Emergency Medicine Flashcards

Question

Paracetamol overdose late presentation

Answer 1

Late (12-36hrs): * Moderate/severe abdominal pain * Metabolic acidosis * Jaundice * Acute kidney injury * Hepatic encephalopathy * Coma * Bruising or systemic haemorrhage may indicate coagulopathy secondary to impaired hepatic clotting factor production

Answer 2

* Paracetamol concentration * Liver function tests * INR * Urea and electrolytes * Plasma bicarbonate * Plasma glucose * Full blood count

Answer 3

* accurate history essential: -- combination/ strength ingested -- length of time ingested over -- time since ingestion * activated charcoal if present within 1hr * IV acetylecysteine given over 1hr if: -- staggered overdose -- present 8-24hrs -- present >24hrs if jaundiced/ hepatic tenderness -- plasma paracetamol conc. on/ above single treatment line

Answer 4

breakdown of skeletal muscle cells -> release of intracellular fluids (CK, myoglobin, urate, electrolytes) into circulation -> electrolyte imbalances/ AKI

Answer 5

* seizure (esp **status epilepticus**) * collapse/coma (prolonged immobilisation) * ecstasy * crush injury * McArdle's syndrome (genetic disorder) * drugs: statins (especially if co-prescribed with clarithromycin)

Answer 6

* AKI with raised creatinine * significantly elevated CK * myoglobinuria: (tea-coloured) * hypocalcaemia (myoglobin binds calcium) * elevated phosphate (released from myocytes) * hyperkalaemia (may develop before renal failure) * metabolic acidosis

Answer 7

* **IV fluids** to maintain good urine output * manage any electrolyte disturbances * urinary alkalinization in severe cases (IV sodium bicarb)

Answer 8

* Unilateral weakness (and/or sensory deficit) of the face, arm and leg * Homonymous hemianopia (loss of half of the visual field in both eyes) * Higher cerebral dysfunction (dysphasia, visuospatial disorder)

Answer 9

TWO of the following: * Unilateral weakness (and/or sensory deficit) of the face, arm and leg * Homonymous hemianopia (loss of half of the visual field in both eyes) * Higher cerebral dysfunction (dysphasia, visuospatial disorder) OR higher cerebral dysfunction alone

Answer 10

* Cranial nerve palsy with a contralateral motor or sensory deficit, or * Bilateral motor/sensory deficit, or * Conjugate eye movement disorder, or * Symptoms of cerebellar dysfunction such as vertigo, nystagmus or ataxia, or * Isolated homonymous hemianopia

Answer 11

* Seizures (Todd’s paresis) * Migraine * Bell’s palsy * Vestibular neuritis / BPPV * Head injuries * Exacerbation of an old stroke * Space-occupying lesions (e.g. tumours) * Demyelinating disorders (e.g. multiple sclerosis) * Delirium * Sepsis and central nervous system infections * Hypoglycaemia and hyperglycaemia * Intoxication with alcohol or drugs

Answer 12

* aspirin 300mg, cont. 2 weeks * thrombolysis with alteplase within 4.5hrs of onset * thrombectomy within 6-24hrs if confirmed PAC * stroke rehab if needed secondary prevention: * clopidogrel/ dipyridamole * treat modifiable RF (eg HTN)

Answer 13

* airway, breathing, circulation * burns caused by heat: remove the person from the source. Within 20 minutes of the injury irrigate the burn with cool (not iced) water for between 10 and 30 minutes. Cover the burn using cling film, layered, rather than wrapped around a limb * electrical burns: switch off power supply, remove the person from the source * chemical burns: brush any powder off then irrigate with water

Answer 14

* Wallace's Rule of Nines: head + neck = 9%, each arm = 9%, each anterior part of leg = 9%, each posterior part of leg = 9%, anterior chest = 9%, posterior chest = 9%, anterior abdomen = 9%, posterior abdomen = 9% * Palmar surface for smaller areas (SA of patients entire hand = 1%) * Lund and Browder chart: the most accurate method

Answer 15

* Superficial (1st degree): Only epidermis damaged * Superficial Partial (2nd degree): Epidermis & upper dermis damaged * Deep Partial (2nd degree): Epidermis, upper & lower dermis damaged * Full Thickness (3rd degree): All skin layers to subcutaneous tissues damaged

Answer 16

* **superficial:** Red and painful, dry, no blisters * **superficial partial:** Pale pink, painful, blistered. Slow capillary refill * **deep partial:** Typically white but may have patches of non-blanching erythema. Reduced sensation, painful to deep pressure * **full thickness:** White ('waxy')/brown ('leathery')/black in colour, no blisters, no pain

