Emergency Medicine Flashcards

Question

Ectopic pregnancy - when should you consider?

Answer 1

CONSIDER IN EVERY WOMAN OF CHILD-BEARING AGE PRESENTING WITH COLLAPSE, ACUTE ABDO PAIN +/- PV BLEEDING

Answer 2

Usually presents at 6-9wk gestation. Abdominal pain, shoulder tip/back pain, PV bleeding, recent amenorrhoea, dizziness. Ruptured ectopic = collapse, shock, peritonism.

Answer 3

Abdo: unilateral iliac fossa pain +/- mass; if rupture, guarding. ↑HR, ↓BP. PV: bleeding, extreme cervical pain.

Answer 4

↑maternal age, previous ectopic, tubal surgery, previous STIs/PID, IUCD, assisted conception techniques, smoking.

Answer 5

Miscarriage, appendicitis, pelvic infection, ovarian cyst.

Answer 6

Bloods - Β-hCG (serum and urine), FBC USS – foetal sac/pole in the adnexae, free fluid. Relevant to Initial Management - Group and save/X-match

Answer 7

Emergency - IV access (14-16G), IV fluids and urgent referral to gynae. Medical - Methotrexate used for small ectopics in stable patients. Surgical - Laparoscopic/open salpingectomy/salpingostomy/oophorectomy.

Answer 8

Vaginal bleeding, crampy lower abdominal pain, nausea, vomiting, dizziness.

Answer 9

May be shocked; abdominal tenderness suggests ectopic. PV - Check size of uterus, exclude adnexal tenderness; speculum -open/closed cervical os, clots, products of conception.

Answer 10

Threatened, inevitable, missed, incomplete, complete

Answer 11

Bloods – FBC, group and save, β-Hcg Urine - β-Hcg USS - transvaginal Exclusion - If marked abdo/cervical tenderness – exclude ectopic by USS and serial serum β-Hcg.

Answer 12

If Shocked - Insert grey cannula, fluid resuscitate and remove products of conception from os (can cause vasovagal); ergometrine 0.5mg IM given for severe bleeding. Offer all patients analgesia.

Answer 13

Severe, sudden onset lower abdominal pain, iliac fossa pain radiating to right flank, nausea, vomiting, fever.

Answer 14

Abdo – tenderness | PV – adnexal tenderness

Answer 15

Developmental abnormalities, early pregnancy, women undergoing hormonal stimulation for IVF.

Answer 16

Appendicitis, diverticulitis, ectopic pregnancy, UTI

Answer 17

Urine – dipstick +/- MSU USS Exclusion - Urine and serum β-Hcg (to exclude pregnancy/ectopic)

Answer 18

IV access for fluids, analgesia; laparoscopy if not settling.

Answer 19

Infection, peritonitis, adhesions, infertility (rare)

Answer 20

Constant severe epigastric pain radiating to back, improved by sitting forward, nausea, vomiting, anorexia.

Answer 21

↑HR, ↓BP, ↑temp, cold extremities, epigastric tenderness with peritonitis, abdominal distension, ↓bowel sounds, mild jaundice. Cullen’s sign (bruised umbilicus), Grey-Turner’s sign (bruised flanks).

Answer 22

I GET SMASHED Idiopathic, gallstones (50%), ethanol (25%), trauma, steroids, mumps, autoimmune, scorpion bites (rare), hyperlipidaemia, hypercalcaemia, hypothermia, ERCP, drugs (thiazide diuretics)

Answer 23

Bloods - ↓Hb, ↑WCC, ↑↑↑lipase (or amylase), ↑glucose, ↓Ca2+, deranged clotting (+/- DIC), LFT USS - ?gallstones CT – if diagnosis in doubt

Answer 24

Emergency - IV fluid resuscitation, O2, analgesia, urinary catheter, NBM, NG tube. Escalation - If severe involve ICU and plan ERCP if gallstone aetiology. Routine - Monitor fluid balance, obs, glucose. Daily U+E, FBC, CRP, prophylactic LMWH.

Answer 25

Lower abdominal pain, vaginal discharge, intermesnstrual/postcoital bleeding, pyrexia, dysuria, dysparenuria, nausea, vomiting, infertility, general malaise.

Answer 26

Abdo – tenderness | PV – adnexal tenderness, cervical excitation

Answer 27

Infection and inflammation of upper gential tract commonly with STIs (Chlamydia Grachomatis or Neisseria Gonnorrhoeae)

Answer 28

Young age at first intercourse, multiple sexual partners, no barrier contraception, smoking.

Answer 29

Appendicitis, endometriosis, ovarian cysts, ectopic pregnancy, other STIs, HIV, UTI

Answer 30

MSU – genital swabs (high vaginal, endocervical, chlamydia) for M, C + S Bloods – FBC, CRP, cultures Exclusion - USS – to exclude ovarian cyst

Answer 31

IV access for fluids + analgesia Remove IUCD Antibiotics (ceftriaxone 250mg IM stat, then metronidazole 400mg/12h PO and doxycycline 100mg/12h PO for 14 days) Refer to GUM clinic for contact tracing

Answer 32

Untreated may lead to chronic pelvic pain and infertility; tubo-ovarian abscess, septicaemia, secondary infertility, ectopic pregnancy.

Answer 33

Burning retrosternal or epigastric pain, worse on bending and lying. Waterbrash, acid reflux, nausea, vomiting, nocturnal cough. Symptoms improved by antacids.

Answer 34

Epigastric tenderness (no peritonitis), rarely epigastric mass.

