Emergency Med

Question 1

You are called to a situation of anaphylaxis, how do you proceed?

Answer 1

ABCDE Approach
- assess, is this life threatening needing senior input?

Lie them down, put their legs up, Call for help

Adrenaline 500mcg 1:1000 IM (adult) - if had epipen may be enough or need 2nd dose

IV Fluids: 500ml-1L

IV Chlorphenaramine 10mg

IV hydrocortisone 200mg

Question 2

when are iv fluids given in anaphylaxis? how much to give and which?

Answer 2

fluid if hypotension does not rapidly respond to adrenaline.

Rapid infusion of 1–2L IV 0.9% saline

Question 3

What situation during ABCDE indicate life threatening situation needing seniors?

Answer 3

From Resus council:

Airway: Swelling, hoarseness, stridor

Breathing: Tachypneoa, wheeze, cyanosis, fatigue, sats <92, confusion

Circulation: Pale, clammy, drowsy/coma, hypotension,

Question 4

what do we do in the following situations:

• profound shock or immediately life-threatening situations,

Answer 4

1. Give CPR/Advanced Life Support (ALS) as necessary
2. Consider slow IV adrenaline 1:10,000 or 1:100,000 solution.
3. Glucagon 1–2mg intramuscular (IM)/IV every 5min
   
   • If no response to adrenaline

->This is recommended only for experienced clinicians who can also obtain immediate IV access.

Question 5

What are the key bits of info iewth chest compressions?

Answer 5

Press down to depress the sternum 5–6cm.
• Release all the pressure and repeat at a rate of 100–120/min.
• Compression and release phases should take the same time.
• Use a ratio of 30 chest compressions to two ventilations (30:2).

Question 6

Which are the shockable rhythms?

what is the importance of a pulse?

Answer 6

Ventricular fibrillation (VF)/ventricular tachycardia (VT)

patients with pulseless VT/VF: give a single precordial thump

Question 7

best airway to use?

Answer 7

1. Gold standard - Tracheal intubation
   - only attemptif experienced
   - End-tidal CO2 monitoring to confirm correct placement
2. Supraglottic airway
   - igel, LMA

Question 8

which are the Non-shockable rhythms?

management?

Answer 8

PEA and asystole

Mx:
Continue CPR
Give adrenaline every 3-5 mins (asystole)

asystole has very poor prognosis.

Question 9

List some measures by which to detect an unwell/ septic patient?

what do they entail?

which scores can indicate sepsis?

Answer 9

NEWS2;
- systems that alert to deteriorating adult patients in hospital
• RR.
• SpO2.
• Systolic BP.
• Pulse rate.
• Level of consciousness or new confusion (delirium).
• Temperature.
- score 5+ = consider sepsis

qSOFA;
- septic organ failure assessment
• RR ≥22 breaths/min.
• Systolic BP ≤100mmHg.
• Altered mental state (lower GCS than usual).
- score 2+ = increased risk of death or ITU stay. Act fast

Question 10

components of the sepsis 6 bundle?

Answer 10

All must be done within 1 hour:

1. Call seniors
2. O2 100%
3. IV access (2 large bore) - blood cultures, UEs, clotting, lactate, glucose, FBC, CRP
4. IV antibiotics - Piptazobactam + Gentamicin (dep. local)
5. IV fluids, 20-30kg/kg
6. Monitor; blood lactate measurement, urine output

• may need to start vasopressors (such as a noradrenaline infusion) for persistent hypotension

Question 11

how do we manage neutropaenic sepsis?

Answer 11

giving broad-spectrum antibiotics according to local protocols—an example of one regime is:

• Piperacillin–tazobactam IV 4.5g every 8hr or
• If penicillin-allergic: ceftazidime IV 2g every 8hr.

Question 12

define sepsis

define shock

Answer 12

Sepsis occurs when life-threatening organ dysfunction is associated with infection.

Shock is circulatory failure resulting in inadequate perfusion and oxygenation of organs.

Question 13

clinical features of shock?

Answer 13

Defined by;
1. low bp— systolic <90mmHg or
mean arterial pressure (map) <65mmHg

2. with evidence of tissue hypoperfusion;
   eg mottled skin,
   urine output (uo) of <0.5mL/kg for 1 hour,
   serum lactate >2mmol/L

• Poor peripheral perfusion: cool peripheries, clammy/sweaty skin, pallor, and ↓ capillary return

• Tachypnoea.
• Purpuric rash.
• Oliguria: ↓ renal perfusion with urine output <50mL/hr (in adults
• Altered consciousness and/or fainting
• Hypotension:

Question 14

how do we approach shock generally

Answer 14

ABCDE approach

O2

Bloods - inc glucose and lactate, cultures if needed

ABG, ECG (hypoxia?), CXR

Monitor urine output hourly - catheter

Iv fluids - 0.9% saline, if low volume shock

Ivx & Treat underlying cause of shock eg ECG, Echo

Question 15

How do you approach a patient with Burns injury?

