Emergencies PACES

Question 1

What NEWS score is considered significant?

Answer 1

5 or more in total or 3 or more in one domain

Question 2

Prior to performing an A to E approach, what would you do?

Answer 2

Safety net any other patients and inform SHO/reg that there are potentially X unwell patients

Request an SBAR handover from the nurses and the NEWS scores

Ask the nurses to have the drug chart and the notes by the bedside, and identify the ceiling of care

Ask for PPE to be prepared

If the patient is likely to require surgery, keep them NBM and perform a group and save

Question 3

How would you assess the airway?

Answer 3

If the patient is vocalising, assume the airway is patent

Look inside the mouth and remove obvious objects and dentures

Listen for upper airway noises - stridor, snoring, gurgling

Do: large bore suction under direct vision if secretions are present

Do: manoeuvres to establish patent airway i.e. head tilt/chin lift, jaw thrust (with C spine control in trauma)

Do: adjuncts as tolerated to establish patent airway, such as nasopharyngeal or oropharyngeal airway

If airway is still compromised, call the arrest team (2222)

Ask the nurse to put on monitoring at this point. If the patient is in peri-arrest, ask for the crash trolley now.

“If I’m happy that the airway is patent or being managed by a suitably qualified colleague, I’d move on to assess breathing.”

Question 4

How do you assess breathing?

Answer 4

Observations: SpO2, RR
Look: respiratory distress, chest expansion (if even between sides)
Listen: air entry, added sounds
Feel: trachea, chest expansion, percussion

Investigation:

• ABG (CCOT nurses may be able to get this in advance, nurses can take VBGs)
• Portable CXR

Management
Do - non-rebreather mask and 15L/min O2
Do - bag valve mask if poor or absent breathing effort
If tension pneumothorax then perform immediate needle decompression
If poor or absent respiratory effort then call cardiac arrest team

Question 5

How do you assess circulation?

Answer 5

Observations: HR, BP
Look: colour, diaphoresis, oedema, bleeding, cyanosis, distended neck veins
Feel: temperature, central pulses (carotid/femoral), CRT
Listen: heart sounds

Investigations:

• 12 lead ECG
• Blood pressure
• IV access + bloods (FBC, U&E, LFTs, coagulation, group and save, troponin)
• Catheter: input / output

Management
If no pulse - call cardiac arrest team
Do: get venous access and send bloods
Do: get VBG with bloods or ABG if spO2 <95
Do: give fluids if hypotension or high pulse - 500mL stat unless pt in over heart failure

sepsis, STEMI, arrhythmia, haemorrhage

Question 6

How do you assess disability?

Answer 6

Assess consciousness (AVPU or GCS)
Observations: Glucose
Pupils - size, reaction to light
Feel tone in all 4 limbs
Drug chart

Management
Do give glucose if <4 mmol/l, 100mL of 20% glucose IV

stroke, hypoglycaemia

Question 7

How do you assess exposure

Answer 7

Observations: temperature
Focused examination:
- Skin
- Abdomen
- Calves
- Lines / drains

Investigations:

• USS/ FAST scan
• Urinalysis + pregnancy test

Management:
Do warm patient if hypothermic
Look all over body for injuries - MUST keep patient covered to protect dignitiy

Question 8

Following the acute setting, what needs to be done

Answer 8

COVID nudge test if not already done
Referral to team
Document in notes
Update family
Thromboprophylaxis
Update seniors

Question 9

What are some common causes of peri-arrest?

Answer 9

Arrhythmia
MI
Hypovolaemia
Sepsis
Hypoglycaemia
Hypoxia
Pulmonary oedema
PE
Metabolic (hypo or hyperkalaemia)
Tension pneumothorax

Question 10

What are the components of qSOFA?

Answer 10

RR > 22
GCS < 15
SBP < 100

Question 11

What is the difference between severe sepsis and septic shock?