Answer 35

Smoking, alcohol, obesity, pregnancy, hiatus hernia, medications (bisphosphonates, calcium antagonists, nitrates, corticosteroids, NSAIDs).

Answer 36

Urgent endoscopy if ‘red flag’ symptoms (chronic GI bleeding/iron deficiency anaemia, unintentional weight loss, progressive dysphagia, persistent vomiting, epigastric mass) or >55 and persistent/unexplained dyspepsia.

Answer 37

1-2 months full dose PPI. 95% duodenal and 80% gastric ulcers are related to H.pylori so ensure eradication. Repeat endoscopy at 6 weeks to ensure healing – ulcers associated with malignancy. H. Pylori Eradication C-urea breath testing – wash-out period of 2 weeks off PPI required. Treatment Triple therapy for 1 week – lansoprazole 30mg/12h PO, amoxicillin 1g/12h PO, clarithromycin 500mg/12h PO.

Answer 38

Acute onset severe unilateral colicky pain radiating from loin to groin, nausea and vomiting, sweating, haematuria, dysuria, strangury (frequent, painful passage of small volumes of urine with sensation of incomplete emptying); iliac fossa or suprapubic pain suggests another pathology.

Answer 39

↑HR, sweating, patient restless and in severe pain, usually no tenderness on palpation unless superimposed infection.

Answer 40

Renal stones – always consider other causes of abdo pain, including AAA, especially if no history of renal stones.

Answer 41

``` Urine – Hb on dipstick, nitrates suggest UTI β-HCG - if female Bloods – FBC, U+E, Ca2+ KUB – detects 60% stones CT – detects >99% stones ```

Answer 42

Analgesia (NSAID first, then opioids); if <5mm should pass spontaneously. If evidence of infection give IV abx (check local policy) If evidence of infection or hydronephrosis refer urgently to urologist for nephrostomy or stent

Answer 43

Cystitis – frequency, dysuria, urgency, pyuria, haematuria, suprapubic pain. Pyelonephritis – fever, rigors, vomiting, loin pain

Answer 44

Warm peripheries, vasodilation, tachycardia, suprapubic/loin pain.

Answer 45

↓BP/shock, temp >40, new renal impairment, elderly patients can be afebrile or hypothermic but heavily bacteraemic.

Answer 46

Sexual intercourse, catheterisation, DM, immunosuppression, pregnancy, structural abnormalities of urinary tract, stones, elderly.

Answer 47

Urine dipstick – nitrities, leucocytes, blood and protein. MSU culture = gold standard. C+S if clinical suspicion of UTI and in all pyrexial/vomiting children. Bloods – FBC (↑WCC, ↑Nø), U+E (↑urea + creatinine if outflow obstruction), ↑inflammatory markers, ↑glucose (?DM) Blood cultures – if ↑temp or systemically unwell

Answer 48

If ↓BP treat as septic shock; otherwise paracetmol (for fever) and consider empirical abx therapy (trimethoprim 200mg/12h PO, or co-amoxiclav 1.2g/8h IV if septic) whilst awaiting sensitivities. ↑oral fluid intake. Treat for 3 days in simple infection in females, 7 days if structural abnormality, immunosuppressed or male.

Answer 49

↓BP --> treat as septic shock; admit for IV abx if septic, pregnant, frail elderly, immunosuppressed or structurally abnormal urinary tract. Give paracetamol and start empirical abx therapy (eg. Co-amoxiclav 625mg/8h PO or 1.2g/8h IV) whilst awaiting sensitivities. Increase oral fluid intake. Treat for 7-10 days.

Answer 50

Unilateral painful, tingling, weak limb, worse on raising limb.

Answer 51

Absent pulses, slow cap refill (compare with opposite limb), cold and pale (can be red limb if below heart), reduced power and sensation.

Answer 52

Emboli, thrombosis, dissecting aneurysm, trauma

Answer 53

Arterial graft, PVD, previous thrombo-embolism, AF, prosthetic heart valves, recent MI, dehydration, malignancy

Answer 54

Doppler – will show reduced or absent pulse. | Angiography may demonstrate an obstruction.

Answer 55

Urgent surgery – call senior surgeon who will consider embolectomy, intra-arterial thrombolysis, bypass or amputation. Emergency - 15 L/min O2 + analgesia (morphine); IV access + IV fluids if dehydrated; may require heparinisation pre- or post-op.

Answer 56

Amputation, gangrene, hyperkalaemia, renal failure, sepsis.

Answer 57

Hot, sometimes tender area of erythema, usually on leg or face; may be spreading; history of trauma to skin (insect bite, cannula site). May be systemic effects – fever, anorexia, N+V, diarrhoea.

Answer 58

Blanching warm spreading erythema (outline area with marker to observe response to treatment), +/- mild oedema, break in the skin, serous discharge, lymphadenopathy in draining nodes, ↑temp, ↑HR, ↑RR.

Answer 59

Staph Aureus (may be MRSA), group A streptococci

Answer 60

Bloods - ↑WCC and neutrophils, ↑CRP/ESR; blood cultures if pyrexial, D-dimer likely to be raised in infection so not useful in differentiating cellulitis from DVT. Skin swabs – not usually helpful, but check multisite MRSA swab results. USS – to exclude DVT (depending on Wells’ score) or ruptured Baker’s cyst

Answer 61

If patient is well – oral abx (flucloxacillin 1g/6h PO; if MRSA, 200mg doxycycline STAT then 100mg/24h PO) If signs of systemic upset or coexisting disease (DM, IHD, PVD) – admit for short course IV abx (flucloxacillin 1g/gh IV; if MRSA, vancomycin 1g/12h IV). If profoundly unwell – request senior help and consider necrotising fasciitis. Painful or restricted eye movement, proptosis or visual disturbance --> orbital cellulitis (ophthalmology emergency).

Answer 62

Unilateral swelling and/or pain

Answer 63

Warm, red, tender, swollen limb (leg >3cm compared to other calf measured 10cm below tibial tuberosity), pitting oedema.

Answer 64

Age >60 yrs, obesity, recent surgery/immobility/long distance travel, oestrogen (pregnancy, HRT, OCP), PMH or FH of PE/DVT, malignancy, thrombophilia, medical comorbidity (CCF, IBD, active inflammation)

Answer 65

