Emergency Med Flashcards

Question

Management of Acute Asthma Exacerbation in Pediatrics 1 ♦ 2 ♦ Oxygen. 4 ♦ Salbutamol 3 ♦ Add Ipratropium Nebuliser (could be given back-to-back). Nebuliser. “Salbutamol and Ipratropium can be mixed in a solution and repeated) Ipratropium Bromide Corticosteroids. √ Oral prednisolone (either liquid or crushed tablets dissolved in water) √ OR IV hydrocortisone. 5 ♦ If still in asthma exacerbation, consider: “important”. ♠ IV Magnesium sulphate (MgSO4): tried first before the following 2 options. ♠ IV Salbutamol

Answer 1

♠ IV Aminophylline (unlikely to be the correct answer as it is given by seniors in severe life-threatening asthma exacerbations that have failed to respond to the max doses of bronchodilators and steroids) ◙ Once there is a silent chest → Intubate. Salbutamol is a short-acting beta2 agonist (SABA). Ipratropium bromide is anticholinergic. After giving O2, Salbutamol…etc, if the child develops tachypnea, SOP, drowsiness. Request → Arterial blood gas. (To look for respiratory acidosis and manage accordingly).

Answer 2

? → Salbutamol nebulizers.

Answer 3

• 24% - 28% Oxygen (not 100%) using “venturi face mask”. • Maintain O2 saturation between 88-92%. • Nebulised salbutamol (with ipratropium bromide). • Corticosteroids: 100 mg IV hydrocortisone or 30 mg prednisolone stat. (prednisolone should be continued as 30 mg OD for 7-14 days). • Still no response? → IV aminophylline. • If purulent sputum, fever, high CRP → give Antibiotics. → Non-Invasive Ventilation • After giving all these medical options, if he is still dyspnoeic, with impaired blood gas showing respiratory acidosis (low Ph, high PaCO2): (NIV). NICE recommends non-invasive ventilation (NIV) in patients with COPD exacerbation especially if Ph is 7.25-7.35 (respiratory acidosis). Intubate and ventilate • If NIV failed or there is impaired mental status, respiratory arrest, high aspiration risk → (invasive ventilation). • One alternative valid answer is → • shift to icu One important indication for intubation: GCS ≤ 8.

Answer 4

Important: In a recent exam, it was asked about the route of administration of adrenaline in an unresponsive patient with asystole who has been given CPR. The answer was → Intravenously (IV). Note: If IV access is not obtainable, then → Intraosseous (IO)

Answer 5

A) Atropine. B) IV fluids. C) External pacing. D) Amiodarone. E) Adenosine. The answer is → (A) Atropine. √ The first line to treat symptomatic bradycardia is atropine (given as IV boluses 0.5 mg atropine repeated if needed to max of 3 mg). √ Although IV fluids are important here as they can raise the cardiac output - temporarily-; however, the cause of shock here is bradycardia -which needs atropine- rather than hypovolemia. Thus, atropine is more appropriate. √ External pacing is used in symptomatic bradycardia when atropine fails. Both amiodarone and adenosine are used for management of tachycardia.

Answer 6

◙ The first drug of choice for Symptomatic Bradycardia (Dizziness, feeling unwell) is → Atropine √ (Given 0.5 mg IV push and may be repeated up to a total dose of 3 mg). What if the patient was given atropine but no response? Next step would be → Temporary transcutaneous -external- pacemaker. ◙ 2nd Line → Dopamine. ◙ 3rd Line → Epinephrine.

Answer 7

TCA overdose → Excessive sedation, Dry mouth and skin Sympathomimetic effect: Tachycardia, Sweating, Dilated Pupils. ECG: Sinus tachycardia (Common), Prolonged -wide- ORS complexes, QT, PR Usually, the patient is in (ie, pH < 7.35 ▐ HCO3- < 22) metabolic Acidosis → Give IV fluid 250 ml Bolus (0.9% NaCl) + IV injection of Sodium Bicarbonate 50-100 ml of 8.4% slowly (50 mmol Sodium bicarb is given by slow IV injection)

Answer 8

• If the patient is haemodynamically stable → CT scan of abdomen. • If unstable (eg, SBP < 90 ▐ ↑ capillary refilling time) → U/S Abdomen. FAST (Focused Assessment with Sonography for Trauma) is done in RTA if the patient is haemodynamically unstable. This is to save time for possible surgical management. On the other hand, CT abdomen is more specific and sensitive but it is more suitable if the patient is haemodynamically stable as it takes more time.

Answer 9

→ IV fluids (= IV sodium chloride). √• The 2nd line → Bisphosphonate (eg, Alendronate, Risedronate, Pamidronate). ◙ Remember that hypercalcemia manifestations include: Confusion, polyurea, polydipsia, low moods, bone pain, constipation, stones.

Answer 10

The most appropriate test to be done → Serum Lithium concentration. Note, Diuretics and NSAIDs (e.g., Ibuprofen) increases renal reabsorption of lithium and hence, the serum lithium increases and may lead to toxicity.

Answer 11

→ Amit him to the medical ward. (For observation + for measurement of serum lithium levels every 6-12 hours).

Answer 12

bipolar disorder ◙ Features of Lithium toxicity (Important) √ Coarse tremor (a fine tremor is seen in therapeutic levels) √ Muscular twitching, weakness √ Nausea and Vomiting √ Drowsiness, confusion √ Hyperreflexia √ Seizure (in severe toxicity) √ Coma (in severe toxicity) √ Blurred vision √ Tinnitus (ringing ear).

Answer 13

Management (imp). ♦ Stop lithium and take serum lithium levels. If high → hours). Amit the patient to the medical ward (& repeat levels each 6-12 ♦ Mild-moderate toxicity may respond to resuscitation with normal saline. ♦ Haemodialysis may be needed in severe toxicity. ◙ If lithium toxicity developed (eg, blurry vision, tinnitus = ringing ears, dizziness, lethargy, muscle weakness, diarrhea, vomiting) → Stop lithium, take serum lithium level → admit to medical ward, and repeat serum lithium level every 6-12 hours + Supportive care (There is no antidote to lithium toxicity). When toxicity resolves, lithium can be restarted at a lower dose (Never stop lithium suddenly; it has to be gradually over a period of 3 months to prevent relapse).

Answer 14

Since there are only itchy rash → This is an allergic reaction (not anaphylaxis). → Do not pick IM epinephrine (unless SOB, difficulty breathing, wheezes...etc). What if it is a simple allergic reaction -only itch rash- but you have to choose between (Oral antihistamine eg, oral chlorpheniramine) and (IV hydrocortisone)? → Pick oral chlorpheniramine (oral antihistamine). Antihistamine first (either oral or IV), then (IV hydrocortisone) if needed.

Answer 15

◙ Important Causes of Hyperkalemia: • ACE inhibitors (e.g., Enalapril, Ramipril). • ARBs (e.g., Losartan, Valsartan). • Potassium-sparing diuretics (e.g., Spironolactone/ Eplerenone) • Acute or chronic kidney disease. • Crush injury. • Addison’s (1ry Adrenal Insufficiency). • Congenital Adrenal Hyperplasia (CAH).