Answer 11

Severe sepsis: sepsis with evidence of organ hypoperfusion (e.g. hypoxaemia, oligaemia, confusion)
Septic shock: severe sepsis with hypotension despite adequate fluid resuscitation

Question 12

What are the sepsis 6?

Answer 12

Give oxygen (15 L through non-rebreather)
Give IV fluids (bolus = 20 mL/kg)
Take blood cultures
Take lactate
Monitor urine output
Give broad-spectrum antibiotics

ALL WITHIN 1 HOUR

Question 13

When should sepsis patients be escalated further?

Answer 13

SBP fails to reach > 90 mm Hg
Lactate remains > 4 mmol/L

Question 14

How should haemorrhagic shock be managed?

Answer 14

2 L of crystalloid
If this fails to resuscitate –> X-match
Give FFP and packed red cells (1:1) aiming for platelets > 100 and fibrinogen > 1

Question 15

Which medications are used in the management of anaphylaxis?

Answer 15

Adrenaline 0.5 mg IM (0.5 mL of 1:1000)
Repeat every 5 mins as necessary
Chlorphenamine 10 mg IV
Hydrocortisone 200 mg IV
IV fluid bolus if shocked

Question 16

What should be done after the a patient with anaphylaxis has been stabilised?

Answer 16

Admit to ward
Monitor ECG
Continue chlorphenamine 4 mg per 6 hours PO if itching
Suggest MedicAlert bracelet
Prescribe autoejector
Consider skin-prick testing or specific IgE

Question 17

Outline the management of aortic dissection.

Answer 17

Fast bleep cardiothoracic surgery
Transfer to ITU
Use hypotensives (e.g. labetalol) to maintain SBP 100-110
Document and debrief

Question 18

Outline the management of a ruptured AAA.

Answer 18

Fast bleep vascular surgery and anaesthetics
Take the patient straight to theatre
Gain IV access
Administer O- if necessary
Keep SBP < 100 mm Hg

Question 19

Outline the initial management of a STEMI.

Answer 19

Morphine 5-10 mg IV (repeat after 5 mins if necessary)
Metoclopramide 10 mg IV
Oxygen 15 L via non-rebreather
Nitrates
Aspiring 300 mg PO (with clopidogrel or ticagrelor)

Question 20

What doses of second antiplatelet agents are used with aspirin in the prevention of atherothrombotic events in ACS?

Answer 20

Clopidogrel 300 mg followed by 75 mg
Ticagrelor 180 mg STAT followed by 90 mg BD

Question 21

Which medications should patients who have had an MI take home?

Answer 21

Dual antiplatelet therapy (continue for 12 months)
GTN spray
Beta-blocker
ACE inhibitor
Statin

Question 22

Outline the management of acute heart failure.

Answer 22

Diamorphine 1.25-5 mg IV (caution in liver failure or COPD)
Furosemide 40-80 mg IV
GTN spray 2 puffs sublingual (consider isosorbide mononitrate infusion 2-10 mg/hour)

Question 23

What should be considered if a patient in acute heart failure deteriorates?

Answer 23

Further dose of 40-80 mg furosemide
Consider CPAP
Increase nitrate infusion
Refer to ITU

Question 24

How should a patient with acute heart failure be managed once they have been stabilised?

Answer 24

Monitor daily weight and observations
Repeat CXR
Switch to oral furosemide or bumetanide
ACE inhibitor if LVEF < 40%
Consider beta-blocker and spironolactone
Consider biventricular pacing or transplantation
Consider digoxin and warfarin

Question 25

Outline the management of broad complex tachycardia in a haemodynamically UNSTABLE patient.

Answer 25

- DC cardioversion - Hypokalaemia and hypomagnesaemia - Amiodarone 300 mg IV over 10-20 mins through a central line - Procainamide and sotalol in refractory cases

Question 26

Outline the management of broad complex tachycardia in haemodynamically STABLE patients.