``` Active cancer (or last 6 mths) Leg paralysed or in plaster Recent bed rest >3d or major surgery within 12wks Previous documented DVT Visible collateral superficial veins (not varicose) Pitting oedema Tenderness along veins Whole leg swollen >3cm calf swelling ``` 1 point for each – subtract 2 points if there is another diagnosis more likely (e.g. cellulitis).

Answer 66

<1 = unlikely (5.5%) – D-dimer, if +ve --> USS; if -ve, unlikely to be DVT. >2 = likely (28%) – arrange USS; LMWH if delay in USS >4h If score >2 but USS -ve, arrange D-dimer – if +ve, repeat USS in 6-8 days.

Answer 67

Bloods – FBC, U+E, D-dimer (if indicated). | ECG/ABG – if suspected PE

Answer 68

Commence parenteral anticoagulation (enoxaparin 1.5mg/kg/24h SC) if USS +ve or delayed >4 hours. If confirmed DVT, start oral anticoagulation.

Answer 69

PE, post-thrombotic syndrome (chronic pain and swelling)

Answer 70

Monoarticular in 90% - great toe, MTP, ankle, knee.

Answer 71

Acute onset painful joint, +/- fever, ↓RoM.

Answer 72

Swollen, hot, tender, red, painful joint. | Chronic = tophi (white/yellow or skin coloured nodules of urate) over Achilles, elbow, knee or ear.

Answer 73

Age, male sex, thiazide diuretics, red meat, alcohol.

Answer 74

Exclusion - Exclude septic arthritis Bloods - ↑WCC/ESR/CRP Diagnosis - Joint aspiration - -ve birefringent needle-shaped crystals X-ray = normal

Answer 75

Acute attack – rest, high fluid intake, reduce thiazides, alcohol and red meat. NSAIDs (diclofenac 50mg/8h PO) or steroids (pred 40mg/24h PO for 3 days then tapered over 3 wks). Chronic = allopiurinol (not in acute attack)

Answer 76

Single knee or hip

Answer 77

Staphylococci, Strep Pyogenes; Gram -ve bacilli or fungi in elderly or debilitated; TB.

Answer 78

Acute onset painful joint, swelling, fever

Answer 79

Swollen, hot, tender, red, painful joint, often held slightly flexed, ↓RoM

Answer 80

Joint disease, prosthetic joint, immunosuppression, age, DM, trauma.

Answer 81

Bloods - ↑WCC, CRP and ESR, +ve blood culture Joint Aspiration - ↑WCC, organisms on gram stain, +ve culture X-ray – as baseline

Answer 82

Analgesia + urgent orthopaedic referral High dose IV abx for >6 weeks (co-amoxiclav 1.2g/8h IV) after diagnostic joint aspiration. May require repeated aspiration/surgical washout.

Answer 83

Joint destruction, secondary arthritis, septicaemia

Answer 84

Episodic breathlessness, dyspnoea and wheeze, night or morning cough, excess sputum; triggers may include exercise, NSAIDs, β-blockers, allergens, cold. FH or personal Hx of atopy (hayfever, eczema, asthma).

Answer 85

Wheeze, prolonged expiration, tachypnoea, hyperinflated chest

Answer 86

PEFR – reduced in acute setting compared with best or predicted based on age/height. ABG – normal or ↓PaO2 with a ↓PaCO2 due to hyperventilation – beware normal/rising CO2 --> ?pt tiring CXR – hyperexpanded, exclude pneumonia and pneumothorax

Answer 87

Incomplete sentences, PEFR <50% of best, HR >110, RR >25

Answer 88

PEFR <33% of best, silent chest, sats <92%, PaO2 <8kPa, normal PaCO2, poor respiratory effort, exhaustion, cyanosis, altered GCS, arrhythmia

Answer 89

CO2 retention – CALL ICU

Answer 90

Sit up – give 15L/min O2. Salbutamol 5mg NEB +/- ipratropium 500mcg NEB and prednisolone 40mg PO (or hydrocortisone 200mg IV) – drive nebuliser mask from O2 supply, not air. Repeat salbutamol 2.5mg nebs every 10-15 mins + reassess PEFR/sats. If not improving… - Senior help - Consider ICU input - Aminophylline 5mg/kg IV bolus over 20min - Mg2+ sulphate 2g (8mmol) IV over 20 mins Admit if PEFR <75% predicted after 1 hour – gradually reduce O2 and change nebs to inhalers over several days.

