mask
• remove the cause
• adrenaline IM 0.5mg (0.5mL of 1:1000)
• secure IV access
• chloramphenamine 10mg IV and hydrocortisone 200mg IV
• IV saline
• if wheeze, treat for asthma

Question 11

tests on admission if suspected STEMI?

Answer 11

12 lead ECG, U&E, troponin, glucose, cholesterol. FBC. CXR

Question 12

initial treatment of STEMI?

Answer 12

Aspirin 300mg PO
Morphine 5-10mg IV with metoclopramide 10mg IV
O2 if sats <95%
GTN spray

Question 13

when should PCI be performed?

Answer 13

within 120 mins of admission

if not possible fibrinolysis should performed and if unsuccessful, transfer for rescue PCI or angiography

Question 14

main choice of agent for thrombolysis?

Answer 14

tissue plasminogen activator e.g. alteplase or tenecteplase

Question 15

what med needs to be given in primary PCI?

Answer 15

IV anticoagulant e.g. bivalirubin

Question 16

contraindications to thrombolysis?

Answer 16

prev intracranial haemorrhages
ischaemic stroke <6 months
cerebral malignancy 
recent major trauma or surgery (<3 weeks)
GI bleeding (<1 month)
known bleeding disorder
aortic dissection `

Question 17

ECG criteria for thrombolysis?

Answer 17

ST elevation
LBBB
Posterior changes e.g. deep ST depression and tall R waves in leads V1 to V3

Question 18

complications to STEMI?

Answer 18

recurrent ischaemia
stroke
pericarditis
cardiogenic shock
HF

Question 19

brief history questions in NSTEMI?

Answer 19

prev angina
relief with nitrates/rest
hx of cv diseaase
RFs for IHD

Question 20

brief examination in NSTEMI?

Answer 20

pulse
BP
JVP
cardiac murmurs
signs of HF
peripheral pulses
scars from prev cardiac surgery

Question 21

acute management of NTEMI?

Answer 21

O2
morphine and metoclopramide
GTN spray
aspirin and second antiplatelet agent e.g. clopidogrel, ticagrelor
oral beta blocker if hypertensive
anticoagulant e.g fondaparinux (factor Xa inhibitor) or LMWH

Question 22

causes of severe pulmonary oedema?

Answer 22

1. cardiovascular e.g. ususally left vetricular failure, valvular heart disease, arrhythmias, malignant hypertension
2. ARDS caused by trauma, malaria, drugs
3. Fluid overload
4. Neurogenic e.g. head injury

Question 23

differential diagnosis of pulmonary oedema?

Answer 23

asthma/ COPD

pneumonia

Question 24

symptoms of pulmonary oedema?

Answer 24

dyspnoea
orthopnoea
pink, frothy sputum

Question 25

signs of pulmonary oedema?

Answer 25

``` distressed pale sweaty tachycardia pulsus alternans high JVP fine lung crackles gallop rhythm wheeze ```

Question 26

Ix of pulmonary oedema?

Answer 26

``` CXR- cardiomegaly, shadowing, small effusions at costophrenic angles, fluid in the ling fissures, kerley B lines ECG- signs of MI Bloods- U&E, troponin, ABG ECHO plasma BNP ```

Question 27

mx of acute heart failure?

Answer 27

1. sit the patient upright 2. O2 3. IV access and monitor ECG 4. diamorphine 1.25-5mg IV slowly 5. Furosemide 40-80mg IV 6. GTN spray 7. if systolic BP >100 start a isosorbide dinitrate infusion 0. if systolic BP <100 treat as cardiogenic shock LOON

Question 28

long term mx of heart failure?

Answer 28

``` daily weight repeat CXR change to oral furosemide can add thiazide ACEi if LVEF <40% consider beta-blocker and spironolactone ```

Question 29

what is cardiogenic shock?

Answer 29

a state of inadequate tissue perfusion primarily due to cardiac dysfunction

Question 30

causes of cardiogenic shock?

Answer 30

``` MI arrhythmias PE tension pneumothorax cardiac tamponade myocarditis; myocardial depression (drugs, hypoxia) valve destruction (endocarditis) aortic dissection ```

Question 31

mx of cardiogenic shock?

Answer 31

``` O2 Diamorphine 1.25-5mg IV investigations and close monitoring correct arrhythmias, U&E abnormalities or acid-base disturbance look and treat reversible causes ```

Question 32

what is cardiac tamponade?

Answer 32

pericardial fluid collects -> intrapericardial pressure rises -> heart cannot fill -> pumping stops

Question 33

what 4 things to check in CXR if you think it's normal?

Answer 33

apices (TB or sarcoid) diaphragm (perforation) bones (fractures) behind the heart (shadowing)

Question 34

what can be seen on a CXR in pulmonary fibrosis?

Answer 34

reticulonodular opacities

Question 35

causes of cardiac tamponade?

Answer 35

``` trauma lung/breast cancer pericarditis MI bacteria e.g. TB ```

Question 36

signs of cardiac tamponade?

Answer 36

falling BP rising JVP muffled heart sounds (beck's triad) kussmaul's sign (JVP rising on inspiration) pulsus paradoxus (pulse fades on inspiration)

Question 37

diagnosis of cardiac tamponade?

Answer 37

CXR- globular heart, left heart border convex or straight, right costophrenic angle <90 degrees ECG- electrical altercans

Question 38

what is broad complex tachycardia?

Answer 38

rate >100bpm and QRS complex >120ms (>3 small squares)

Question 39

principles of mx of broad complex tachycardia?

Answer 39

- if in doubt, treat as VT | - identify the underlying cause

Question 40

differentials of broad complex tachycardia?

Answer 40

- VT including torsade de pointes - SVT with aberrant conduction e.g. AF, atrial flutter with bundle branch block - pre-excited tachycardia e.g. AF, atrial flutter, AVRT

Question 41

what are adverse signs of broad complex tachycardia?

Answer 41

systolic BP <90 chest pain/ischaemia on ECG heart failure heart rate >150bpm