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Emergency Flashcards

1
Q

Drugs that can cause hypoglycemia

A

Excess antidiabetic agents - insulin, glicazide

Excess paracetamo, apsirin, sulphonylureas

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2
Q

Treatment of hypoglycemia
1- conscious + can swallow
2- conscious+ cant swallow
3-unconscious

A

1- 200ml fruit juice oral oral glucose gel
2- 200ml 10% glucose IV or 1mg glucagon IM or SC
3- IV 75ml of 20% glucose or 1 mg glucagon IM or SC

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3
Q

When is glucagon ineffective in the treatment of hypoglycemia

A

Alcohol related hypoglycemia

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4
Q

Wallace rule of 9

A 
Each full arm - 9
Head+ neck = 9
Ant leg = 9
Post leg = 9
Ant chest = 9
Post chest = 9
Ant abdomen = 9
Post abdomen = 9 
Perineum = 1%
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5
Q

Superficial epidermal burn appearance

1st degree

A

Red + painful

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6
Q

Pale pink painful blistered skin after house fire

Type of burn?

A 
Partial thickness (superficial dermal)
2nd degree
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7
Q

Non blanching erythema, reduced sensation at site of burn

Type of burn

A

Partial thickness, deep dermal

2nd degree

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8
Q

White/ brown/black burn
No blisters
Not painful
Type?

A

Full thickness

3rd degree

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9
Q

Immediate management burns
Thermal
Chemical
Electrical

A

ABC
Remove non adherent clothing
Thermal - remove them from source of heat, irrigate wound with cool water b/w 10-30 mins, cover with cling film (layered not wrapped)
Chemical - brush any powder off and then irrigate for 1 hour - do not attempt to neutralise

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10
Q

When to refer to secondary care in burn cases

A

All full thickness cases
Deep dermal > 5 % in adults, all deep dermal burns in children
Superficial dermal burns - face hands feet, perineum, genitalia, flexures or circumferential burns of abdomen , limbs or torso or neck
Any inhalation injury
Any electrical or chemical burn
Suspicion of non accident injury

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11
Q

Management of burns

A

ABC, referral criteria
Sup epiderm al analgesia, emollient
Sup dermal - cleanse wound, leave blister intact
= avoid topical creams and apply non adherent dressing - review 24 hrs

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12
Q

Management of severe burns

A

Stop burn process and resuscitate
Analgesia
IV fluids , insert catheter
= > 10% TBSA in children , >15% in adults
Echarotomies - in circumferential full thickness burns of torso or limbs

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13
Q

IV fluid calculation in burns

Parkland formula

A

TBSA% x Kg x 4 = ml
50% given in first 8 hrs
50% over best 16 hrs

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14
Q

Starting point of resuscitation in burns

A

Time of injury

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15
Q

Referrals for burns (burns unit)

A

> 5% children
10% adults

Give IV fluids if > 10, 15% adults

Burns of hands perineum face

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16
Q

RFs for paracetamol overdose

A

Liver enzyme inducing drugs - CRAP GPs
Malnourished patients - anorexia, bulimia, hepatitis C , cystic fibrosis, HIV
Patient who have not eaten for few days

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17
Q

Management

  • investigations
  • treatment
A

FBC UE LFT INR blood gas glucose
-Serum paracetamol @ >=4 hr post ingestion if >150mg/kg consumed or unknown amount (NOT post admission)
-Admit anyone with ingestion within 8 hrs >150mg/kg (>24 pills) or unknown amount
- if presents within 1 hr with >150mg/kg - activated charcoal
-N- acetyl cysteine = 5 situations
Liver transplant

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18
Q

When should n acetyl cysteine be given in paracetamol overdose (5)

A
  • staggered overdose - all tablets were not taken within 1 hr
  • doubt over paracetamol ingestion - regardless of plasma paracetamol concentration
  • if plasma conc paracetamol (@ 4 hrs) is above appropriate line
  • > 8hrs (late presentation) + ingested >150mg/kg or dose unknown
  • jaundice or liver tenderness
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19
Q

Features of paracetamol poisoning

  • 24 hrs
  • 48 hrs
A

Initial - nausea , vomiting, pallor
24 0- hepatic enzymes rise
48- jaundice, enlarged liver

Hypoglycaemia, hypotension, encephalopathy, coagulopathy, coma can also occur

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20
Q

Liver transplant criteria in paracetamol overdose ?