Answer 16

Notes: • Calcium resonium has no role in managing acute hyperkalemia as it lowers serum potassium level very slowly. • Remember, if ECG shows tall tented T waves or there are symptoms of hyperkalemia: → Give IV calcium gluconate OR calcium chloride “to protect the heart”. • After that, shift the potassium intracellularly by giving → Give insulin + dextrose OR nebulized salbutamo

Answer 17

Example (1): A 24-year-old female was found unconscious by her roommate. The paramedics has found an empty bottle of vodka next to her. She is unresponsive but breathing normally. Her airways are patent and she has vesicular breath sounds. Her heart rate is 96 bpm. What is the NEXT step in the management ? → Check capillary blood glucose. So, the primary survey (ABCDE) → (ABC) are checked here, remaining (D) includes excluding hypoglycemia. Also, remember the following point: In contrast to chronic alcohol consumption in the fed state—which raises blood sugar levels, resulting in hyperglycemia—alcohol consumption in the fasting state can induce a profound reduction in blood glucose levels (i.e., hypoglycemia).

Answer 18

→ Administer 75 ml of 20% glucose intravenously.

Answer 19

→ Deliver a shock. (VT in a pulseless patient and VF requires immediate shock delivery

Answer 20

→ Start CPR (Chest Compressions). Important: If CPR is not among the options, what’s to pick? → Give adrenaline (Epinephrine) 1 mg IV. (A flat ECG reading means asystole which is a non-shockable rhythm). • Flat ECG reading + pulseless → Asystole. • Asystole is a non-shockable rhythm (ie, do not deliver shock). • In Asystole and PEA (pulseless electrical activity): CPR → adrenaline (epinephrine) 1 mg IV → resume CPR → Recheck pulse every 2 minutes → resume CPR and give adrenaline every 3-5 minutes (every alternate rhythm check).

Answer 21

→ Start acetylcysteine intravenously. • This is staggered overdose (which requires acetylcysteine infusion). • Also, the paracetamol serum level is hight. Read the following: √ All patients with plasma paracetamol level ≥ 100mg/L at 4 hours after ingestion should receive acetylcysteine regardless of risk factors. √ All patients with plasma paracetamol level ≥ 15mg/L at 15 hours after ingestion should receive acetylcysteine regardless of risk factors. √ Where there is doubt over the timing of paracetamol ingestion including when ingestion has occurred over a period of one hour or more – ‘staggered overdose’ – acetylcysteine should be given without delay. √ administer the initial dose of acetylcysteine as an infusion over 60 minutes to minimise the risk of common dose-related adverse reactions. √ hypersensitivity is no longer a contraindication to treatment with acetylcysteine.

Answer 22

Remember that each paracetamol tablet contains 500 mg The maximum daily dose of paracetamol is: → 4 gram/day = 8 tablets per day = 2 tablets every 6 hours. If someone is taking 2 tablets (ie, 1 gram) every 6 hours, the total daily dose (in 24 hours) will be 8 tablets (ie, 4 gram).

Answer 23

Can swallow = can tolerate orally, not vomiting. • If Conscious and Can swallow (can tolerate orally) → give 200 ml fruit juice Or Oral glucose gel. • If Unconscious → IV Glucose OR (In case of IV access is already put). Conscious but Cannot swallow OR IM or SC glucagon 1 mg (2 tubes) (In case of IV line is not available or not put yet or difficult to put as in patients who are having seizure/ convulsions).

Answer 24

A) Intravenous glucose 20%. B) Glucose gel 40% (2 tubes). C) Intramuscular glucagon 1 mg. D) 200 ml orange juice. E) Intravenous glucose 10% • The patient is scenario has features of hypoglycemia (sweating, shaking (trembling), tachycardia, confusion) + her blood glucose level is < 4 mmol/L. • She is Confused and is unable to swallow (vomiting and not tolerating orally) Therefore → IM glucagon or IV glucose. • Since she does not have IV access currently and is confused → IM glucagon. • Remember that glucagon 1 mg can also be given subcutaneously.

Answer 25

circulation. So: √ Full thickness circumferential burns that led to compartment syndrome → Urgent escharotomy. √ Crushing injury that has led to compartment syndrome → Urgent fasciotomy.

Answer 26

? → Thoracic aortic dissection. The pain of MI increases in intensity with time and it is crushing or dull. The pain of aortic dissection is Sudden (abrupt) and sharp/ tearing. • HTN is a risk factor for both conditions. However, it is a more prominent risk factor for aortic dissection. • Elevated D-dimer and troponin can be seen in both conditions. • Unequal BP in both arms is a feature of aortic dissection and not MI. • Thus, the features are more towards thoracic aortic dissection.

Answer 27

→ Always carry ORAL antihistamine with her. This is urticaria – alleric reaction. She needs Oral Antihistamine. • This should not be mistekn by anaphylaxis which would show lips and mouth swelling followed by breathing problem “wich requires adrenaline”. • This woman should be advised to always carry oral antihistamine with her. Eruption of itchy rash after URTI, or after stress (e.g., playing football) ie, exercise-induced urticaria, or after taking aspirin or opiates, certain foods, or soon after insect bite → Think urticaria (an allergic reaction, not anaphylaxis) Give → Oral Antihistamine (eg, Cetirizine, Loratadine, or less favored Chlorpheniramine as it is sedating). The rash is described as wheals. This is an allergic reaction (severely itch rash). We do not give IM adrenaline unless anaphylactic shock is suspected by any of the following: Shortness of breath ▐ Stridor ▐ Hoarseness of voice ▐ Wheezes ▐ Shock ▐ Swelling of tongue, face, cheek √ If any of these develops → IM adrenaline (epinephrine). √ If only itchy rash → oral antihistamine.

Answer 28

Management of Hemothorax: √ O2. √ Insert 2 large venous canulae and send blood for cross matching. √ Chest Drain Insertion → To evacuate blood and prevent empyema. √ Syurgery to stop bleeding is RARELY needed as the lung is a low pressure system and thus bleeding usually stops on it own.

Answer 29

→ Refer to alcohol abuse services.

Answer 30

Next Step? → Indirect Laryngoscopy ± Fibre optic examination of the pharynx ◙ N.B. It is most commonly seen in children from 6 months to 5 years old. ◙ If (Direct Laryngoscopy) was given instead of “Indirect”, Pick it. Magill’s forceps is used under direct laryngoscopy.

Answer 31

”. ◙ Features of Opioid Overdose - Symmetrical bilateral MIOSIS “constricted pin-point pupils”. - Respiratory depression. - Bradycardia. - Altered level of consciousness. In other words, → Low RR, Low BP, Low HR, Pinpoint constricted pupils

Answer 32

Superficial epidermal burns < 15% of the TBSA in adults: Analgesia, → Give → Check his tetanus status and give tetanus toxoid if required. → F/U in an outpatient clinic twice a week for inspection. Apply non-adherent dressing and bandage and discharge. Note, if no improvement in 2-3 weeks → refer to 2ry care unit or burn clinic. When to give IV fluid (Parkland formula)? If the TBSA burnt is > 15% in adults and > 10% in children. ◙ Complex burns → burns involving the hand, perineum, face and burns >10% in adults and >5% in children should be transferred to a burn’s unit.

Answer 33

• All full-thickness burns. • Deep dermal burns of more than 5% TBSA in adults, and all deep dermal burns in children. • superficial dermal burns involving the face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso, or neck • any inhalation injury • any electrical or chemical burn injury • suspicion of non-accidental injury

Answer 34

1. GCS < 13 on initial assessment. “GCS = Glasgow Coma Scale”. 2. GCS < 15 at 2 hours post-injury. 3. Suspected open or depressed skull fracture. 4. Any sign of basal skull fracture (Hemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign). 5. Post-traumatic seizure. 6. Focal neurological deficit. 7. > 1 episode of vomiting.