Answer 91

Breathlessness, cough, ↑sputum, tight chest, confusion, ↓exercise tolerance

Answer 92

Wheeze, cyanosis, barrel-chested, poor expansion, tachypnoea

Answer 93

ABG – compare with previous samples and pay close attention to FiO2; repeat after 30 mins in seriously ill patients. CXR – hyperextended, flat diaphragm (look for evidence of infection, pneumothorax or bullae)

Answer 94

Sit patient up and given patient minimum amount of O2 to maintain sats >88% (PaO2 8kPa). Salbutamol 5mg +/- ipratropium 500mcg nebs (drive by air, leave nasal cannula on under mask if necessary) and prednisolone 30mg PO (or hydrocortisone 200mg IV). Sputum for M, C + S. Use ABG results to guide further treatment Normal (for them) – continue current O2 and give regular nebs Worsening hypoxaemia - ↑FiO2, repeat ABG <30 min, watch for confusion which should prompt a repeat ABG sooner; consider NIV. ↑CO2 retention or ↓GCS – request senior help urgently – consider ICU input, aminophylline 5mg/kg IV bolus over 20 mins, NIV. Antibiotics Consider if patient has increase SoB, fevers, worsening cough, purulent sputum, or focal changes on CXR. Doxycycline 200mg PO loading then 100mg/24h PO or amoxicillin 500mg/8h PO.

Answer 95

Cough, increased sputum (coloured), pleuritic chest pain, breathless, haemoptysis, fever, unwell, confusion, anorexia

Answer 96

↑temp, ↑RR, ↑HR, ↓sats, unequal air entry, reduced expansion, dull percussion, bronchial breathing

Answer 97

CURB-65 ``` Confusion Urea >7mmol/L RR >30/min Blood pressure <90 or DBP <60 Age >65 yrs ```

Answer 98

``` 0-1 = Low severity - Risk of death <3% 2 = Moderate severity – Risk of death 9% 3-5 = High severity – Risk of death 15-40% ```

Answer 99

Step pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae. Staph Aureus, Maroxella catarrhalis, Chlamydia. Viruses 15%.

Answer 100

Gram -ve enterobacteria (pseudomonas, klebsiella, E.coli), S.Pneumoniae, S.Aureus (+ MRSA).

Answer 101

Bloods - ↑WCC, neutrophils, CRP Blood Cultures – if CURB-65 >2 Sputum Cultures – if CURB-65 >3 ABG - ↓PaO2 (↓PaCO2 due to hyperventilation but not if tiring or COPD) CXR – may show focal consolidation; repeat at 6wks if ongoing symptoms or high risk for malignancy.

Answer 102

Sit up + give O2 as required. Give Abx according to local guidelines. Look for dehydration and give IV fluids. Most can be switched to PO abx by day 3. If symptoms not resolving, repeat CRP + CXR to exclude pleural effusion/empyema.

Answer 103

CAP, CURB65 = 1 Amoxicillin 500mg-1g/8h PO CAP, CURB65 = 2 Amoxicillin 1g/8h PO/IV + clarithromycin 500mg/12h PO/IV CAP, CURB65 >3 Co-amoxiclav 1.2g/8h PO/IV + clarithromycin 500mg/12h PO/IV HAP Co-amoxiclav 1.2g/8h IV (if severe, Tazocin 4.5g/8h IV)

Answer 104

Breathlessness +/- chest pain

Answer 105

Hyper-resonant and reduced air entry on affected side, tachypnoea, may have tracheal deviation or fractured ribs. TENSION PNEUMOTHORAX Hypotensive, tachycardic, tachypnoeic, unilateral hyperresonance and reduced air entry.

Answer 106

Primary (Spontaneous) Thin, tall, male, Marfan’s, recent central line, pleural aspiration or chest drain Secondary (In presence of lung disease or injury) COPD, asthma, infection, trauma, mechanical ventilation

Answer 107

CXR – lung markings not extending to the peripheries, line of pleura seen away from peripheries.

Answer 108

Sit up and give 15 L/min O2. Primary If >2cm/breathless – aspirate with 16-18G cannula --> chest drain/discharge. Secondary If >2cm/breathless – chest drain + admit If 1-2cm – aspirate + admit Everyone else – admit, high flow O2, observe for 24 hours.

Answer 109

Sit up and give 15 L/min O2. Treat prior to CXR Insert grey/orange cannula into 2nd intercostal space, midclavicular line. Listen for a hiss and leave it in situ; insert a chest drain on the same side. If no hiss, leave cannula in situ and consider placing a 2nd cannula or alternative diagnosis.

Answer 110

Often no symptoms except breathlessness; may have pleuritic chest pain, haemoptysis, dizziness, leg pain.

Answer 111

↑JVP, ↑RR, ↑HR, ↓BP, RV heave, pleural rub +/- pyrexia. Tachycardia and tachypnoea may be only clinical signs.

Answer 112

Signs/symptoms of DVT - 3 PE most likely clinical diagnosis - 3 HR > 100 - 1.5 >3d immobilisation or surgery in past 4 weeks - 1.5 Previous DVT/PE - 1.5 Haemoptysis - 1 Malignancy (current treatment or in past 6 months or palliative) - 1

Answer 113

``` <4 = low risk – test for D-dimer. If elevated --> CTPA. >4 = high risk. Proceed to CTPA (with LMWH if scan can’t be done immediately ```