Answer 15

Check: Airway, Breathing, and Circulation

Particular problems associated with burns are:

• Airway burns: suggested by hoarseness, stridor, dysphagia, facial and mouth burns, singeing of nasal hair, soot in nostrils or on palate.
• Spinal injury: particularly seen with blast injuries and in those who have jumped from buildings to escape fire.
• Breathing problems: contracting full-thickness circumferential burns (‘eschar’) of the chest wall may restrict chest movement.
• Circulatory problems: hypovolaemic shock is a feature of severe burn

Then take a history

Question 16

what are the components of assessing a burn?

Answer 16

Assess the:

Extent - 9% etc
Depth - full/partial thickness

Question 17

How do you manage a burn?

Answer 17

ATLS protocols !!!
Deal with shock before thinking about burns

1. Airway and cervical spine protection
   - high flow o2, c-spine immobilisation if needed
   - intubation if impending obstruction
2. IVs
   - 2 large bore grey cannulas
   - Take bloods
   - IV Morphine sulphate (pain), IV Cyclizine (antiemetic)
3. IV Fluid resus
   - 0.9% saline
   - follow local guides, may request colloid
   - burns >10% may ned red cells
4. Breathing
   - check COHb, get CXR, escharotomy?
5. Burns
   - Cover the burn with cling film or dry sterile sheets
   - Call burns specialist (ie dont start burns dressing yet)
   - Tetanus prophylaxis

Note: no mention of abx!

Question 18

causes of cyanide poisoning and treatment?

Answer 18

burnt plastic furniture in a house fire

Mx: give an appropriate antidote, eg dicobalt edetate

Question 19

what are the Clinical features of smoke inhalation injury?

Answer 19

After exposure to smoke or fire in an enclosed space;

• confusion or altered/loss of consciousness
• oropharyngeal burns,
• hoarseness/loss of voice, singed nasal hairs,
• soot in nostrils or sputum, wheeze,
• dysphagia, drooling or dribbling, and stridor.

Question 20

How do we ivx smoke inhalation injury ?

Answer 20

ABG - Hypoxia, hypercapnia, and acidosis
CXR - ARDS may develop

COHb - as SPO2 doesn’t detect CO poisoning
ECG - arrhythmias, ischaemia, or even MI

Question 21

How do we mx smoke inhalation injuries?

Answer 21

Secure airway
High flow humidified O2
Salbutamol for bronchospasm

IV fluids
Treat cyanide poisoning

Question 22

For simple burns, when do we consider escalation?

Answer 22

Refer patients (to a burns specialist eg regional burns unit) with the following:

• Airway burns.
• Significant full-thickness burns, especially over MAJOR joints.
• Burns >10%.
• Significant burns of special areas (hands, face, perineum, feet).

perhaps:
in pregnant patients, chemical/electrical ones

Question 23

what are the sx of CO poisoning?

Answer 23

Early features are headache, malaise, nausea, and vomiting

(sometimes misdiagnosed as a viral illness or gastroenteritis, especially if several members of a family are affected).

If severe:
coma with hyperventilation, hypotension,
↑ muscle tone, ↑ reflexes, extensor plantars, and convulsions.
Cherry-red colouring of the skin may be seen when dead

Question 24

List some complications of CO poisoning?

Answer 24

Cardiovascular - such as myocardial ischaemia, infarction, dysrhythmias, and cardiac arrest, MI.

Neurological symptoms include acute stroke-like symptoms, altered mental status, confusion, coma, and syncope.

MSK - Rhabdomyolysis

Question 25

Management of CO poisoning?

Answer 25

• Clear the airway and maintain ventilation with as high a concentration of O2 as possible. * ECG —arrhythmias and signs of acute MI. * VBG or ABG—SpO2 - acidosis • COHb levels - COHb >20% - serious poisoning. • Correct metabolic acidosis by ventilation and O2—try to avoid bicarbonate, which may worsen tissue hypoxia. * Consider mannitol if cerebral oedema is suspected. * Hyperbaric O2 therapy is logical, but of no proven benefit for CO poisoning.

Question 26

how do we mx salicylate poisoning?

Answer 26

Mild: discharge if normal vbg Moderate: within 1 hour - activated charcoal/ sodium bicarbonate Severe: haemodialysis/haemodiafiltration

Question 27

What is the difference between 2nd and 3rd degree burns?

Answer 27

2nd - has sensation, blanches 3rd - doesnt do the above, is leathery and dry

Question 28

how do we calculate fluid requirement in burns patient in first 24 hrs?

Answer 28

4ml x patient weight kg x % burn give half in first 8 hrs

Question 29

what are the causes of sepsis?

Answer 29

Common; * Staphylococcus aureus * Enterobacteriaceae e.g. Escherichia coli, Klebsiella sp., Enterobacter sp., * Pseudomonas sp. * Neisseria meningitidis

Question 30

what do NEWS scores mean?