A 
Arterial ph <7.3, 24 hrs after ingestion 
Or all of the following :
- PT > 100 s
- creatinine > 300 umol/l
- grade III or IV encephalopathy
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21
Q

Hepatic encephalopathy grading

A

1 - behavioural changes, mild confusion, slurred speech, disordered sleep
2- lethargy, moderate confusion
3- stupor, incoherent speech, sleeping but arousable
4- coma, unresponsive to pain

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22
Q

Aspiration of FB in child

Next step?

A

Indirect laryngoscopes +- fibre optic examination of pharynx

If ^ not given and you see direct , pick that

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23
Q

Magills forecps

Where are they used?

A

Direct laryngoscopy

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24
Q

Treatment of opioid overdose

A

IV naloxone
- fast action , short duration

Can be repeated every 2-3 minutes if no response
Shorter half life than methadone

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25
Features of opioid overdose (4)
Symmetrical Miosis Respiratory depression Bradycardia Altered consciousness = low RR BP HR and pinpoint pupils
26
``` NICE guidelines on head injury - Immediate CT (within 1 hr ) Adults (7) ```
1. GCS <13 2. GCS <15 @ 2hrs post injury 3. Open/depressed skull frx 4. Any sign if basal skull fracture 5. post traumatic seizure 6. Focal neurological deficit 7. >1 episode of vomiting
27
Signs of basal skull fracture (4)
Haemotympanum Panda eyes CSF leakages - ear nose Battles sign
28
NICE guideline CT head - head injury Within 8 hours Adults (6)
Adult + Loss of consciousness or amnesia + RFs: - >= 65 years old - history of bleeding or clotting disorders/ on warfarin - dangerous mechanism of injury - > 30 mins of retrograde amnesia - can’t remember events before injury
29
What GCS is an indication for intubation
= 8
30
CT guidelines head injury - within 1 hr | Children (6)
``` Seizure GCS < 14 - initial assessment GCS <15 after 2 hrs of injury Basal skull fracture signs Tense fontanelle/open skull fracture/ depressed fracture Focal neuro deficit ```
31
CT head within 1 hr in children | According to RF in head injury (6)
``` Head injury + >/= 2 of the following - LOC >/= 5 mins Amnesia >/= 5 mins >/= 3 episodes vomiting FFH> 3 metres RTA high speed Abnormal drowsiness ``` If only 1 RF - observe for at least 4 hrs after injury
32
Management of anaphylaxis
ABC , high flow O2, lay patient flat IM adrenaline - ant lateral aspect middle 1/3 thigh Observe for 6-12 hrs after onset of symptoms Serum tryptase - sometime taken to establish anaphylaxis - remain elevated up to 12 hrs If hypotensive - give IM adrenaline 1st then IV fluids
33
``` Doses of epinephrine/hydrocortisone/chlrophenamine <6 mo 6mo - 6 years 6-12 years Adults/ children > 12 ```
<6 mo - 150mcg/ 25mg / 250mcg/kg 6-6 yrs - 150mcg / 50mg / 2.5mg 6-12 - 300 mcg / 100mg/ 5 mg Adults - 500 mcg / 200mg / 10 mg Adrenaline/ epinephrine (MCG/1000= ml ) 1 in 1000 E.g 0.15 ml 1 in 1000
34
What causes tingling in panic attacks
Hypocalcemia | - caused by resp alkalosis due to CO2 washout
35
Management of panic attacks
Upcoming attack - beta blocker During : Breathing excercise - paper bag If severe and ongoing - benzo Long term - CBT , SSRIs
36
Diaphragmatic rupture - dx - features
Chest and abdominal pain , resp distress, diminished breath sounds Usually left side affected Dx - initial - CXR - unreliable (curt NGT in stomach is pathognomonic) Thoracoabdominal CT - diagnostic
37
Confusion + ataxia + squint in chronic alcoholics Treatment
Chronic alcohol syndrome Urgent IV thiamine Vitamin B1
38
Confusion ataxia and squint + retrograde amnesia + confabulation Dx?
Wernicke’s korsakoff syndrome
39
Aspirin overdose Symptoms - earliest, clinically significant Acid-base abnormality
Tinnitus , impaired hearing - early Hyperventilation, nausea, vomiting, dehydration fever double vision Feeling faint Early - resp alkalosis Late - metabolic acidosis