Answer 114

``` Age <50 years Pulse <100 BPM SaO2 >95% on room air No haemoptysis No exogenous oestrogen use No prior VTE No surgery or trauma requiring hospitalisation in past 4 weeks No unilateral leg swelling ``` If all criteria negative and pre-test probability <15%,, PE can be ruled out.

Answer 115

D-dimer – raised in many situations, whilst normal D-dimer must be interpreted in clinical context. ECG – sinus tachy, RBBB, inverted T waves V1-V4 or S1Q3T3. ABG - ↓CO2 +/- ↓O2 if large CT-PA – definitive imaging modality V/Q scan – may be used e.g. in renal failure

Answer 116

Acute Sit up (unless ↓BP) and give 15 L/min O2. If life threatening seek immediate senior support, arrange urgent CT-PA +/- echo and consider thrombolysis. Otherwise, parenteral anticoagulation (enoxaparin 1.5 mg/kg/24h SC) and pain relief; IV fluids if hypotensive. ``` Chronic Oral anticoagulation (warfarin – INR 2-3) for at least 3 months. ```

Answer 117

Dyspnoea, orthopnoea, PND, frothy sputum, coexistent dependent oedema or previous heart disease.

Answer 118

↑JVP, tachypnoea, fine inspiratory basal crackles, wheeze, pitting cold hands and feet; oedema (ankles and/or sacrum) suggests right heart failure

Answer 119

Bloods – look for anaemia, infection or MI; FBC, U+E, CRP, cardiac markers; BNP (normal levels unlikely in cardiac failure) ABG – may show hypoxia ECG – exclude arrhythmias and acute STEMI, may show old infarcts, LV hypertrophy or strain CXR – cardiomegaly (not if AP projection), signs of pulmonary oedema Echo – poor LV function/ejection fraction

Answer 120

Acute Sit up and give 15 L/min O2. If attack is life threatening call an intensivist early as CPAP and ICU may be required. Monitor HR, BP, RR and O2 sats whilst giving furosemide 40-120mg IV +/- diamorphine (repeat every 5 minutes up to 5mg max, watch the RR). If further treatment required, be guided by blood pressure: Systolic >100 – give 2 sprays of sublingual GTN followed by IV nitrate infusion (e.g. GTN starting at 4mg/h and increasing by 2mg/h every 10 min – aiming to keep systolic >100) Systolic <100 – patient is in shock, probably cardiogenic. Get senior help as inotropes required. Do not give nitrates. Wheezing – treat as for COPD alongside above treatment No improvement – Give furosemide up to 120mg total (more if chronic renal failure) and consider CPAP. Insert urinary catheter to monitor urine output +/- CVP monitoring. Request senior help. Consider HDU/ICU.

Answer 121

Central, crushing, heavy chest pain (>20 mins) +/- radiating to left arm/jaw, shortness of breath, nausea, sweating, palpitations, anxiety

Answer 122

Examination | Tachycardia, cool and sweaty (‘clammy’) +/- LV failure or hypotension

Answer 123

Smoking, obesity, DM, hypertension, hypercholesterolaemia, FH, previous IHD

Answer 124

ECG – ST elevation (>1mm in 2 or more contiguous limb leads or >2mm in chest leads) or new LBBB; subsequent Q waves +/- T wave inversion CXR – cardiomegaly, signs of LV failure Cardiac Markers – will be raised but treatment should not be withheld as ECG findings and history alone are sufficient to make diagnosis

Answer 125

GOAL = PCI within 12 hours of onset of symptoms – seek senior help. O2 – 15 L/min Aspirin – 300mg Clopidogrel – 300mg Diamorphine – 2.5-5mg IV Antiemetic GTN – two puffs SL/5min until pain free; infusion if ongoing pain after 3 SL doses provided not hypotensive B-blockade – bisoprolol 10mg/PO – limits infarct size and reduces mortality but avoid in COPD, hypotension and overt failure.

Answer 126

Dysrhythmias (AV block, bradycardia, VF/VT), LVF, valve prolapse, ventricular septal rupture, ventricular aneurysm formation, pericarditis, Dressler’s syndrome, recurrent pain

Answer 127

Similar to STEMI; patients usually older, with more co-morbidities.

Answer 128

ECG – ST depression, inverted T waves; subsequent evolution of changes +/- T wave inversion CXR – cardiomegaly, signs of LV failure Cardiac Markers – differentiate from unstable by elevated troponin – taken on presentation and 12 hours after worst pain.

Answer 129

``` O2 – 15 L/min Aspirin – 300mg Clopidogrel – 300mg Diamorphine – 2.5-5mg IV Antiemetic GTN – two puffs SL/5min until pain free; infusion if ongoing pain after 3 SL doses provided not hypotensive Anticoagulation – with fondaparinux β-blockade – bisoprolol 10mg/PO – limits infarct size and reduces mortality but avoid in COPD, hypotension and overt failure. ```

Answer 130

Scoring algorithms – Thrombolysis in Myocardial Infarction (TIMI) risk score, The Global Registry of Acute Coronary Events (GRACE) algorithms. Risk scores can be calculated on admission (to predict in hospital and 6 month mortality) or on discharge (to predict 6 month mortality). High-risk – need a CCU, bed, consideration for GP IIb/IIIa inhibitors and urgent catheterisation (within 96hrs) Low/Intermediate risk – require risk observation to ensure pain free, then further stratification using exercise ECG, coronary calcium scoring or stress imaging to determine need for cathterisation.

Answer 131

Overlap with other forms of ACS; typically, episodes of angina occurring on minimal provocation or at rest, with poor response to GTN; more frequent and more severe pain than patient’s ‘usual’ angina; few symptoms or signs between episodes of pain. Diagnosis is based upon typical history in presence of ECG changes, but without subsequent elevation of cardiac markers.