Answer 30

* Low risk (aggregate score 1 to 4) – prompt assessment by ward nurse to decide on change to frequency of monitoring or escalation of clinical care. * Low to medium risk (score of 3 in any single parameter) – urgent review by ward-based doctor to determine cause and to decide on change to frequency of monitoring or escalation of clinical care. * Medium risk (aggregate score 5 to 6) – urgent review by ward-based doctor or acute team nurse to decide on escalation to critical care team. * High risk (aggregate score of 7 or over) – emergency assessment by critical care team, usually leading to patient transfer to higher-dependency care area.

Question 31

How do you figure out the type of shock going on?

Answer 31

Cold and clammy suggests cardiogenic shock or Hypovolaemic shock. Raised jvp - cardiogenic shock Signs of anaemia or dehydration, eg skin turgor, postural hypotension? Abdomen; trauma, bleed, aneurysm - Haemorrhagic shock Warm and well perfused, with bounding pulse points to septic shock. Any features suggestive of anaphylaxis—history, urticaria, angio-oedema, wheeze? - anaphylactic shock

Question 32

how do we mx haemorrhage shock?

Answer 32

Depends on ATLS classification 1-4 Stop bleeding if possible. • If still shocked despite 2L crystalloid or present with class III/IV shock (1.5L+ loss) then crossmatch blood (request O Rh–ve in an emergency) • Give FFP alongside packed red cells (1 : 1 ratio) and aim for platelets >100 and fibrinogen >1. Discuss with haematology early.

Question 33

how do we mx hypovolaemic shock?

Answer 33

Identify and treat underlying cause. Raise the legs. • Give fluid bolus 10–15mL/kg crystalloid - if shock improves, repeat, • If no improvement after 2 boluses, consider referral to icu.

Question 34

causes of tamponade?

Answer 34

Trauma, lung/breast cancer, pericarditis, myocardial infarct, bacteria, eg tb. coronraty artery dissection ventricular rupture

Question 35

signs and sx of tamponade?

Answer 35

↓bp, ↑jvp, and muffled heart sounds (Beck’s triad); ↑jvp on inspiration (Kussmaul’s sign); pulsus paradoxus (pulse fades on inspiration). Echocardiography may be diagnostic. cxr: globular heart; left heart border convex or straight; right cardiophrenic angle <90°. ecg: electrical alternans - alternating amplitude of qrs

Question 36

how do we manage NCT which is AF?

Answer 36

If NCT is irregular, manage as AF by far the most likely diagnosis; • Control rate with: o • β‎-blocker: eg metoprolol IV o • rate-limiting Ca2+-channel blocker eg Verapamil 5–10mg iv * digoxin is an alternative in heart failure PO * Consider anticoagulation with warfarin or noac to ↓ risk of stroke. * Synchronised DC cardioversion - If onset definitely <48h, or if effectively anticoagulated for >6wk.

Question 37

complications of pneumonia?

Answer 37

Respiratory failure Hypotension Atrial fibrillation Pleural effusion Empyema septicaemia, pericarditis, myocarditis, cholestatic jaundice, acute kidney injury.

Question 38

types of respiratory failure and mx?

Answer 38

(See p[link].) Type I respiratory failure (PaO2 <8kPa) is relatively common. Treatment is with high-flow (60%) oxygen. Transfer the patient to itu if hypoxia does not improve with O2 therapy or PaCO2 rises to >6kPa. Be careful with O2 in copd patients; check abgs frequently, and consider elective ventilation if rising PaCO2 or worsening acidosis. Aim to keep SaO2 at 94–98%, PaO2 ≥8kPa.

Question 39

list the causes of bradycardia

Answer 39

1. Drug-induced: • β‎-blockers, amiodarone, verapamil, diltiazem, digoxin. 2. Non-cardiac origin: • Vasovagal—very common (p[link]). • Endocrine—hypothyroidism, adrenal insufficiency. • Metabolic—hyperkalaemia, hypoxia. • Other—hypothermia, ↑icp (Cushing’s triad: bradycardia, hypertension, and irregular breathing -> Emergency). 3. Physiological: athletes. 4. Cardiac: • fibrosis of conduction pathways • Post-mi • Sick sinus syndrome • Iatrogenic—ablation, surgery. • Aortic valve disease, eg infective endocarditis • Myocarditis, cardiomyopathy, amyloid, sarcoid, sle.

Question 40

how do we manage problemativc bradycardia

Answer 40

IV Atropine 500mcg - if risk of asystole or no adverse signs If no response: Repeat above every 3-5mins Call anaesthetist for transcutaneous pacing Give Adrenaline/Isoprenaline whilst waiting If none of above: Observe

Question 41

how to manage CO poisoning (carbon monoxide)

Answer 41

Give 100% O2 until COHb <10%. Metabolic acidosis usually responds to correction of hypoxia. If severe, anticipate cerebral oedema and give mannitol ivi

Question 42

which types of ventilation are indicated in pulmonary oedema, covid and copd?

Answer 42

cpap – pulmonary oedema, covid | bipap aka non invasive ventilation – COPD

Question 43

A patient who has 2nd degree heart block. Eventually their hr slows and bp drops and they become brardycardic. treatment?

Answer 43

Atropine wont work because of the heart block. Give transcutaneous pacing.