40
``` Excessive sedation, dry mouth, skin Tachycardia, dilated pupils ECG - prolonged QRS, QT, PR Suspected overdose? Treatment? ```
TCA IV fluid bolus 250ml NS IV sodium bicarbonate 50-100ml 8.4% slowly - corrects ECG changes Aim for pH 7.5-7.55
41
Organophosphate overdose | Features
``` Increased saliva ,tear production, diarrhoea Vomiting Small constructed pupils Sweating Muscle tremors Confusion ```
42
Plummer Vinson syndrome Triad - Treatment
Dysphagia Glossitis IDA Treatment - iron supplementation, dilation of webs
43
Boerhaave syndrome
Severe vomiting - oesophageal rupture
44
Management of Mallory Weiss tear
If vitally stable and hemodynamically stable = - discharge with advice or repeat FBC or observe vitals for fear of deterioration Discharge low risk blatchford score patients Severe - resuscitation ( high flow O2, IV fluids, IV blood)
45
Blatchford score : low risk
``` SBP >/= 110 Urea < 6.5 Hb >/= 13 males or >/= 12 females Pulse < 100 Absence of melena , liver disease, HF, syncope ```
46
Admission and early endoscopy for GI bleed + calculation of Rockall score if :
SBP <100 and pulse >/= 100 - hemo disturbance Continued bleeding Age >/= 60, all patients over 70 should be admitted Liver disease, HF , known varices
47
Class 1 hemorrhage can shock
``` <750 ml blood loss / <15% Pulse < 100 Normal BP RR 14-20 UO >30 ml Normal sx ```
48
Class II hemorrhagic shock
``` 750-1500 ml blood loss (15-30%) Pulse 100 199 Normal BP RR 20-30 UO. 20-30 ml Anxious ```
49
Class III hemorhhagic shock
``` 1500-2000 ml blood loss / 30-40% Pulse 120-139 Decreased BP RR 30-40 UO 5-15ml Confused ```
50
Class IV hemorhhagic shock
``` >2000 ml blood loss / >40% Pulse > 140 Decreased BP UO < 5 ml Lethargic ```
51
CO poisoning Causes Features Investigation of choice
Cause - car exhaust, fires, faulty gas heaters, paints Paint = methylene chloride (dichloromethane) from paint fume IOC - carboxyhaemoglobin levels Features- severe dizziness, headache (tension), malaise, vomiting If severe - pink skin and mucosa, fever, hyperventilation, arrhythmia, coma
52
Management of CO poisoning
ABC 100% oxygen via tight fitting mask - if conscious If unconscious / SBP <100 - intubate + ventilate IPPV 100% O2
53
Management of upper GI bleed due to varices
1. Initial step - IV fluids 2- terlipressin - 2mg IV repeat every 4-6 hrs + prophylactic antibiotics - cipro or cephalosporin 3- endoscopy - Oesophageal - band ligation Gastric -N butyl 2 cyanoacrylate inj 4. Transjugular intrahepatic portsystemic shunt (TIPS) - if bleeding not controlled with above measures Avoid PPI unless known peptic ulcer pt INR prolonged - Vitamin K Liver disease + haematemesis + raised INR = FFP Active bleeding + Plt < 50000 - transfusion of platelet s
54
Pelvic fracture with urinary retention | Next step
Suprapubic catheter - why? = post urethral tear usually associated with pelvic frx
55
When should you suspect urethral injury in pelvic frx | How do you manage it?
perineal bruising, blood at external meatu s PR = abnormal high rising prostate or inability to palpate prostate Refer to urology - suprapubic cath +- retrograde/ascending urethrogram imaging to assess injury
56
Management of flail chest
Avoid over hydration and fluid overload 1-Vitally stable + normal vitals + normal sats = analgesia - paracetamol/NSAIDs/opiates/intercostal block*/thoracic epidural up to T4 2- vitally unstable = ABC / high flow O2 and analgesia 3-drowsy, laboured breathing, worsening RR - intubate (double lumen ETT)
57
Hereditary angioedema Cause? Inheritance pattern
Autosomal dominant Low plasma levels of C1 esterase inhibitor (C1-INH) protein - during attack Low C2 C4 Serum C4 - most reliable , screening tool
58
Hereditary angioedema | - symptoms
Recurrent episodes of facial and tongue swelling Family history Attacks may be proceeded by painful macular rash Occasionally presents as abdominal pain - viscera oedema Urticaria not really a feature