Answer 17

* local progressive tissue loss/ damage * loss of capillary membrane integrity -> plasma leakage into interstitial space -> hypovolaemic shock (up to 48h after injury) - decreased blood volume and increased haematocrit * Immunosuppression is common -> high risk of sepsis

Answer 18

* stop burning process * assess airway - consider early intubation (eg smoke inhalation/ deep facial burns/ blisters to oropharynx) * IV fluids: children with burns >10% of total body surface area, adults with burns >15% TBSA * urinary catheterisation * analgesia * transfer to burns unit if complex

Answer 19

4Hs and 4Ts: * Hypoxia * Hypokalaemia/hyperkalaemia * Hypothermia/hyperthermia * Hypovolaemia * Tension pneumothorax * Tamponade * Thrombosis * Toxins

Answer 20

* NSAIDs * Aspirin * Certain antacids and antidiarrhoeal meds

Answer 21

* stimulate cerebral medulla -> hyperventilation -> respiratory alkalosis * salicylate metabolisation -> uncoupling of oxidative phosphorylation -> anaerobic respiration -> increased lactate -> metabolic acidosis * this results in a mixed respiratory alkalosis and metabolic acidosis

Answer 22

* **hyperventilation** (centrally stimulates respiration) * **tinnitus** * **lethargy * sweating, pyrexia ** * **nausea/vomiting** * hyperglycaemia and hypoglycaemia * seizures * coma

Answer 23

* general (ABC, charcoal) * urinary alkalinization with intravenous sodium bicarbonate - enhances elimination of aspirin in the urine * haemodialysis

Answer 24

* the skull has a fixed capacity and contains 3 main substances: brain tissue, CSF and blood * if the volume of 1 of these increases, the volume of one of the others must decrease to maintain a constant ICP (compliance) * eg bleed in the brain = reduced CSF production * once this compensatory compliance mechanism is overwhelmed, small increases in the volume of any one of the three substances will lead to dramatic increases in ICP

Answer 25

* **Headache** * **Nausea and vomiting** * **Papilloedema** * Restlessness, agitation or drowsiness * Slow slurred speech * Ipsilateral sluggish dilated pupil which then becomes fixed (“blown pupil”) * Cranial nerve palsy (e.g. CN III palsy with ‘down and out’ pupil) * Seizures * Reduced GCS * Abnormal respiratory pattern * Abnormal posturing, initially decorticate and then decerebrate

Answer 26

* Widening pulse pressure (inc. systolic, dec. diastolic) * Bradycardia * Irregular respirations

Answer 27

* CPP = Mean Arterial Pressure (MAP) – ICP

Answer 28

* GCS < 13 on initial assessment * GCS < 15 at 2 hours post-injury * suspected open or depressed skull fracture * post-traumatic seizure. * focal neurological deficit. * more than 1 episode of vomiting * any sign of basal skull fracture

Answer 29

LOC/ amnesia since injury, plus any of: * age 65 years or older * any history of bleeding or clotting disorders including anticogulants * 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

Answer 30

* Reduced level of consciousness (including coma): if severe this can result in loss of airway tone and reflexes leading to hypoxia if left untreated. * Respiratory depression: decreased respiratory rate can result in hypoxia and inadequate tissue perfusion. * Hypotension * Bradycardia * Rhabdomyolysis * Hypothermia

Answer 31

* Reduced level of consciousness (including coma): if severe this can result in loss of airway tone and reflexes leading to hypoxia if left untreated. * Respiratory depression: decreased respiratory rate can result in hypoxia and inadequate tissue perfusion. * Hypotension * Bradycardia * Rhabdomyolysis * Hypothermia

Answer 32

Flumazenil

Answer 33

* Recent surgery * Recent fractures * Recent immobility * Personal or family history of a clotting disorder or PE/DVT * Obesity * Malignancy * Infection * Pregnancy * Medications such as the combined oral contraceptive pill or hormone replacement therapy

Answer 34

* Shortness of breath * Pleuritic chest pain * Cough * Haemoptysis: secondary to infarcted lung tissue. * Dizziness or syncope Signs: * Tachypnea * Crackles * Tachycardia * Fever

Answer 35

PE Wells Score * PE likely (>4): CTPA, interim DOAC * PE unlikely (4 or less): D-Dimer -> positive result -> CTPA