Answer 26

Correct electrolyte abnormalities Amiodarone 300 mg IV over 10-20 mins If it fails --\> DC cardioversion NOTE: after correction of VT, patients should be given maintenance antiarrhythmic therapy (e.g. sotalol)

Question 27

Outline the management of torsades des pointes.

Answer 27

Stop predisposing drugs (e.g. TCAs) Correct hypokalaemia Give magnesium sulphate 2 g over 10 mins

Question 28

Outline the management of narrow complex tachycardia.

Answer 28

Vagal manoeuvres Adenosine 6 mg IV bolus (followed by 0.9% saline flush) If unsuccessful --\> after 2 mins give 12 mg bolus If unsuccessful --\> after 2 mins give 12 mg bolus Alternative: verapamil 2.5-5 mg over 2 mins

Question 29

How should AF in an unstable patient be treated?

Answer 29

Emergency cardioversion If unavailable --\> IV amiodarone Control ventricular rate: verapamil 40-120 mg/8 hrs PO or bisoprolol 2.5-5 mg/day PO Start anticoagulation with LMWH NOTE: cardioversion is only recommended if it can be done within 48 hours of the onset of symptoms

Question 30

Which medications should patients with AF be given to take away?

Answer 30

``` Use CHADS-Vasc to calculate need for anticoagulation (1 or more requires warfarin) Rate control (beta-blocker or CCB) Rhythm control (flecainide if no structural heart disease, otherwise amiodarone) ```

Question 31

Outline the investigations that you would request for a suspected acute asthma attack.

Answer 31

Bedside: PEFR, ECG, ABG, SaO2 Bloods: FBC, U&E Imaging: CXR?

Question 32

Outline the management of severe acute asthma.

Answer 32

Nebulised salbutamol 5 mg with oxygen IV hydrocortisone 100 mg (or PO prednisolone 40-50 mg) If it worsens - add ipratropium bromide nebuliser 0.5 mg - stat dose of magnesium sulphate 1.2-2 g IV over 20 mins

Question 33

If a patient with a severe asthma is showing signs of improvement, how should they be cared for?

Answer 33

Nebulised salbutamol every 4 hours Prednisolone 40-50 mg OD for 5-7 days Monitor PEFR and oxygen saturations

Question 34

How should a patient with life-threatening acute asthma be escalated if initial treatment fails to cause an improvement?

Answer 34

Refer to ICU May need ventilatory support (e.g. intubation) May need intensified treatment (e.g. IV aminophylline, IV salbutamol)

Question 35

Outline the management of an infective exacerbation of COPD.

Answer 35

BRONCHODILATOR: nebulised salbutamol 5 mg/4 hr + nebulised ipratropium 0.5 mg/6 hr OXYGEN: at 24-28% via venturi mask aiming for 88-92% STEROIDS: IV hydrocortisone 200 mg (or oral prednisolone) ANTIBIOTICS: trust guidelines (e.g. amoxicillin or doxycycline)

Question 36

How should the treatment of a patient with an infective exacerbation of COPD be escalated if they fail to respond to initial treatment?

Answer 36

Consider IV aminophylline Consider NIV Consider intubation and ventilation Consider respiratory stimulant (e.g. doxapram)

Question 37

Which investigations may be useful in patients with acute pancreatitis?

Answer 37

Bedside: glucose Bloods: amylase, lipase, FBC, U&E (calcium), LFTs, ABG, glucose Imaging: USS, erect CXR, AXR (rule out other causes of acute abdomen), ERCP

Question 38

Outline the management of acute pancreatitis.

Answer 38

Assess severity using Modified Glasgow Criteria NBM IV fluids to achieve normal vital signs (3rd spacing) Insert catheter to monitor urine output Analgesia (IM pethidine 75-100 mg/4 hr or morphine) If worsening --\> ITU (may need ERCP)

Question 39

Outline the management of a primary pneumothorax.

Answer 39