Answer 35

- For adults with any of the following risk factors who have experienced some loss of consciousness or amnesia “a partial or total memory loss” since the injury: • ≥ 65 years. • Any history of bleeding or clotting disorders or being on warfarin. • Dangerous mechanism of injury (a pedestrian or cyclist struck by a motor vehicle, an occupant ejected from a motor vehicle, or a fall from a height of greater than 1 metre or 5 stairs). • More than 30 minutes retrograde amnesia of events immediately before the head injury. (He cannot remember the events before the injury) If a patient is on warfarin, and has sustained a head injury with no other indications for a CT head scan → perform a CT head scan within 8 hours of the injury. Being on warfarin is a risk factor for intracranial bleeding. In absence of the 7 immediate CT indications mentioned above, do head CT scan within 8 hours.

Answer 36

→ Retrograde Amnesia + Dangerous mechanism of injury → Perform CT Head within 8 hours.

Answer 37

◙ For children, do CT scan of the head within 1 hour of the injury if any of the following: √ Seizure after the accident. √ GCS < 14 (on initial assessment). √ GCS < 15 (after 2 hours of the injury). √ Any sign of basal skull fracture. √ Suspected depressed or open skull fracture or tense fontanelle. √ Focal neurological deficit.

Answer 38

√ Loss of consciousness for ≥ 5 minutes. √ Amnesia (loss of memory) for ≥ 5 minutes. √ ≥ 3 episodes of vomiting. √ Fall from a height of > 3 metres. √ Road traffic accident of a high speed. √ Abnormal drowsiness.

Answer 39

→ Observe for at least 4 hours after the injury. Only one risk factor (amnesia > 5 minutes). Note that losing consciousness for a few seconds does not count as a risk factor. Losing consciousness for > 5 minutes counts.

Answer 40

. → CT scan of the head within 1 hour. 2 risk factors (amnesia > 5 minutes + 3 episodes of vomiting).

Answer 41

- It is painful and potentially serious condition caused by bleeding or swelling within an enclosed bundle of muscles. Examples: It can occur after a traumatic injury (e.g. car crush), Prolonged compression (a limb stuck under a heavy object). - This leads to severely high pressure within the compartment, leading to insufficient blood supply to the muscles and nerves. - N.B. The presence of pulse on the affected limb does not exclude compartment syndrome. - Acute compartment syndrome is a medical emergency that requires surgery (Fasciotomy) to be corrected. - If untreated, lack of blood supply can result in a permanent damage to the muscles and nerves; thus, loss of function of the affected limb. - N.B. Myoglobinuria may result after fasciotomy which may lead to renal failure. Therefore, is required if myoglobinuria develops. - N.B. Death of muscle group may result within 4 to 6 hours.

Answer 42

→ Refer to a burn’s unit One Full Arm = 9% of the TBSA. What if it was Deep Dermal? → In children, all burns that are Deep Dermal or Full Thickness should be referred to a specialised burn’s unit regardless of the TBSA being burnt.

Answer 43

→ In adults, Deep Dermal burns of > 5% and All Full Thickness burns should be referred to a specialised burn’s unit. What if it was Superficial Epidermal (First Degree)? → Analgesia + Non-adherent Dressing + Discharge with F/U in Outpatient clinic twice a week. → IV fluid only if >15% in adults or >10% in children. • In burns, always check the tetanus status of the victim and give tetanus toxoid if required.

Answer 44

→ In adults, Deep Dermal burns of > 5% and All Full Thickness burns should be referred to a specialised burn’s unit. What if it was Superficial Epidermal (First Degree)? → Analgesia + Non-adherent Dressing + Discharge with F/U in Outpatient clinic twice a week. → IV fluid only if >15% in adults or >10% in children. • In burns, always check the tetanus status of the victim and give tetanus toxoid if required.

Answer 45

. ◙ Common identified causes of anaphylaxis • Food (e.g., nuts) – the most common cause in children • Drugs (e.g., Penicillin → Amoxicillin, Co-Amoxiclav) • Venom (e.g., wasp, bee sting)

Answer 46

• Skin rashes, itching and hives (Urticarial rash). • Swelling of the lips, tongue or throat. • Shortness of breath, trouble breathing, wheezing (whistling sound during breathing), Cough, Cyanosis. • Dizziness and/or fainting. • Stomach pain, vomiting or diarrhea.

Answer 47

√ ABC. √ High flow O2. √ Make the patient lay flat. √ IM adrenaline (epinephrine) in the anterolateral aspect of the middle third of the thigh. (In a hypotensive patient, give IM adrenaline first followed by IV fluids). Anaphylaxis is one of the few times when you would not have time to look up the dose of a medication. Adrenaline (epinephrine) is by far the most important drug in anaphylaxis and should be given as soon as possible.

Answer 48

• Skin rashes, itching and hives (Urticarial rash). • Swelling of the lips, tongue or throat. • Shortness of breath, trouble breathing, wheezing (whistling sound during breathing), Cough, Cyanosis. • Dizziness and/or fainting. • Stomach pain, vomiting or diarrhea.

Answer 49

The recommended doses for adrenaline, hydrocortisone and chlorphenamine are as follows: Age IM Adrenaline (Epinephrine) Hydrocortisone Chlorphenamine < 6 months 150 micrograms 25 mg 250 micrograms/kg (0.15ml 1 in 1,000) 6 months – 6 years 150 micrograms 50 mg 2.5 mg (0.15ml 1 in 1,000) 6-12 years 300 micrograms 100 mg 5 mg (0.3ml 1 in 1,000) Adult and child > 500 micrograms 200 mg 10 mg 12 years (0.5ml 1 in 1,000) ♠ Adrenaline can be repeated every 5 minutes if necessary. ♠ The best site for IM injection is → the anterolateral aspect of the middle third of the thigh. ♠ After giving Adrenaline, give Hydrocortisone and Chlorpheniramine. Note: Adrenaline is ALWAYS given IM; Intramuscularly.

Answer 50

• Patients who have had emergency treatment for anaphylaxis should be observed for 6–12 hours from the onset of symptoms, as it is known that biphasic reactions can occur in up to 20% of patients • sometimes it can be difficult to establish whether a patient had a true episode of anaphylaxis. Serum tryptase levels are sometimes taken in such patients as they remain elevated for up to 12 hours following an acute episode of anaphylaxis. If there is only allergic reaction (rash only), with no difficulty of breathing → This is an allergic reaction, not anaphylaxis. → Give oral antihistamine (eg, oral chlorpheniramine). Antihistamine first (either oral or IV) followed by IV hydrocortisone.

Answer 51

- Periods of intense fear characterised by: palpitations, sweating, tremors, SOB that develop rapidly. - It peaks around 10 minutes and then gradually resolves over the next 20 minutes. - The Usual Manifestations: Dizziness, circumoral paraesthesia and tingling, carpopedal spasm ± sharp or stabbing chest pain.

Answer 52

◙ Management of Panic Attacks: √ Simple breathing exercise such as breathing through nose, paper bag, slowing down breathing + Reassurance is all that is needed. √ Other lines, in severe and acute (still ongoing): → Benzodiazepines + Propranolol (if no Asthma; as beta blockers are contraindicated in asthma). Panic Disorder Management simplified: √ Rx before attack (to help in an upcoming event) → Propranolol (Beta-

Answer 53

√ Rx during attack → First line: Rebreathe into a paper bag. If still? → Benzodiazepines √ Long-term general Rx and to prevent further attacks → 1st: Psychological → CBT. “Cognitive Behavioural Therapy”. → 2nd: Medical → SSRIs. “Selective Serotonin Reuptake inhibitors e.g. Citalopram, Fluoxetine, Sertraline”.