Answer 132

ECG – ST depression, flat or inverted T waves with dynamic changes over time, signs of previous MI. Cardiac Markers – not elevated

Answer 133

Same as NSTEMI.

Answer 134

Sudden onset severe chest pain, anterior or interscapular, tearing in nature, dizziness, breathlessness, sweating, neurological deficits.

Answer 135

Unequal radial pulses, tachycardia, hypotension/hypertension, difference in brachial pressures >15 mmHg, aortic regurgitation, pleural effusion (L>R), neurological deficits from carotid artery dissection,

Answer 136

Smoking, obesity, DM, ↑BP, ↑cholesterol, FH, previous IHD

Answer 137

ECG – may be normal or show LV strain/ischaemia CXR – classically widened mediastinum >8cm (rarely seen), irregularity of aortic knuckle and small left pleural effusion can develop from blood tracking down. Echo – May show aortic root leak, aortic valve regurgitation or pericardial effusion. Also consider MRI/CT/conventional angiography.

Answer 138

Seek senior help. If hypotensive, treat as shock – O2 15 L/min, two large bore cannulae, X-match 6 units, analgesia (IV opioids). If hypertensive, aim to keep systolic BP <100 mmHg – oral therapy with ACEi or CCB. Further treatment = surgery (type A – ascending aorta) or conservative management (type B – only descending aorta)

Answer 139

12-36h post-alcohol; anxiety, shaking, sweating, vomiting, tonic-clonic seziures. 3-4d post-alcohol; delirium tremens may develop; coarse tremor, confusion, delusions, hallucinations (untreated mortality 15%)

Answer 140

Hypertension, tachycardia, pale, sweaty, tremor, hypoglycaemia, delirium tremens, pyrexia.

Answer 141

Bloods – may have ↓Mg2+, ↓PO3-4 or ↓urea.

Answer 142

Monitor patients with significant alcohol history for withdrawal. Prescribe reducing dose of chlordiazepoxide (benzo; correct electrolyte abnormalities; give vitamin replacements PO (thiamine 25mg/24h an vitamin B one tablet/24h) or IV (Pabrinex 2 pairs/8h IV for 5 days – a high-potency combination of B and C vitamins – may sometimes cause anaphylaxis). Monitor BP and blood glucose. Withdrawal seizures usually self-limiting.

Answer 143

Asymptomatic, dizziness (+/- on standing), palpitations, shortness of breath, +/- chest pain.

Answer 144

↓BP (and potentially ↓GCS), cannon waves in ↑JVP (due to asynchronous contraction of right atria against closed tricuspid valve), signs of heart failure, features of underlying disease.

Answer 145

Underlying ischaemic damage (typically after inferior MI); also post cardiac surgery, drug induced (B-blockers, Ca2+ channel blockers), amyloid, saecoid, myeloma, infective (Chagas, Lyme).

Answer 146

ECG – complete dissociation of P waves from QRS complexes; narrow QRS implies proximal lesion (may respond to atropine). Broad complex implies distal lesion (less likely to respond to atropine). Look for evidence of MI. Bloods – FBC, U+E, Ca2+, Mg2+. TFT, cardiac markers, coagulation (if considering pacing wire) CXR – unlikely to be helpful in immediate resuscitation phase.

Answer 147

If symptomatic (dizzy or GCS <15) or systolic <90mmHg… - Monitor HR on defibrillator - Lay flat with legs elevated - O2 supplementation - Secure IV access and take bloods. - Call senior help/Arrest team Titrate 500mcg atropine IV every 2-3 mins (max of 3mg), followed by large flush, until HR improves. Identify and correct precipitant. Consider external pacing/pacing-wire via central line; a rhythmical precordial thump (percussion pacing) can be used in extremis when external pacing machine not available.

Answer 148

Severe bradycardia and high vagal tone can deteriorate into asystole so prompt treatment required. Remember to talk continuously to the patient and/or check for a pulse because pulseless electrical activity (PEA) is common and ECG trace may not change.

Answer 149

‘Osmotic symptoms’ – (thirst, polyuria, frequency, urgency) – tiredness, weight loss, vomiting, rashes, breathlessness, cough, sputum, chest pain, abdo pain, dysuria.

Answer 150

Temp, RR, GCS, recent and current blood glucose, fluid balance. Look for: volume status, sweet smelling breath (ketones).

Answer 151

1. Presence of hyperglycaemia (>11mmol/L) 2. Acidosis (venous pH <7.3) 3. Blood ketones >3mmol/L or ketonuria (>++)

Answer 152

0.9% saline is most appropriate in DKA. In adults – 1L over 1 hour, another 1L over 2 hours, another 1L over 3 hours, another 1L over 4 hours. Fluid challenge if SBP <90 – reassess frequently for signs of fluid overload.

Answer 153

ABCDE - 15L/min O2 if SoB or sats <94% - Call for senior help - Establish venous access – take bloods. FBC, U+E, glucose, osmolarity, HCO3-, blood cultures - Check BP - If SBP <90 – fluid challenge (0.9% saline), then recheck. - If SBP <90, further fluid challenge and call ICU/critical care teams. - If SBP >90, give 1L 0.9% saline IV over 60 mins. - Check finger-prick glucose and ketones (dipstick urine for ketones if capillary testing unavailable). - Start a fixed rate insulin infusion of 0.1 unit/kg/hr IV (use 50 units human soluble insulin e.g. Actrapid in 50ml 0.9% saline. - VBG – if pH <7.1, call ICU/critical care team. - Monitor glucose and ketones hourly, and venous HCO3-, K+ and pH at 60 min and 2 hourly thereafter; K+ will fall unless replaced. Further management – ECG, CXR, MSU – to determine cause. Reassess – ABCDE. Continue insulin infusion until ketones<0.3mmol/L and pH >7.3. At this point convert to regular SC insulin if eating and drinking normally, otherwise using a sliding scale.