No SOB + \< 2 cm rim of air on CXR --\> consider discharge and repeat CXR in a few weeks SOB + \> 2 cm rim of air on CXR --\> aspiration - if unsuccessful --\> repeat aspiration - if unsuccessful --\> insert chest drain

Question 40

Outline the management of a secondary pneumothorax.

Answer 40

No SOB, age \< 50 yrs + \< 2 cm rim of air --\> aspiration - if successful --\> admit for 24 hours - if unsuccessful --\> insert chest drain SOB, age \> 50 yrs and \> 2 cm rim of air --\> insert chest drain

Question 41

Outline the management of tension pneumothorax.

Answer 41

Insert a large-bore needle that is partially filled with saline into the 2nd intercostal space in the MCL on the side of the suspected pneumothorax - remove plunger to allow air to bubble through the syringe OR: into the safe triangle

Question 42

Outline the management of PE in a stable patient.

Answer 42

Oxygen Morphine 5-10 mg IV with 10 mg metaclopramide SC tinzaparin 175 U/kg/24 hrs (or UFH 10,000 IV bolus)

Question 43

How does the systolic BP affect the management of PE?

Answer 43

SBP \> 90 mm Hg --\> warfarin loading regimen (e.g. 5-10 mg warfarin PO) SBP \< 90 mm Hg --\> IV colloid infusion + contact ICU --\> dobutamine 2.5-10 µg/kg/min IV --\> IV noradrenaline infusion --\> consider thrombolysis

Question 44

Describe the ongoing management of PE after the immediate situation has been dealt with.

Answer 44

Reduce risk of recurrence (e.g. compression stockings) LMWH should be continued with warfarin until INR \> 2 for 24 hours or 5 days after starting warfarin (whichever is longest) If obvious cause of VTE --\> 3 months warfarin If no obvious cause of VTE --\> continue for 3-6 months

Question 45

How is a massive PE in a haemodynamically compromised patient treated?

Answer 45

10 mg alteplase followed by 90 mg infusion over 2 hours

Question 46

What crucial blood tests should be requested in patients with an acute upper GI haemorrhage?

Answer 46

FBC Group and save X-match 6 units of blood Clotting screen LFT

Question 47

Outline the immediate management of shocked patients with an acute upper GI bleed.

Answer 47

Protect airway and keep NBM Insert two large-bore cannulae Rapid IV crystalloid infusion up to 1 L If grade III-IV shock, give O- blood until X-match is complete Correct clotting anomalies (e.g. PCC, vitamin K) Consider ICU referral for central venous line Catheterise to monitor urine output (aim \> 30 mL/hour) Monitor vital signs Notify surgeons Endoscopy within 4 hours for variceal bleed and within 12-24 hours if unstable on admission

Question 48

Outline the medical management of acute upper GI bleeds.

Answer 48

Major ulcer bleeding --\> omeprazole 80 mg IV stat over 40-60 mins followed by 8 mg/hour for 72 hours Variceal bleeding --\> resuscitate then urgent endoscopy for banding or sclerotherapy + terlipressin 2 mg SC QDS NOTE: if large bleed, Sengstaken-Blakemore tube may be used to tamponade the bleed and lactulose may be given to reduce absorption of nitrogenous products

Question 49

Outline the management of bacterial meningitis.

Answer 49

Sepsis 6 Cefotaxime 2 g IV (add ampicillin 2 g/6 hrs IV if immunocompromised or \> 55 years) Call critical care team If meningitis only: consider adding dexamethasone 4-10 mg/6 hrs IV

Question 50

Outline the ongoing management of a patient with bacterial meningitis who has been stabilised.

Answer 50

Discuss antibiotic treatment with microbiology Isolate in side-room for 24 hours Treat contacts with ciprofloxacin 500 mg PO

Question 51

Which drug treatment is used for suspected encephalitis?

Answer 51

IV aciclovir (10 mg/kg/8 hrs IV)

Question 52

How much insulin should be given to patients with DKA?