Answer 54

Very Important: Intubate and Ventilate any patient with GCS ≤ 8 Other possible answer → Inform the anaesthetist. Do not rush and pick something else!

Answer 55

◙ Management of Panic Attacks: √ Simple breathing exercise such as breathing through nose, paper bag, slowing down breathing + Reassurance is all that is needed. √ Other lines, in severe and acute (still ongoing): → Benzodiazepines + Propranolol (if no Asthma; as beta blockers are contraindicated in asthma). Panic Disorder Management simplified: √ Rx before attack (to help in an upcoming event) → Propranolol (Beta-

Answer 56

• Triad of CAS: - Confusion - Ataxia (Uncoordinated gait, unsteadiness) - Squint (Nystagmus, or Ophlamoplegia) • Rx → Urgent IV Thiamine (Vitamin B1) even before glucose replacement.

Answer 57

• If not treated → It might develop to Wernicke’s Korsakoff Syndrome = (The above triad + Retrograde Amnesia + Confabulation). Confabulation = the patient makes up stories to replace the forgotten details (he is not lying; he thinks that these stories have truly occurred). They may carry on a coherent conversation, but moments later, they cannot remember that they had a conversation

Answer 58

Paracetamol Antipyretic and Analgesic. • First 24 hours → Asymptomatic. • After 24 hours → Acute liver failure (Very high ALT and AST) • ALT and PT usually peak at 72 to 96 hours.q

Answer 59

Aspirin A potent Antiplatelet, Antipyretic, Analgesic and Anti- inflammatory drug. √ The earliest symptoms of acute aspirin poisoning may include ringing in the ears (tinnitus) and impaired hearing. √ More clinically significant signs and symptoms may include rapid breathing (hyperventilation), Nausea, vomiting, dehydration, fever, double vision, and feeling faint. (early: respiratory alkalosis. Late: Metabolic Acidosis)

Answer 60

TCA (Tricyclic Antidepressant) Overdose → Excessive sedation, Dry mouth and skin Sympathomimetic effect: tachycardia, Sweating, Dilated Pupils. ECG: Sinus tachycardia (Common), Prolongation of ORS, QT, PR → Give IV fluid 250 ml Bolus (0.9% NaCl) + Usually, the patient is in metabolic Acidosis, IV injection of Sodium Bicarbonate 50-100 ml of 8.4% slowly (50 mmol Sodium bicarb is given by slow IV injection) N.B. aim for pH of 7.5-7.55! Sodium bicarb will correct ECG changes and cardiac rhythm. In TCA toxicity- eg, amitriptyline overdose: There could be hyperkalemia resulting from the metabolic acidosis → Give IV fluids and IV sodium bicarbonate to treat the metabolic acidosis and therefore the hyperkalemia would resolve. So, pick IV sodium bicarbonate Instead of calcium gluconate.

Answer 61

Overdose: Increased Saiva and Tears production, Diarrhea, Vomiting, Small Constricted pupils, sweating, muscle tremors and confusion. Active ingredients in insecticide

Answer 62

→ Acute Liver Failure due to Paracetamol Overdose. He might have been taking paracetamol as he was drunk and having headache. Acute liver failure usually develops 24 hours after paracetamol overdose. The patient presented after 24 hours, which supports the answer.

Answer 63

IV N-Acetylcysteine should be given immediately if: • There is a staggered overdose (all the tablets were not taken within 1 hour) • There is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration. • Patients present > 8 hours after ingestion. • Jaundice or liver tenderness. • The Patient is unconscious or have a suspected overdose. • The 4-hour post ingestion plasma paracetamol concentration is on or above treatment line regardless of risk factors of hepatotoxicity

Answer 64

→ request for serum paracetamol levels after 2 hours (He presents 2 hours after ingestion + additional 2 hours = 4 hours after ingesting paracetamol)

Answer 65

IV Fluids (Along with Cross-Match). IV fluid is superior to blood transfusion as an initial step. This is because IV fluid is available at the A&E department while the Packed RBCs need some time to arrive. Thus, we start with IV fluid resuscitation while waiting for the Blood to arrive.

Answer 66

Types of Surgical Bleeding Primary hemorrhage Bleeding at the time of surgery. Rx: Replacing Blood or return to theatre if severe. Reactionary hemorrhage Bleeding within 24 hours after surgery/ Trauma. e.g. a patient is bleeding and is hypotensive while in the recovery room. Usually due to slipping of ligatures, dislodgement of clots, warming up post-op leading to vasodilatation and rising of BP to normal. Rx: IV fluid, replacing blood, wound re-exploration.

Answer 67

An unresponsive patient after a trauma (e.g. a punch on the face, an accident). → The initial step → Clear Airways (ABC: Airway, Breathing, Circulation). We Always Start With ABC Airway → Breathing → Circulation.

Answer 68

Disorder Notes Plummer- Triad of: Vinson • dysphagia (secondary to oesophageal webs) syndrome • glossitis • iron-deficiency anaemia Treatment includes iron supplementation and dilation of the webs. Mallory- Severe vomiting → painful mucosal lacerations at the Weiss gastroesophageal junction resulting in haematemesis. Common in alcoholics. syndrome (Tear) See Below Boerhaave Severe vomiting → oesophageal rupture

Answer 69

The type of bleeding? → Reactionary Hemorrhage (It occurs within the first 24 hours after the operation)

Answer 70

Severe repetitive vomiting → painful mucosal lacerations at the gastroesophageal junction resulting in haematemesis. Common in alcoholics. - If the patient is vitally and haemodynamically stable, with a normal Hb, either one of the following is the correct answer: - Discharge with Advice. OR - Repeat FBC (Full Blood Count). OR - Observe Vital Signs for fear of deterioration. - Discharge low-risk patients home according to ‘’Blatchford Score”

Answer 71

Disorder Notes Plummer- Triad of: Vinson • dysphagia (secondary to oesophageal webs) syndrome • glossitis • iron-deficiency anaemia Treatment includes iron supplementation and dilation of the webs. Mallory- Severe vomiting → painful mucosal lacerations at the Weiss gastroesophageal junction resulting in haematemesis. Common in alcoholics. syndrome (Tear) See Below Boerhaave Severe vomiting → oesophageal rupture syndrome

Answer 72

Severe repetitive vomiting → painful mucosal lacerations at the gastroesophageal junction resulting in haematemesis. Common in alcoholics. - If the patient is vitally and haemodynamically stable, with a normal Hb, either one of the following is the correct answer: - Discharge with Advice. OR - Repeat FBC (Full Blood Count). OR - Observe Vital Signs for fear of deterioration. - Discharge low-risk patients home according to ‘’Blatchford Score”:

Answer 73

• Systolic BP ≥ 110 • Urea <6.5 • Hgb: ≥ 13 in males, or ≥ 12 in females. • Pulse: <100 • Absence of Melena, Liver disease, HF, Syncope. If severe → Resuscitation (high flow O2, IV fluids, IV blood if needed) - Admission and early endoscopy + calculation of full “Rockall score” if: • SBP <100 and pulse ≥100 (Haemodynamic disturbance). • Continued bleeding (i.e. witnessed haematemesis or haematochezia). • Age: ≥ 60 (all patients > 70 Y/O should be admitted). • Liver disease, HF, Known oesophageal varices.

