Emergencies

Question 1

Patient presents with acute hypotension, collapse, wheeze/stridor, hoarse voice, swollen lips and tongue and N+V- what is the diagnosis?

Answer 1

anaphylaxis reaction

Question 2

what is the pathophysiology of anaphylaxis?

Answer 2

exposure to allergen results in IgE antibody production and inflammatory mediator release from mast cells/basophils. This causes local histamine release, which results in bronchoconstriction, vasodilation, and increased vessel permeability.

Question 3

what is the management of acute anaphylaxis?

Answer 3

1. ABC + secure airway + IV access + 100% O2
2. Adrenaline 0.5mg IM (1:1000) every 5 mins as required (if over 3 times call for help)
3. 10 mg Chlorphenamine
4. 200mg IV hydrocortisone
5. IV saline fluid challenge
6. Nebulised SABA

Question 4

what investigation would indicate a true anaphylaxis?

Answer 4

test serum tryptase up to 12 hours after the event (indicates degranulation of mast cells)

Question 5

where is the best location for an IM injection of adrenaline 0.5mg (1:1000)

Answer 5

anterolateral aspect of the middle third of the thigh

Question 6

what is the further management of a patient in anaphylaxis after initial resuscitation?

Answer 6

observation for 6-12 hours from the onset as biphasic reaction can happen
give epi-pen (x6)
3 day course of oral steroids

Question 7

most likely diagnosis and some differentials in a patient with central chest pain, radiating to the arm/neck/jaw that is associated with exertion?

Answer 7

ACS
costochondritis
PE
GORD
pericarditis 
panic attack

Question 8

what are some investigations for ACS?

Answer 8

CK-MB
Troponin I + T (specific to MI, trop I is more sensitive)
ECG
D-dimer to exclude PE 
ECHO
Angiogram
CXR

Question 9

management of ACS?

Answer 9

MONA/ROMANCE:
Reassure
Oxygen
Morphine 10mg IV (+antiemetic) 
Aspirin 300mg
Nitrates 
Clopidogrel 300mg
Enoxiparin 2.5mg
ECG- if STEMI then PCI asap.

Question 10

what is unstable angina?

Answer 10

angina with increased frequency and unpredictability

chest pain at rest

Question 11

what does the ECG of unstable angina look like?

Answer 11

can be normal
ST depression
or T wave changes

Question 12

what are the reversible causes of cardiac arrest?

Answer 12

4H's and 4T's: 
Hypoxia 
Hypovoalemia 
Hypothermia 
Hyper/hypokalaemia 

Tension penumothorax
Tamponade
Thrombosis- PE
Toxins

Question 13

management of cardiac tamponade?

Answer 13

thoractomy or pericardiocentesis

Question 14

management of cardiac arrest?

Answer 14

ABCDE-secure airway
Oxygen 100%
Start CPR
call 2222/crash call 
IV access + adrenaline 0.5mg (1:1000)
shock if shockable rhythm

Question 15

how do you calculate GCS?

Answer 15

Verbal: 
oriented 5
confused 4
words 3
sounds 2
none 1

Motor:
obeys commands 6 
localises to pain 5
withdraws from pain 4
flexion to pain 3 
extending to pain 2
none 1

Eye opening: 
spontaneous 4
to speech 3
to pain 2
none 1

Question 16

immediate investigations in unresponsive patient?

Answer 16

blood glucose 
ECG
U+E
urine 
blood cultures 
check for trauma sites

Question 17

what are the indications for emergency intubation of a patient?

Answer 17

GCS <8
unable to maintain own airway 
inadequate ventilation 
facial injury compromises airway 
inhalation injury

Question 18

what are the clinical features of opiate overdose?

Answer 18

pinpoint pupils

respiratory depression

Question 19

management of opiate overdose?

Answer 19

IM/IV naloxone (opiate receptor antagonist)

Question 20

what are the clinical features of cocaine/amphetamine overdose?

Answer 20

tachycardia 
mydriasis 
euphoria 
agitation 
convulsions
tremor

Question 21

management of cocaine/amphetamine overdose?

Answer 21

diazepam

Question 22

features of paracetamol overdose?

Answer 22

hepatic necrosis: jaundice, RUQ pain, encephalopathy , N+V, oliguria, metabolic acidosis

Question 23

investigations of paracetamol overdose?

Answer 23

paracetamol serum level 
LFT
glucose 
U+E
prothrombin time
INR
ABG- metabolic acidosis

Question 24

what is the management of paracetamol overdose?

Answer 24

activated charcoal if <1hrs

N-acetylcycsteine if >100mg/L paracetamol at 4hrs

Question 25

what is the kings college criteria for liver transplant?

Answer 25

acidosis raised creatinine PT>100 encephalopathy

Question 26

what are the features of tricyclic overdose?

Answer 26

anticholinergic: dry mouth, blurred vision, retention, dilated pupils CNS: dizzy, headache, confusion cardio: arrhythmias, heart block and reduced seizure threshold seizures

Question 27

management of tricyclic overdose?

Answer 27

activated charcoal if <1-2hrs IV sodium bicarbonate diazepam for seizures IV fluids if hypotensive

Question 28

management of status epilepticus?

Answer 28

``` ABCDE buccal/IM midazolam, rectal diazepam IV lorazepam IV phenytoin Intubation and GA ```

Question 29

what are some of the complications of status epilepticus?

Answer 29

``` hypoxia -> ischaemia rhabdomyolysis leading to AKI (due to rise in creatinine kinase causing increase in myoglobin and deposition in renal tubules) hyperkalaemia -> cell breakdown lactic acidosis aspiration pneumonia ```

Question 30

management of delirium tremens/alcohol withdrawal?

Answer 30

``` ABCDE benzo if seizures pabrine (to avoid wernicke) chlordiazepoxide fluid CT head ```

Question 31

what is the primary survey conducted at a trauma call?

Answer 31

``` cABCDE: c- c-spine control A- airway B- breathing with haemorrhage control C-HR, CRP, BP D- pupils, temp, GCS, BM, peripheral neuropathy ```

Question 32

pathophysiology of tension pneumothorax?

Answer 32

gas enters pleural space and pressure builds with each breath, causing mediastinal shift and compression of the heart - cardiogenic shock and death

Question 33

signs of a basal skull fracture?

Answer 33

battle sign - bruising over mastoid process racoon eyes- pre-orbital haematoma CSF otorrhoea/rhinorrhea Haemotympanium

Question 34

features of PE?

Answer 34

``` acute chest pain sharp worse on inspiration dyspnoea haemoptysis reduced spO2 ```

Question 35

what are the ECG findings of PE?

Answer 35

S1Q3T3

Question 36

what are the investigations of

Answer 36

D-dimer CTPA USS doppler

Question 37

management of PE?

Answer 37

LMWH (Subcut dalteparin) or NAOC (fondaparinux) -> for 5 days warfarin for 3 months (6 months if unprovoked)

Question 38

management of DKA?

Answer 38

IV insulin - 0.1 units/kg/hour once blood glucose <15mmol/l start dextrose infusion IV fluid infusion