Answer 52

50 u actrapid in 50 mL of 0.9% saline Infused continuously at 0.1 u/kg/hour Aim for a fall in ketones of 0.5 mmol/L/hour OR rise in venous bicarbonate of 3 mmol/L/hour with a fall in glucose of 3 mmol/L/hour NOTE: check VBG at 1 hour, 2 hours and 2 hourly thereafter

Question 53

When should glucose be added to the infusion in DKA?

Answer 53

10% glucose at 125 mL/hour alongside saline when glucose \< 14 mmol//L

Question 54

Outline the management of acute abdomen.

Answer 54

Gain IV access Catheterise and place on fluid balance chart if hypotensive Analgesia: 100 mg diclofenac PR for renal pathology, or 5-10 mg morphine IV for intra-abdominal pathology Send blood sample for FBC, U&E, amylase, LFT, CRP and G&S IV antibiotics if indicated NBM

Question 55

Outline the management of stroke.

Answer 55

15 L/min oxygen if low saturations or SOB NBM 100 mL/hour 0.9% saline Treat arrhythmias Get exact timescale of symptom onset Request urgent CT scan Once haemorrhagic stroke ruled out: aspirin 300 mg STAT and thrombolyse with tPA of \< 80 yrs and \< 4.5 hours or \> 80 yrs and \< 3 hours

Question 56

Outline the treatment of hyperkalaemia.

Answer 56

10 mL 10% calcium gluconate IV over 2 mins (repeat every 15 mins up to 5 doses) 10 IU Actrapid with 50 mL 50% dextrose IV over 10 mins Consider 5 mg salbutamol nebuliser Monitor ECG and have access to crash trolley Check ABG for acidosis

Question 57

How are pre-renal and post-renal causes of AKI treated?

Answer 57

Pre-renal: fluid resuscitation with 0.9% saline (250-500 mL bolus) followed by infusion of 20 mL + last hour's urine output Post-renal: catheterise NOTE: pulmonary oedema should be treated with furosemide IV

Question 58

List the indications for dialysis in AKI.

Answer 58

Hyperkalaemia unreponsive to medical treatment in an oliguric patient Pulmonary oedema unresponsive to medical treatment Uraemia (e.g. encephalopathy) Severe metabolic acidosis (pH \< 7.2)

Question 59

Outline the management of hypokalaemia.

Answer 59

Monitor U&E and ECG 40 mmol/L KCl in 1 L of 0.9% saline (unless oliguric --\> insert catheter to ensure accurate assessment of urine output) Admit to ICU for insertion of a central line if \> 10 mmol/hr needed If MILD: oral K+ supplementation (SandoK)

Question 60

Which investigations would be useful in a patient with hyponatraemia?

Answer 60

Hypovolaemic --\> low urine sodium Euvolaemic --\> TFT, SST, plasma and urine osmolality Hypervolaemic --\> low urine sodium

Question 61

Outline the management of hyponatraemia.

Answer 61

Do NOT correct faster than 8-10 mmol/L/24 hrs Hypovolaemic --\> 0.9% saline Euvolaemic --\> fluid restriction

Question 62

Outline the management of hypocalcaemia.

Answer 62

Mild and asymptomatic: monitor, consider vitamin D supplements and calcichew Severe tetany: 10 mL 10% calcium gluconate IV over 10 mins

Question 63

Outline the management of hypercalcaemia.

Answer 63

Correct dehydration with 0.9% saline (3-6 L in 24 hours with the first 1 L going in over 1 hour) Furosemide may be needed in elderly patients who are prone to pulmonary oedema Insert catheter to monitor urine output IV bisphosphonate for bone pain (takes 1 week to work)

Question 64

Which investigations are important to order in patients with status epilepticus?

Answer 64

U&E FBC LFT Glucose Calcium Toxicology AED levels CT/MRI head

Question 65

Outline the management of status epilepticus.

Answer 65