59
Hereditary angioedema - management = acute , prophylaxis
Acute - IV C1 inhibitor concentrate ^ FFP if not available Prophylaxis - anabolic steroid Danazol may help
60
When does heroin withdrawal begin & peak
12 hours after last dose - starts | Peak - 24-48hrs
61
When does benzodiazepine withdrawal begin
1-4 days - begins | Peaks @ 2 weeks
62
Cocaine - withdrawal starts - peaks at
- within hours of last dose | Peaks in few days
63
Alcohol withdrawal sx - 6-12 hours - incidence of seizure - delirium tremens
Sx - tremors sweating tachycardia anxiety Seizure - 36. Hrs is peak incidence Peak incidence of delirium - 48-72 hrs = coarse tremor , confusion, delusions, auditory and visual hallucinations, fever, tachycardia
64
Management of acute alcohol
1 - Chlordiazepoxide (benzodiazepine) 2- if seizure use - lorazepam or diazepam 3- vitamin B1 - IV pabrinex
65
Drug for alcohol abstinence
Disulfiram
66
Drug to reduce craving for alcohol withdrawal
Acamprosate
67
Metabolic disturbance in ecstasy overdose
Metabolic acidosis | - increased venous lactic acid
68
Sx of ecstasy overdose
Tachycardia tachypnea Thirst Agitation confusion Hyperthermia, spots of colours (flashing) Uncontrolled body movements, muscle rigidity
69
Treatment of ecstasy
Supportive : ABC + treat metabolic acidosis IV diazepam or lorazepam - for agitation Dantrolene for hyperthermia
70
LSD overdose | Sx
``` Delusions and hallucinations Mydriasis Flushing sweating TremorsHyperreflexiaDiarrhoea Paraesthesia Smells colours sees sounds Sees colours when eyes are closed ```
71
``` Thoracic aortic rupture Clinical features CXR changes Site injured commonly Dx ```
Contained hematoma = persistent hypotension CXR - wide mediastinum, trachea/oesphagus to the right Dx - CT aortogram Proximal descending aorta
72
Femur frx management
Stable (SBP >100 ) - Thomas splint first, then IV fluid ABCDE - align frx to reduce further blood loss Not stable ABCDEs (ATLS)
73
Burn injury + evidence of airways obstruction | What do you do?
Cal senior ED/ anaesthetist | Urgent tracheal intubation
74
CPR ratio
Adults - 30:2 Paeds - layman 30:2 - professional 15:2
75
Splenic trauma | Management
FAST US - Iofchoice or CT scan- subcapsular hematoma Stable - observation Unstable + free peritoneal fluid - emergency laparotomy
76
Urticaria | Treatment
Oral antihistamine | IM adrenaline - if in anaphylactic shock
77
Unilateral dilation of pupil | Suspect
Space occupying lesion
78
Bilaterally constructed pupils | Suspect
Opiate overdose - heroin morphine | CVA affecting brainstem
79
Bilaterally dilated pupils
TCA overdose | Cocaine overdose
80
Side effects of benzodiazepines
``` Respiratory distress - apnea Hypotension Anterograde amnesia Sedation Cognitive impairment ```
81
Mild vs severe airway obstruction | Treatment
Mild - able to speak , cough, breathe Severe - wheezy breath, silent coughs Mild - encourage them to cough Severe - 5 back blows if unsuccessful - 5 Heimlichs or for kids < 1 yr - 5 chest thrusts If unconscious - call ambulance , start cpr
82
Aspirin and paracetamol cause what metabolic disturbance
Metabolic acidosis Aspirin/as;icy late - early = resp alkalosis Late = met acidosis
83
ACEi and NSAIDS
Metabolic alkalosis
84
Acid base disturbance caused by benzodiazepines
Respiratory acidosis
85
MAIIAD
``` Metabolic acidosis drugs Metformin Aspirin Isoniazid Iron Alcohol Digoxin ```
86
Causes of metabolic acidosis
MAIIAD Diarrhoea Renal insufficiency Addisons
87
Metabolic alkalosis causes
``` ACEi, NSAIDs Diuretic Vomiting Hypovolemia, HypOkalemia 2ry hypoparathyroidism ```
88
Respiratory acidosis causes
Any cause of airway obstruction Benzos, organophosphates COPD Pneumothorax, haemothorax, ascites
89
Respiratory alkalosis causes
``` Any cause of hyperventilation - high RR Pulm embolism Salicylate, aspirin (early poisoning) Mechanical ventilation - rapid ventilation Panic attack ```
90
Mixed acidosis seen in | Treatment