Answer 36

collection of air between the parietal and visceral pleura of the lung

Answer 37

sudden onset: * dyspnoea * chest pain: often pleuritic * sweating * tachypnoea * tachycardia

Answer 38

* no SOB, <2cm rim of air on CXR: no tx required, F/U in 2-4 weeks * SOB or >2cm rim of air on CXR: aspiration and reassess -> chest drain if needed

Answer 39

* thoracic trauma -> creates one-way valve, air let in but not out of pleural space * trapped air creates pressure inside thorax -> pushes mediastinum across -> kinks big vessels -> cardiorespiratory arrest

Answer 40

* Tracheal deviation away from the side of the pneumothorax * Reduced air entry on the affected side * Increased resonance to percussion on the affected side * Tachycardia * Hypotension

Answer 41

Insert a large bore cannula into the second intercostal space in the midclavicular line

Answer 42

* Pain radiating to the jaw or arms * Nausea and vomiting * Sweating and clamminess * A feeling of impending doom * Shortness of breath * Palpitations

Answer 43

* M - IV morphine * O - oxygen if sats below 94 (aim 94-98) * N - nitrate * A - aspirin 300mg

Answer 44

* 1st line: 4mg IV lorazepam (give buccal/ IM if no IV access) * Repeat after 10 minutes * Phenytoin/ levetiracetam/ sodium valproate infusion

Answer 45

* Secure airway (nasopharyngeal) * Position pt on left side (aspiration risk) * Give oxygen * Glucose/ thiamine if indicated * Medical management (BDZs)

Answer 46

* Risk of arrhythmias (avoid if cardiac problems)

Answer 47

* Peptic ulcers (the most common cause) * Mallory-Weiss tear (a tear of the oesophageal mucosa) * Oesophageal varices (secondary to portal hypertension in liver cirrhosis) * Stomach cancers

Answer 48

* Haematemesis (vomiting blood) * Coffee ground vomit (caused by vomiting digested blood with the appearance of coffee grounds) * Melaena (tar-like, black, greasy and offensive stools caused by digested blood)

Answer 49

* Haemoglobin (falls in upper GI bleeding) * Urea (rises in upper GI bleeding) * Systolic blood pressure * Heart rate * Presence of **melaena** * **Syncope** * Liver disease * Heart failure

Answer 50

* “Group and save": the lab checks the patient’s blood group and saves a blood sample to match blood if needed * “Crossmatch”: the lab allocates units of blood, tests that it is compatible, and keeps it ready in the fridge

Answer 51

ABATED: A – ABCDE approach to immediate resuscitation B – Bloods A – Access (ideally 2 x large bore cannula) T – Transfusions are required E – Endoscopy (within 24 hours) D – Drugs (stop anticoagulants and NSAIDs)

Answer 52

* Massive haemorrhage * Active bleeding plus thrombocytopenia (plt<50) * Give prothrombin complex concentrate if active bleeding + warfarin

Answer 53

* 50% blood loss within 3 hours * Blood loss at a rate >150ml/minute * Loss of one blood volume over 24 hours In an acute scenario, bleeding plus: * A blood pressure <90mmHg systolic * A heart rate >110bpm

Answer 54

* On the floor (external wound) and four more: * chest cavity (haemothorax) * abdominal cavity (injury to a solid organ/ major blood vessel) * pelvis (fracture) * long bones (fracture)

Answer 55

* Stopping the bleeding (direct pressure, medical/ surgical mx) * Replacing lost blood volume (give colloids, 1:1 ratio of units of plasma and RBC) * Avoid lethal triad (hypothermia, acidosis, coagulopathy - keep pt warm, maximise oxygenation, avoid crystalloids)

Answer 56

* oxygen * nebulised salbutamol/ ipratropium bromide * consider NIV * consider antibiotics * corticosteroids

Answer 57

PEFR 50-75% best or predicted Speech normal RR < 25 / min Pulse < 110 bpm

Answer 58

PEFR 33 - 50% best or predicted Can't complete sentences RR > 25/min Pulse > 110 bpm

Answer 59

PEFR < 33% best or predicted Oxygen sats < 92% Silent chest, cyanosis or feeble respiratory effort Bradycardia, dysrhythmia or hypotension Exhaustion, confusion or coma

Answer 60

* admit to hospital if life-threatening * give oxygen if hypoxaemic * SABA - nebulised if life-threatening * oral prednisolone for >5 days, in addition to ICS * ipratroprium bromide if no response to SABA/ steroids * IV magnesium sulfate/ aminophylline - senior management

Emergency Medicine Flashcards

(84 cards)