Secure the airway (may need adjuncts) STEP 1: Slow IV bolus of IV lorazepam 2-4 mg Second dose if no response within 10 mins Thiamine if alcoholism is suspected Glucose 50 mL 50% IV if hypoglycaemia is suspected STEP 2: IV phenytoin infusion 15-20 mg/kg at \< 50 mg/min STEP 3: rapid sequence induction with thiopental and EEG monitoring

Question 66

Outline the management of pneumonia.

Answer 66

Treat hypoxia and hypotension if necessary Antibiotics following local guidelines (e.g. CAP = coamoxiclav and clarithromycin; HAP = tazocin) Analgesia if pleuritic chest pain CPAP if no improvement

Question 67

Which investigations should be requested in suspected pneumonia?

Answer 67

Bedside: oxygen saturation, ABG, sputum sample, urine sample (Legionella) Bloods: FBC, U&E, CRP, atypical serology Imaging: CXR

Question 68

Which investigations would you request in a patient with delirium?

Answer 68

Bedside: glucose, ABG, ECG, urine dipstick Bloods: FBC, U&E, LFTs, blood glucose, blood cultures Imaging: CXR, CT/MRI

Question 69

Outline the management of bradycardia.

Answer 69

Sit the patient up (unless dizzy) 15 L/min oxygen if hypoxic Give 0.5 mg atropine IV every 2-3 mins (up to max 6 doses) If unsuccessful --\> isoprenaline 5 µg/min If unsuccessful --\> adrenaline 2-10 µg/min If unsuccessful --\> transcutaneous pacing

Question 70

Outline the management of hyperosmolar hyperglycaemic state (HHS/HONK).

Answer 70

Rehydrate slowly with 0.9% saline over 48 hours (deficit is typically 110-220 mL/kg) Equated to 8-15 L for 70 kg adult First 1 L may be given quickly over 30 mins Replace K+ when urine starts to flow Use insulin sliding scale if glucose is NOT falling by 5 mmol/L/hr with rehydration Keep glucose at 10-15 mmol/L for first 24 hours (avoid cerebral oedema)

Question 71

If a nurse contacts you regarding a patient who has become unconscious, what should you tell them to do?

Answer 71

Check for respiratory effort/pulse and begin CPR if absent

Question 72

How should an Addisonian crisis be treated?

Answer 72

100 mg hydrocortisone STAT Followed by 100 mg/8 hrs hydrocortisone NOTE: they may need fludrocortisone, glucose and fluids

Question 73

What are the components of a SOFA score?

Answer 73

Respiratory rate Bloodpressure GCS Liver (bilirubin) Coagulation (platelets) Renal (creatinine and urine output) Sepsis = infection + increase of 2 or more on SOFA

Question 74

Outline the management of NSTEMI.

Answer 74

Give oxygen if breathless or SaO2 \< 90% Morphine 5-10 mg IV + antiemetic Nitrates (GTN spray or sublingual) Aspirin 300 mg PO + second antiplatelet agent (clopidogrel, ticagrelor, prasugrel) Oral beta-blocker (e.g. metaprolol) if hypertensive/tachycardic/low LV function Fondaparinux 2.5 mg OD SC or LMWH 1 mg/kg/12 hours SC IV nitrate if pain continues HIGH RISK PATIENT - Features: rise in troponin, dynamic ST or T wave changes, risk factors - Begin infusion of tirofiban and refer for inpatient angiography (within 72 hours) - Angiography may need to be within 24 hours if GRACE score \> 140

Question 75

Which additional measures may be used during the A to E approach of a trauma patient?

Answer 75

Check for blood on the floor Arrange FAST scan/pelvic X-ray For unstable pelvic fractures use a pelvic band to reduce blood loss

Question 76

Outline the algorithm for the major haemorrhage protocol.

Answer 76

Take baseline blood samples (FBC, G&S, X-match, Clotting, fibrinogen) If trauma \< 3 hrs: give tranexamic acid (1 g over 10 mins, then 1 g/8 hrs infusion) Limit use of O-negative blood and use group-specific blood as soon as possible

Question 77

What is the definition of major haemorrhage?

Answer 77

Loss of more than one blood volume in 24 hrs Loss of 50% blood volume in 3 hours Bleeding in excess of 150 mL/minute