Answer 74

Therefore, If a patient presents with ongoing hemorrhage (Bleeding), always try to link the Pulse rate to the Class (Stage) of the hypovolemic shock. Example (1), A patient presents u with severe bleeding after stabbing his thigh. His HR is 130. → He is in Class III → i.e. he has lost around 30-40% of his blood, and so on. Example (2), A patient presents with severe bleeding after stabbing his thigh. His HR is 112. What is the estimated blood loss? Class II 15-30% → He is in → i.e. he has lost around This means 750-1500 ml. In a recent exam, the closest answer within this range was of his blood, 1000 ml.

Answer 75

Whenever you see → immediately think of GCS ≤ 8 Intubation (or: Inform the anaesthetist).

Answer 76

In an alcoholic patient who wants to stop drinking but his main concern is that he lacks support and encouragement. → Refer for social services to get the required support. Note that his main concern is to get support. We do not need to admit him to the hospital for detoxification or to psychiatry. All he requires is social support and a push! This is usually the job of the social services.

Answer 77

◙ The most appropriate management→ Liver Transplantation! ♠ Be careful, acute liver failure in paracetamol starts 24 hours after the overdose being ingested. ♠Here, the pH is 7.1, which is an indication for liver transplantation. When to refer a patient with paracetamol overdose for Liver Transplantation? (Imp) King’s College Hospital criteria for liver transplantation (Paracetamol Liver Failure) ◙ Arterial pH < 7.3, 24 hours after ingestion ◙ Or all of the following: • Prothrombin time (PT) > 100 seconds • Creatinine > 300 µmol/l • Grade III or IV encephalopathy

Answer 78

- Causes → Car exhausts, Fires, Faulty gas heaters, Paints. - Pathogenesis: CO decreases the Oxygen-carrying capacity by binding to the Haemoglobin to form Carboxyhaemoglobin (COHb) → This impairs O2 delivery to the tissues, leading to → Tissue hypoxia. - One example is CO poisoning due to → inhalation of Methylene Chloride (Dichloromethane) from the PAINT fume. - Features → Severe Dizziness, headache (usually tension headache) + Malaise + Vomiting. - If severe → Pink skin and mucosae, Fever, Hyperventilation (trying to get O2 as much as possible), Arrhythmia, Coma. - The investigation of choice → Carboxyhemoglobin levels.

Answer 79

- Management → 100% Oxygen administered via a tight-fitting face mask. (Standard Oxygen Therapy). - Points on Management: • The elimination of half-life of CO takes about 4 hours on breathing air, 1 hour on 100% O2, and 23 minutes on O2 atmosphere pressures. • ABC: - Clear airway. - Maintain ventilation with high concentration of O2. - If Conscious → 100% O2 via a tight-fitting face mask with an O2 reservoir. - If Unconscious → Intubate and Ventilate with IPPV (Intermittent Positive- Pressure Ventilation) on 100% O2. Careful! If the patient is hypotensive (SBP < 100) and Unconscious → Intubation + IPPV 100% O2

Answer 80

1) Always start with IV fluids. (if the question asks about the “initial” step). 2) Terlipressin (2mg IV repeated every 4-6 hours) and prophylactic antibiotics (e.g. Ciprofloxacin or Cephalosporin) should be given to patients at presentation (i.e. before endoscopy) 3) Endoscopy → band ligation should be used for oesophageal varices and injections of N-butyl-2-cyanoacrylate for patients with gastric varices. 4) Transjugular intrahepatic portosystemic shunts (TIPS) should be offered if bleeding from varices is not controlled with the above measures

Answer 81

Other Important Notes: - Avoid PPI (e.g. Omeprazole) in acute cases unless the patient is a known peptic ulcer patient. - If INR is prolonged → Vitamin K. - Liver disease + Hematemesis + ↑ INR → Fresh frozen plasma. - If the patient is actively bleeding and the platelet count is < 50.000 → Platelet transfusion. - Balloon Tamponade is only used as a salvage procedure when the patient is massively bleeding non-stop and at risk of death. - GI bleeding is dealt with by [Medical team] not surgeons! ◙ Very Important: √ If a patient with liver disease presents with Hematemesis and high INR → Give Fresh Frozen Plasma (FFP). √ However, if the question asks about the most appropriate “initial” step, the answer would be → IV fluid.

Answer 82

- Posterior urethral tear is often associated with pelvic fracture. - Look for perineal bruising, blood at the external urethral meatus. - PR examination: an abnormally high-riding prostate OR inability to palpate the prostate → Suspect Urethral injury. - Management: Refer to Urology team for: Suprapubic catheterization ± Retrograde/ Ascending urethrogram imaging to assess the urethral injury. - We cannot perform urethral catheterisation as the urethra is injured!

Answer 83

Other Important Notes: - Avoid PPI (e.g. Omeprazole) in acute cases unless the patient is a known peptic ulcer patient. - If INR is prolonged → Vitamin K. - Liver disease + Hematemesis + ↑ INR → Fresh frozen plasma. - If the patient is actively bleeding and the platelet count is < 50.000 → Platelet transfusion. - Balloon Tamponade is only used as a salvage procedure when the patient is massively bleeding non-stop and at risk of death. - GI bleeding is dealt with by [Medical team] not surgeons! ◙ Very Important: √ If a patient with liver disease presents with Hematemesis and high INR → Give Fresh Frozen Plasma (FFP). √ However, if the question asks about the most appropriate “initial” step, the answer would be → IV fluid.

Answer 84

• Associated with pulmonary contusion (a trauma to the chest) • Abnormal chest motion (Paradoxical; on inspiration, one side pulls inwards while the other side pulls outwards), Chest pain, SOB. • There may be absent breath sounds. • Avoid over hydration and fluid overload ◙ Management of Flail Chest: • High Flow O2 (Initial). • Analgesia (Initial): Paracetamol/ NSAIDs/ Opiates/ Intercostal block/ Thoracic epidural (up to T4). • Intubation/ Mechanical Ventilation: if worsening fatigue and RR (laboured breathing). The usual hint is the Trauma + Paradoxical Chest movement ◙ Flail Chest “Initial” Management simplified: - If vitally Stable + Normal Vitals + Normal SpO2 → Analgesia (e.g. intercostal block). - If vitally Unstable → ABC first then Analgesia (High flow O2 then Analgesia). - If Drowsy, Laboured breathing, Worsening Respiratory Rate → Intubate first. (usually with a double lumen endotracheal tube as one side of the chest is affected more than the other).

Answer 85

Investigation • C1-INH level is low during an attack (Acutely). • low C2 and C4 levels are seen, even between attacks. • Serum C4 is the most reliable and widely used screening tool. S&S • Recurrent episodes of facial and tongue swelling (May begin in early childhood). • attacks may be proceeded by painful macular rash.

Answer 86

Family History. • Painless, non-pruritic swelling of subcutaneous/submucosal tissues. • May affect upper airways, skin or abdominal organs (can occasionally present as abdominal pain due to visceral oedema). • urticaria is not usually a feature. Management • Acute: IV C1-inhibitor concentrate, fresh frozen plasma (FFP) if this is not available • Prophylaxis: anabolic steroid Danazol may help.

Answer 87

- Progress to generalised abdominal rigidity. - Hx of taking NSAIDs (e.g. for Rheumatoid Arthritis or any other condition). - Dx: Erect Abdomen and Chest X-Ray (NOT U/S)! →Air under diaphragm.