Cardiac arrest Low pH, high pCo2, low HCO3 = accumulation of CO2 , kidneys not perfused due to low cardiac output Increase ventilation
91
Pulmonary embolism vs panic attack
Respiratory alkalosis PE - low PaO2 PA - normal PaO2
92
qSOFA
Heightened risk of mortality if score = or > 2 RR > 22/min Altered mental state SBP <100
93
Red flag sepsis criteria
``` Unresponsive/ responds to voice or pain SBP = 90 or >40 mm drop from normal HR > 130 RR >/= 25 /min UO /= 2 mmol/l ```
94
Sepsis 6
``` Started if any red flags seen Admit patient Give 3 1.High flow oxygen 2. IV fluids - 500ml bolus over <15mins 3. IV broad spectrum ABx Take 3 1.blood culture 2. FBC UE clothing’s lactate 3. UO hourly ```
95
TCA overdose immediate management
ECG - widened QRS, PR,QT, broad complex tachy Iv fluid NS bolus. + sodium bicarbonate 8.4% slow IV injection
96
Indications for adrenaline
``` SOB Stridor Hoarseness Wheeze Shock Swelling tongue face cheek ```
97
Hypovolemic shock - physiology
Early - Loss of blood - stretches the receptors in the atria > the baroreceptors in the aorta activated > vasomotor centre stimulates efferent output > catecholamine release > increased sympathetic activity = vasoconstriction,arteriolar constriction and tachycardia to maintain blood Late Decreased GFR - aldosterone & ADH activated - salt and water reabsorption - activation of thirst centr e - maintain volume
98
Toxic shock syndrome | Diagnostic criteria
S.aureus - fever>38.9 - SBP <90 - diffuse erythematous rash - desquamation of rash - palms soles - involvement of 3 or more organ systems = renal failure, hepatitis , thrombocytopenia , CNS, mucous membrane erythema , GI sx * high WBC plts <100,000
99
Absent left psoas shadow on abdominal X ray | FAST US = free peritoneal fluids
Splenic rupture
100
Diagnostic imaging for splenic rupture and treatment
CT abdomen | Urgent surgery
101
Treatment of costochondritis
Self limiting | Mild analgesics and NSAIDs
102
Liver disease + haematemesis + high INR Treatment Most appropriate initial step
FFP Initial - IV fluid
103
Investigation of choice in acute renal trauma
Abdomen CT.
104
Orbital blowout frx - commonest bones affected - manifestations
Maxilla (orbital floor), ethmoid (medial wall) Diplopia on upward gaze - impingement of superior rectus muscle
105
ACS treatment
ST elevation - MONA then PCI (preferred) or alteplase NSTEMI - Normal ECG + high troop in - LMWH (Fonda) + aspirin ECG + troponin normal . Pt stable- discharge with cardi review
106
Cardiac tamponade | Becks triad
Hypotension Muffled heart sounds High JVP
107
CXR in cardiac tamponade
Enlarged globular heart
108
Diagnostic imaging of cardiac tamponade
Echo
109
Cardiac tamponade management
Urgent periocardiocentesis Oxygenation and ventilation 1-2 L of IV fluid NS
110
Basal skull / temporal bone fracture (Petrous part) | Features
``` Battle sign - mastoid ecchymosis CSF rhinorrhoea Peri-orbital ecchymosis - raccoon eyes Hearing loss Heamotympanum Facial n palsy ```
111
Initial management of DKA
IV fluids - NS | IV infusion insulin(.1/kg/hr) + ABG
112
Dx of DKA
pH < 7.3 , ketonemia ++, glucose >11 , bicarbonate <15
113
Beta blocker poisoning | Management
Hypotension bradycardia dizziness Management - supportive IV fluids for hypotension if SBP <90 Symptomatic bradycardia- atropine
114
Most appropriate test to determine asthma exacerbation
PEFR Moderate = 50-75% best or predicted Acute severe - 33-50% Life threatening <33%
115
Severe Hyperkalemia management
Calcium gluconate/chloride/carbonate Insulin Bedside Blood glucose normal - 10 units IV with 50- ml of 50% dextrose over 10-15 mins Glucose >11.1 (high) Iv insulin 10 units with 50 ml .9% NaCl over 10-15 mins Insulin = act rapid - soluble short acting insulin used in hyperK
116
Inhaled FB | Investigation
CXR +- bronchoscopy
117
Haemothorax management
O2 2 large venous cannula - send blood fro cross match Chest drain Surgery - rarely

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