Question 78

Which extra parts of an A to E would you do in a patient with suspected spinal cord compression?

Answer 78

D - palpate for spinal tenderness and perform a lower limb neurological examination to assess tone, power, reflexes and sensation E - percuss the bladder (urinary retention), perform a rectal examination (tone and saddle anaesthesia) - important to consider cauda equina as a differential

Question 79

Outline the management of cord compression.

Answer 79

Ix: urgent MRI whole spine within 24 hours Rx: dexamethasone 16 mg PO Discuss with neurosurgery Definitive: RADIOTHERAPY or decompressive surgery

Question 80

What must be done before a CTPA is performed in a patient with suspected PE?

Answer 80

Check renal function and ask about allergy to contrast

Question 81

What must always be done before thrombolysing a patient?

Answer 81

Discuss with a senior

Question 82

What is Cushing's reflex?

Answer 82

Irregular breathing (Cheyne-Stokes) Hypertension Bradycardia

Question 83

Who could angry patients be directed towards?

Answer 83

PALS NOTE: always gain consent from the patient before discussing their care with a family member

Question 84

What is the first step in managing a patient with VT?

Answer 84

Put out a peri-arrest call

Question 85

What are the 4 Hs and 4 Ts of cardiac arrest?

Answer 85

Hypoxia Hypovolaemia Hypokalaemia/hyperkalaemia Hypothermia Toxic Thromboembolic Tamponade Tension pneumothorax

Question 86

Which medications should be continued after correction of VT?

Answer 86

Establish and treat the cause Maintenance: amiodarone infusion for 12-24 hours followed by oral sotalol or amiodarone

Question 87

How can recurrence of VT be prevented?

Answer 87

Ablation of arrhythmogenic area OR ICD

Question 88

Outline the management of hypothermia.

Answer 88

Prepare crash trolley Confirm temperature with low-reading thermometer (PR) and check every 30 mins Set up ECG (bradycardia and J waves) Remove wet clothing Give warmed humidified oxygen Slowly rewarm at 0.5 degrees per hour CARDIAC MONITORING IS ESSENTIAL

Question 89

What is the difference between the Glasgow Blatchford and Rockall scores?

Answer 89

Blatchford - used at first presentation Rockall - used after intervention to determine risk of re-bleed/death

Question 90

Which investigations are important to request in someone who has taken a paracetamol overdose?

Answer 90

Paracetamol levels (4 hrs post-dose) LFTs Clotting studies U&E FBC Bone profile ABG (acidosis and lactate)

Question 91

Outline the management of bowel obstruction.

Answer 91

IV 0.9% saline 5-10 mg morphine IV NBM NG tube aspiration Correct electrolyte imbalance Consider giving antibiotics if septic/perforated (co-amoxiclav and gentamicin)

Question 92

Outline the management of acute limb ischaemia.

Answer 92

URGENT open surgery and angioplasty ALERT the vascular surgeons If embolic: surgical embolectomy or thrombolysis (tPA) Anticoagulate with LMWH after either procedure and look for source of emboli (e.g. AF, aneurysms) WARNING: post-op reperfusion injury can lead to compartment syndrome Compartment syndrome is treated with fasciotomy It is very painful so patients should be given morphine

Question 93

Who is part of the cardiac arrest team?

Answer 93

Medical team on call (Med reg, SHO, FY1) Anaesthetist Nurse Porters CCOT

Question 94

What are some contraindications for NIV?

Answer 94

Pneumothorax Drowsiness

Question 95

For the treatment of hyperkalaemia, what do you mix the insulin in?

Answer 95

10 U Actrapid in 100 mL of 20% dextrose given over 30 mins