Answer 88

Very Important NOTE A Post-op patient (in LL femoral arteries) develops LL swelling + is going into shock (Hypotensive) → Think of a hemorrhage at the site of the swelling and INITIALLY and IMMEDIATELY → APPLY PRESSURE at the site of the swelling even before giving IV fluid as there is most likely bleeding beneath it.

Answer 89

The answer is → High flow O2. Remember, always start with ABC (Airway → Breathing → Circulation). So, Oxygen is before Securing venous access.

Answer 90

tachycardic (125) and tachypnic (33). Chest X-ray reveals homogenous opacity in the lower left lung. The trachea is central. What is the likely diagnosis? The likely diagnosis is → Haemothorax ◙ There is bleeding manifested by the hypovolemia (hypotension and tachycardia). Blood accumulates in the pleural cavity. ◙ Homogenous Opacity = White = fluid not gas = either blood or effusion. ◙ In pneumothorax, the x-ray will be Hyperlucent (air) not homogenous (fluid). ◙ In Tension Pneumothorax, the trachea will most likely be deviated away from the pneumothorax side. ◙ Percussion: • Pneumothorax → Hyperresonance. • Haemothorax → Dullness.

Answer 91

◙ Other points on Haemothorax: • Most commonly due to laceration of lung, intercostal vessel or internal mammary artery • Haemothoraces that are large enough to appear on CXR are treated with large bore Chest drain (Chest tube) → Evacuation of blood may be necessary to prevent the development Empyema. • Surgical exploration is warranted if >1500ml blood drained immediately (rarely needed as the source of bleeding is the lung which is a low-pressure system). • Dullness on percussion, Hypovolemia, No fluid level on CXR.

Answer 92

In (severe alcohol intake → severe vomiting → Gastroesophageal laceration → hematemesis): endoscopy - Admission and early if: hemodynamically unstable or continued hematemesis: • SPB <100 and pulse ≥100. • Continued bleeding. • Age: ≥ 60 (all patients > 70 Y/O should be admitted). • Liver disease, HF, Known oesophageal varices. - If the patient is vitally and haemodynamically stable, with a normal Hb, either one of the following is the correct answer: - Discharge with Advice. OR - Repeat FBC (Full Blood Count). OR - Observe Vital Signs for fear of deterioration.

Answer 93

- If the patient is vitally and haemodynamically stable, with a normal Hb, either one of the following is the correct answer: - Discharge with Advice. OR - Repeat FBC (Full Blood Count). OR - Observe Vital Signs for fear of deterioration.

Answer 94

Your (heroin) leaves you “Withdrawal”. “different from heroin overdose!” • You cry a lot → Watery eyes and runny nose. • You cannot sleep → Insomnia. • You miss her → Agitation. Body aches, runny nose, agitation → opiate withdrawal.

Answer 95

Heroin - Withdrawal begins 12 hours after last dose - Peaks at 24-48 hours - Increased body secretions: sweating, diarrhea, runny nose, tearing (Flue-like symptoms esp. early in withdrawal) + - Pain: Abdominal pain, joints (arthralgia), muscle aches. + - Others: agitation, insomnia, anxiety (common in other drugs)

Answer 96

diazepines - Withdrawal begins 1-4 days and peaks at 2 weeks. - Panic attacks + Other common (agitation, insomnia, anxiety) Remember: Benzodiazepines are used to treat panic attacks and anxiety. They are also used to initially manage cocaine overdose (eg, lorazepam).

Answer 97

- Within hours of last dose and peaks in a few days. - Depression, irritability, muscle aches + Others (insomnia …)

Answer 98

• symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety. • peak incidence of seizures at 36 hours • peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia Management • first line: benzodiazepines e.g. chlordiazepoxide. Lorazepam may be preferable in patients with hepatic failure. Typically given as part of a reducing dose protocol • carbamazepine is also effective in treatment of alcohol withdrawal • phenytoin is said not to be as effective in the treatment of alcohol withdrawal seizures

Answer 99

♦ Benzodiazepines √ √ First line → Chlordiazepoxide. √ First line if there is withdrawal Seizure → Lorazepam (Or Diazepam “If IV Lorazepam is not in the options) ♦ Vitamin B1 (Thiamine) = (IV Pabrinex): To prevent Wernicke’s encephalopathy. Other drugs related to Alcohol Intake: ♦ Disulfiram: Promotes Abstinence. (Serves as a deterrent when he takes alcohol). ♦ Acamprosate: Reduces Craving.

Answer 100

- Respiratory Depression (↓ RR) - ↓ BP - ↓ HR (pulse) - Pinpoint pupils (constricted pupil) - Constipation • Give Naloxone

Answer 101

• ↑ BP (new onset hypertension, mostly young age). • ↑ HR (Pulse). • ↑ RR. • Mydriasis (dilated pupils). • ↓ weight (unexplained). • Hyperthermia and sweating. • Restlessness, Agitation, mood changes, sleep changes. • Intranasal use → epistaxis, rhinitis.

Answer 102

• Complications → Acute MI, intracranial hemorrhage, seizures, aortic dissection. • Request → Urine drug screen (for diagnosis). Initial Management → Benzodiazepines (eg, lorazepam

Answer 103

• Agitation, confusion, anxiety, ataxia. • Tachycardia, hypertension • Tachypnoea. • Thirst. • Metabolic acidosis (e.g., ↑ venous lactic acid). • Hyperthermia (↑ body temperature). • Muscle rigidity. • Spots of colours (flashing/ flouring colours). • Uncontrolled body movements, muscle rigidity, trismus. Management • Supportive: ABC + treat metabolic acidosis. • IV diazepam or lorazepam: for agitation. • Dantrolene can be used for hyperthermia and muscle rigidity if simple measures fail.

Answer 104

) LSD Mydriasis (Dilated pupils) – Flushing and sweating – Tremors – Hyperreflexia-Diarrhea – Paraesthesia (Lysergic Acid Delusions and Hallucinations (Pathognomonic) Diethylamide) A patient smelling colours and seeing sounds → LSD Patients see colours when their eyes are closed.

Answer 105

◙ Heroin → ↑ body secretions (watery eyes, runny nose, diarrhea, sweating) + Pain (abdomen, muscles) + Others. ◙ Cocaine → DEPRESSION + Others. ◙ Benzodiazepines → Panic attacks + Others. ◙ Alcohol →Nausea, Vomiting, Irritability + tremors ± Hallucinations + Others

Answer 106

◙ Heroin → everything is decreased: low HR, Low RR, Low BP, Pinpoint (Constricted) pupils. ◙ Cocaine → The Opposite: high HR, high RR, high BP, Mydriasis (Dilated pupils) ± hyperthermia (fever) and sweating. ◙ LSD → delusions, hallucinations, a patient sees sounds and smells colours.

Answer 107

◙ Simple breathing exercise such as breathing through nose, paper bag, slowing down breathing + Reassurance is all that is needed. ◙ Others, in severe and acute (still ongoing) → Benzodiazepines (e.g. diazepam, lorazepam) + Propranolol (if no Asthma). Remember, Asthma + ß-Blockers → Do not mix ☺

Answer 108

◙ Heroin → everything is decreased: low HR, Low RR, Low BP, Pinpoint (Constricted) pupils. ◙ Cocaine → The Opposite: high HR, high RR, high BP, Mydriasis (Dilated pupils) ± hyperthermia (fever) and sweating. ◙ LSD → delusions, hallucinations, a patient sees sounds and smells colours.