Answer 154

Heart/renal failure GCS <12, sats<92% SBP <90 Young people, elderly, comorbities or pregnancy Ketones >6mmol/L, HCO3- <5mmol/l, pH <7.1 K+ <3.5mmol/L, anion gap >16

Answer 155

Severe, uncorrected hyperglycaemia leads to dehydration (volume depletion + haemoconcentration --> further increase in blood glucose level), but in the presence of residual insulin production in T2DM, ketoacidosis does not develop – (insulin inhibits hormone-sensitive lipase-mediated lipolysis).

Answer 156

``` Raised plasma osmolarity (>340 mOsmol/kg) High glucose (>30mmol/L) ```

Answer 157

‘Osmotic symptoms’ – (thirst, polyuria, frequency, urgency) – tiredness, weight loss, vomiting, rashes, breathlessness, cough, sputum, chest pain, abdo pain, dysuria.

Answer 158

Insulin overdose, oral hypoglycaemia overdose, sepsis, alcohol excess, acute liver failure

Answer 159

ABCDE - O2 15 L/min if SoB or sats <94% - Call for senior help - Establish venous access, take bloods: FBC, U+E, glucose, osmolarity, blood cultures - Give 1L 0.9% saline IV over 30 mins - Check finger-prick glucose. Start a sliding scale if glucose still raised after 1h of fluids and potassium is sufficiently high. - Monitor U+E and glucose - Further management – ECG, CXR, MSU to determine cause - Reassess – ABCDE Continue IV fluid replacement (at half rate used in DKA) – over 24 hours. Electrolyte replacement – severe potassium deficits. Monitor U+E 2 hourly – hyperglycaemia will drive redistribution of water into extracellular fluid (intravascular), lowering serum Na+ concentrations (‘spurious hyponatraemia’). Convert to insulin/oral hypoglycaemics when glucose <12mmol/L.

Answer 160

Dizziness on standing (+/- lying), SoB +/- chest pain Symptoms of underlying disease = trauma to chest, limb, abdo, pelvis, pain/melena/haematemasis, diarrhoea, frequency, epigastric pain to back, abdo swelling/bloating

Answer 161

BP <100mmHg systolic, ↑HR, weak/thready pulse, postural hypotension, cool peripheries/CRT >2s, ↓JVP, ↓GCS/restlessness, oliguria, mottled skin in severe hypotension

Answer 162

Haemorrhage Salt + water loss 3rd space loss

Answer 163

Bloods – FBC (↓Hb, may be normal early in acute blood loss), U+E (↑urea in GI bleed, ↓K+ in D+V), LFT, amylase, clotting, osmolalilty, cross-match ABG – acidosis in haemorrhage, DKA and pancreatitis; alkalosis in vomiting ECG – ischaemia CXR - haemothorax Pelvic X-ray – pelvic fracture Abdo USS/CT – AAA (though if ruptured may need theatre before imaging) or free intra-abdominal fluid Urine – Na+ and osmolality in diabetes insipidus Stool – M, C + S

Answer 164

I - up to 750ml II - 750-1500ml III - 1500-2000ml IV - >2000ml

Answer 165

CALL SENIOR HELP ABCDE * Lay flat and elevate legs * O2 15 L/min; IV access + take bloods * 1L 0.9% saline STAT; attempt to stop bleeding by compression if appropriatel further 1L 0.9% saline STAT if no ↑BP or ↓HR * Consider urgent blood transfusion (O -ve, type specific or full X-match) * Identify likely cause of haemorrhage * Seek involvement of surgeons/ICU * Do not push systolic BP >100mmHg * Monitor response

Answer 166

Type I hypersensitivity reaction via IgE. Mast cell and basophil degranulation --> increased vascular permeability, bronchial smooth muscle contraction and myocardial dysfunction. Sites of treatment = immunosuppression, anti-histamine, α and β(2) adrenoreceptor agonism,

Answer 167

Chest tightness, wheeze, breathlessness, itching, swelling, anxiety/fear/agitation, GI disturbance (vomiting, abdominal pain, diarrhoea) – usually with 30 mins of exposure

Answer 168

Urticaria, bronchospasm/stridor, vomiting and/or diarrhoea, flushing, abdominal pain, sense of impending doom, hypotension, tachycardia, tongue/periorbital swelling, wheeze, cyanosis

Answer 169

Drugs – penicillins, anaesthetic drugs, contrast media, blood products Environmental – latex, stings, eggs, fish, strawberries, nuts

Answer 170

CALL FOR SENIOR HELP ABCDE * O2 15 L/min via NRBM * IV access + bloods (if have time) * Adrenaline 1:1000 solution 0.5mg (0.5ml) IM stat * IV fluid 500-1000ml crystalloid Hydrocortisone 200mg IV slowly Chlorphenamine 10mg IV slowly Salbutamol 5mg neb PRN Consider referral to ICU

Answer 171

Adrenaline - vasoconstriction + reduces oedema (alpha) bronchodilation and increases CO (beta) Hydrocortisone - prevents T cell proliferation Chlorphenamine - inhibits vasodilation and bronchoconstriction Salbutamol - bronchodilation

Answer 172

Fever, BP <100mgHg systolic, tachycardia +/- bounding pulse, warm peripheries, ↓JVP, ↓GCS, oliguria, mottled skin in severe hypotension Cellulitis, non-blanching petechial rash (meningococcal septicaemia), chest creps (pneumonia), abdominal/loin/suprapubic tenderness (intra-abdominal infection)

Answer 173