Answer 109

→ Mallory-Weiss Syndrome

Answer 110

• Widened mediastinum • Trachea/Oesophagus to right • Depression of left main stem bronchus • Widened paratracheal stripe/paraspinal interfaces • Rib fracture/left haemothorax Diagnosis Angiography, usually CT aortogram. Treatment Surgical Emergency. Repair or replacement. Ideally, they should undergo endovascular repair

Answer 111

• Example (1): Road Traffic Accident, Hypotension, Widened Mediastinum on CXR. → Rupture of Thoracic Aorta. → Surgical Emergency. • Example (2): Road Traffic Accident, Hypotension, Homogenous Opacity on CXR. → Hemothorax → Chest drain to prevent empyema. Surgery rarely needed.

Answer 112

Start IV N-Acetyl Cysteine immediately after Paracetamol Overdose (without waiting for the serum paracetamol level) if: √ Unknown dose. √ Unknown time (Doubtful time) of ingestion. √ Staggered dose (all tablets were not taken at the same hour)

Answer 113

→ Psychiatric liaison are nurses who are trained to receive mental health referrals from A&E. They can decide whether the patient is mentally safe to be discharged or they need further psychiatric admission and treatment. (This can be done if a patient attempted a potentially self-harmful act and when no Medical treatment is required. The referral to psychiatry aims at preventing recurrent attempts of suicide and treating any possible psychological abnormalities). ◙ If pH is < 7.3 after 24 hours → Refer for a liver specialist centre. Imp √

Answer 114

The likely diagnosis → Heroin (Opioid) overdose. The initial step → Give Naloxone.

Answer 115

Overdose (Toxicity) - Respiratory Depression (Low RR) - Low BP - Low HR - Pinpoint pupils (constricted pupil - Constipation • Give Naloxone

Answer 116

High RR - High BP - High HR - Mydriasis (dilated pupils) - Hyperthermia and sweating - Restlessness and Agitation Initial Management → Benzodiazepines (eg, lorazepam).

Answer 117

Refer the patient to the psychiatric team. (No Medical treatment is required. However, a referral to psychiatry is usually required to investigate and manage any psychological illnesses that have made this patient to ingest this high dose of paracetamol) Important Note: If the patient attends to the hospital on his own after ingesting paracetamol overdose, NO compulsory admission to the psychiatric ward is required as he regrets his act and comes seeking treatment. We only refer him to psychiatric liaison to assess his psychological wellness and decide on discharge and follow up as needed. NOTE: • Acute Alcohol consumption is an inhibitor of P-450 enzyme system → reduce the risk of paracetamol poisoning.

Answer 118

◙ S&S of smoke inhalation injury - Persistent cough. - Stridor. - Wheezes. - Black sputum and soot (suggesting excessive exposure to soot) - Use of accessory muscles of respiration. - Blistering or oedema of the oropharynx. - Hypoxia or hypercapnia. Also, if unconscious → Intubate and provide IPPV on 100% O2

Answer 119

→ Give 100% O2 Note: (Needle Thoracocentesis is done only if there are clinical manifestations of Pneumothorax such as deviated trachea).

Answer 120

◙ Calf swelling + Positive Homan’s sign (pain on dorsiflexion) → Think of (Deep Vein Thrombosis) even if there are no RFs or skin changes. DVT ◙ Baker cyst (popliteal cyst): a swelling behind the knee, not swelling of the calf muscles, usually asymptomatic. ◙ Popliteal cyst rupture: initially presents with a swelling and discomfort behind the knee which (when ruptures) can present as calf pain and swelling. However, DVT is more common. ◙ Achilles Tendon Rupture: Hx of popping sound + pain around the ankle + diminished plantar flexion.

Answer 121

. CO Poisoning. Carboxyhemoglobin levels. → The likely diagnosis → → The investigation of choice → → The initial step → → If he was unconscious and SBP < 100 (Hemodynamically unstable) 100% O2 given via Tight Fitting Mask. → Intubation and Ventilation.

Answer 122

• The lone rescuer should compress the sternum with the tips of two fingers (Index and Middle fingers of one hand). • If there are two or more rescuers, use the encircling technique: o Place both thumbs not one thumb flat, side-by-side, on the lower half of the sternum, with the tips pointing towards the infant’s head. o Spread the rest of both hands, with the fingers together, to encircle the lower part of the infant’s rib cage with the tips of the fingers supporting the infant’s back. o Press down on the lower sternum with your two thumbs to depress it at least one-third of the depth of the infant’s chest, approximately 4 cm.

Answer 123

• Place the heel of one hand over the lower half of the sternum. • Lift the fingers to ensure that pressure is not applied over the child’s ribs. • Position yourself vertically above the victim’s chest and, with your arm straight, compress the sternum to depress it by at least one-third of the depth of the chest, approximately 5 cm. • In larger children, or for small rescuers, this may be achieved most easily by using both hands with the fingers interlocked.

Answer 124

◙ In adults → 30:2 ◙ In Paediatrics: √ Layman (Normal people) → 30:2 √ Professional → 15:2 N.B. Layman = a person without professional or specialized knowledge in a particular subject.

Answer 125

• Place the heel of one hand over the lower half of the sternum. • Lift the fingers to ensure that pressure is not applied over the child’s ribs. • Position yourself vertically above the victim’s chest and, with your arm straight, compress the sternum to depress it by at least one-third of the depth of the chest, approximately 5 cm. • In larger children, or for small rescuers, this may be achieved most easily by using both hands with the fingers interlocked.

Answer 126

Even if the patient has IV access” we need to secure airway first before giving IV Lorazepam. N.B. A prolonged and ongoing seizure for > 30 minutes can lead to Cerebral Damage!

Answer 127

Common identified causes of anaphylaxis: • Food (e.g. nuts) – the most common cause in children • Drugs • Venom (e.g. wasp sting)

Answer 128

usually involve more than one part of the body such as the skin, mouth, eyes, lungs, heart, gut, and brain. Some symptoms include: • Skin rashes, itching and hives (Urticarial Rash). • Swelling of the lips, tongue or throat. • Shortness of breath, trouble breathing, wheezing (whistling sound during breathing), cough, cyanosis. • Dizziness and/or fainting. • Stomach pain, vomiting or diarrhea. Management: IM adrenaline (epinephrine). The dose is as follows:

Answer 129

Management: IM adrenaline (epinephrine). The dose is as follows: Age IM Adrenaline (Epinephrine) 0 – 6 years 150 micrograms (0.15ml 1 in 1,000) 6-12 years 300 micrograms (0.3ml 1 in 1,000) Adult and child > 12 years 500 micrograms (0.5ml 1 in 1,000)

Answer 130

◙ After RTA, Perform → FAST (Focused Abdominal Sonography (U/S) for Trauma (the investigation of choice) or CT Scan. → Found subcapsular splenic heamatoma ♠ If the patient is hemodynamically stable → ♠ The patient is hemodynamically unstable ± Free peritoneal fluids Observation (by Surgical team). → Emergency Laparotomy. Do not rush into Surgery! A stable patient is managed by surgical team with observation first. If deteriorates or was unstable from the beginning, emergency laparotomy is warranted.

Answer 131

→ Give Oral Antihistamine. (No indication of IM adrenaline here) This is an allergic reaction. We do not give IM adrenaline unless anaphylactic shock is suspected by any of the following: SOB ▐ Stridor ▐ Hoarseness ▐ Wheezes ▐ Shock ▐ Swelling of tongue, face, cheek If only itchy rash → oral antihistamine.

Answer 132

Unilaterally dilated pupil Space occupying lesion e.g. abscess, tumour, hematoma. Bilaterally constricted pupils (pinpoint = Miosis) Opiate overdose e.g. morphine, heroin CVA affecting the brainstem Bilaterally dilated pupils (Mydriasis) TCA overdose (Tricyclic Antidepressant) e.g. amitriptyline. Cocaine overdose

Answer 133

• Hypotension [low BP] • Anterograde Amnesia • Sedation • Cognitive impairment

Answer 134

Features of airway obstruction (taken from the Resus Council) Mild airway obstruction Severe airway obstruction Response to question ‘Are you Response to question ‘Are you choking?’ choking?’ • victim speaks and answers yes • victim is unable to speak, maybe nodding Other signs • victim is able to speak, cough, Other signs and breathe • victim unable to breathe • breathing sounds are wheezy • attempts at coughing are silent • victim may be unconscious If mild airway obstruction • encourage the patient to cough (He can speak and cough). If severe airway obstruction and is still conscious: • Give up to 5 back-blows • If unsuccessful give up to 5 Abdominal thrusts (Heimlich manoeuvre) (for Adults) or 5 Chest thrusts (for infants <1y) • If unsuccessful → continue the above cycle If unconscious • call for an ambulance • start cardiopulmonary resuscitation (CPR)

Answer 135

If coughing is ineffective or is becoming ineffective → shout for help and assess the child’s conscious level. • If the child is conscious, give up to five back blows, followed by five chest thrusts to infants or five abdominal thrusts to adults and children of > 1 YO. • (repeat the sequence until the obstruction is relieved or the patient becomes unconscious). • If he becomes unconscious, call ambulance and begin CPR. For infants (<1-year-old) – back blows and chest thrusts: • In a seated position, support the infant in a head-downwards, prone position to let gravity aid removal of the foreign body. • Support the head by placing the thumb of one hand at the angle of the lower jaw, and one or two fingers from the same hand at the same point on the other side of the jaw. Do not compress the soft tissues under the jaw, as this will aggravate the airway obstruction.

Answer 136

• Deliver up to five sharp blows with the heel of your hand to the middle of the back (between the shoulder blades). • After each blow, assess to see if the foreign body has been dislodged and, if not, repeat the manoeuvre up to five times. • After five unsuccessful back blows, use chest thrusts: turn the infant into a head-downwards supine position by placing your free arm along the infant’s back and encircling the occiput with your hand. Support the infant down your arm, which is placed down (or across) your thigh. Identify the landmark for chest compression. This is the lower sternum, about a finger’s breadth above the xiphisternum. Deliver five chest thrusts. These are similar to chest compressions for CPR, but sharper in nature and delivered at a slower rate.

Answer 137

• Aspirin, Paracetamol → more common) • ACEi (e.g. enalapril) and NSAIDs (e.g. diclofenac) → • Benzodiazepines → (However, pick Aspirin as it is Metabolic Alkalosis Respiratory Acidosis (Apnea → Accumulation of CO2) NOTE: Salicylate (Aspirin) Poisoning → Resp. Alkalosis (Early) then Met. Acidosis (Later). Remember: • In Metabolic Acidosis, a patient would have a high RR (trying to wash out the CO2 which is an acid) + Altered mental status + Nausea + Palpitations + Abdominal pain, Chest pain. • Benzodiazepines (e.g. Lorazepam) overdose → Resp. depression (Apnea) → Accumulation of CO2 which is an acid → Respiratory Acidosis.

Answer 138

The following points are for your knowledge; nonetheless, it is good to try to understand them as they will show up in other chapters. • pH determines whether it is Acidosis or Alkalosis. • Bicarbonate (Normally 22-26), if less → Metabolic Acidosis If bicarb. Is normal → look at PCO2 (Normally 4.7-6), if low → Alkalosis, if high → Acidosis. N.B. DO NOT Directly look at PCO2 neglecting the bicarbonate as sometimes the bicarbonate might be low (Acidosis) simultaneously with a low PCO2 (Alkalosis). The low PCO2 in such a case is due to the respiratory compensation mechanism (washing out the CO2 to buffer the acid)!

Answer 139

1. Is the patient acidaemic (pH <7.35) or alkalaemic (pH >7.45)? 2. Respiratory component: What has happened to the PaCO2? • PaCO2 > 6.0 kPa suggests a respiratory acidosis (or respiratory compensation for a metabolic alkalosis) • PaCO2 < 4.7 kPa suggests a respiratory alkalosis (or respiratory compensation for a metabolic acidosis) 3. Metabolic component: What is the bicarbonate level/base excess? • bicarbonate < 22 mmol/l (or a base excess < -2 mmol/l) suggests a metabolic acidosis (or renal compensation for a respiratory alkalosis) • bicarbonate > 26 mmol/l (or a base excess > +2 mmol/l) suggests a metabolic alkalosis (or renal compensation for a respiratory acidosis) Simply, know that CO2 is an Acid, and Bicarbonate (HCO3) is an Alkali.

Answer 140

Respiratory Alkalosis ANY CAUSE OF HYPERVENTILATION (High RR) e.g. • PE (Pulmonary Embolism) • Salicylate -Aspirin- (early in the course of poisoning). • Mechanical Ventilation (Rapid Ventilation). • Panic attack (Hyperventilation → washing CO2) N.B. A patient with cardiac arrest can develop → MIXED ACIDOSIS → (Low pH, High PaCO2, Low HCO3) as he is not breathing (accumulation of CO2, and his kidneys do not perfuse due to low cardiac output). What to do? → Increase ventilation. (This will rapidly washout the CO2 which is Acid and help resolve the acidosis)

Answer 141

→ Metabolic acidosis (with partial respiratory compensation). ♦ As the pH < 7.35 → definitely Acidosis. ♦ PCO2 (the acid) is low → this is a compensation by the lungs; they try to breathe quickly to get rid of the CO2 (the acid) to buffer the acidity. The patient might present with tachypnea or SOB. ♦ Base excess is very low → metabolic acidosis.

Answer 142

His Base excess is very low (< -2) → Metabolic Acidosis. His blood gas interpretation → Metabolic Acidosis As his pH < 7.35 → Acidosis This patient had profuse diarrhea for 2 days. Remember that profuse diarrhea can lead to loss of HCO3 “Bicarbonate” and thus metabolic acidosis. Also, remember that profuse diarrhea can lead to → Hypovolemia “Dehydration”, which is an important prerenal cause for AKI. That’s why his renal functions are impaired.

Answer 143

Respiratory Alkalosis can be seen in And in Panic attack Pulmonary Embolism However, the associated decrease in PaO2 “Hypoxia” suggests PE. Very Important, Respiratory Acidosis (pH <7.35): e.g. → Asthma, COPD Low or normal PaO2, High PaCO2 (>6), bicarb is normal (22-26) or around it. Respiratory Alkalosis (pH >7.45) in: (Asked twice in recent exams) ◙ Pulmonary Embolism: Low PaO2 (<10), Low PaCO2 (<4.7), bicarb is normal (22-26) or around it. ◙ In Panic attack, it is the same, but the PaO2 will be normal (>10): Normal PaO2 (>10), Low PaCO2 (<4.7), bicarb is normal (22-26) or around it.

Emergency Med Flashcards

(187 cards)