``` Skin/soft tissues - cellulitis/gangrene Intra-abdominal perforation; biliary tract Chest pnuemonia Urinary tract UTI; pyelonephritis Heart endocarditis Post-op wound infection; bowel leak ```

Answer 174

``` Within 1st hour • Blood cultures (before administration of abx) • Urine output • Fluid resuscitation • Antibiotics (broad spec) • Lactate • Oxygen ```

Answer 175

Bloods – FBC (↑WCC +/- ↓Hb), U+E, LFT, ↑CRP/ESR, glucose, clotting/fibrinogen, procalcitonin Blood cultures – at least 2 sets from different sites, plus additional cultures from any central lines ABG – acidosis, ↓BE, ↑lactate ECG – ischaemia Urine dipstick – blood, protein, nitrates, leucocytes, send for M, C + S Erect CXR – consolidation, free air under diaphragm Culture – skin/wound swabs, sputum Echo – valvular lesion/vegetation if suspect endocarditis

Answer 176

Call senior help ABCDE * Lay flat and elevate legs * O2 15 L/min; IV access + take bloods * 1L 0.9% saline STAT – repeat if no ↑BP or ↓HR – 30ml/kg crystalloid boluses until lactate <4mmol/L, systolic BP >90mmHg and MAP >65mmgHg * Give IV abx appropriate to likely source of infection * Consider central line to measure CVP and arterial line for serial ABGs an invasive BP monitoring * Seek involvement of ICU as may need inotropic/ventilatory support

Answer 177

Mechanism of injury, time of injury, loss of consciousness, seizures, memory (before, during and after), blood/fluid from nose or ears, vomiting, weakness/numbness/tingling in limbs, time of last meal, dizziness, visual changes, headache Are they on anticoagulants?

Answer 178

GCS, orientation, CSF leaking from ears (otorrhoea) or ears (rhinorrhoea), Battle’s sign (bruising over mastoid process; late sign), blood behind eardrum (haemotympanum), ‘panda’ eyes (bruising around eyes), focal neurology (e.g. weakness or numbness). If head injury caused by fall, think about what precipitated fall (?dysrhythmia, hypoglycaemia, postural hypotension).

Answer 179

GCS, HR, BP, RR, glucose

Answer 180

SENIOR HELP - bleep anaesthetist immediately if unconscious | ABCDE - follow NICE flowchart for CT

Answer 181

GCS <13 on assessment or <15 after 2 hours Suspected skull fracture Signs of basal skull fracture Post-traumatic seziure Focal neurological deficit More than one episode of vomiting since injury If none of these - are they on warfarin?

Answer 182

Venous bleed into skull; can be acute (↓GCS and ↑ICP, usually post-trauma) or chronic (fluctuating consciousness over days in e.g. elderly, alcoholics, patients on anticoagulation). CT diagnosis; drained by craniotomy or burr hole.

Answer 183

Arterial bleed into skull often from middle meningeal artery after trauma. Initially well but ↓GCS over 4-8h as blood collects. CT diagnosis; drained by craniotomy or burr hole.

Answer 184

Patients may have concussion symptoms for months after a head injury, e.g. headaches, tiredness, depression, memory problems.

Answer 185

Most likely = idiopathic, epilepsy, alcohol withdrawal, hypoglycaemia, hypoxia, trauma. Other = kidney or liver failure, pseudoseizures, overdose (tricyclics, phenothiazines, amphetamines) Non-seizure = brief limb jerking during a faint, syncope, arrhythmias.

Answer 186

``` Hypoxia/cardiac disease Hypoglycaemia Metabolic (↓Ca2+, ↑Na+) Trauma Meningitis, encephalitis, malaria ↑ICP and CVA Drug overdose Hypertension/eclampsia ```

Answer 187

Bloods – FBC, U+E, LFT, glucose, Ca2+, Mg2+, blood cultures, anticonvulsant levels. ABG – if hypoxia or metabolic upset suspected Urine – consider drug screen, β-hCG if pre-menopausal and female. ECG – to exclude dysrhythmia CT – may show a focal lesion, ↑ICP, haemorrhage or infarction. Perform as urgent if the patient has a persistent GCS <15 post-fit, focal neurology or if seizure was <4d post trauma MRI – is neuroimaging of choice in suspected epilepsy LP – if meningitis or encephalitis suspected EEG – may help to exclude encephalitis or as out-patient investigation for epilepsy

Answer 188

ABCDE * If no respiratory effort/no palpable pulse – call arrest team * If GCS <8 – call anaesthetist Call for senior help if seizure >5 min. All timings from start of first fit; clock only restarts once patient has been fit free for >30 mins. Stop the seizure using below pathway. Correct any metabolic upset (glucose, Mg2+, Ca2+, Na+) and exclude life-threatening causes whilst trying to establish cause. Secure airway if still fitting or GCS <8.

Answer 189

* Start timing * 15 L/min O2 via NRBM * Keep patient safe and put into recovery position if possible * Monitor HR, O2, sats, BP, cardiac trace, temp * Venous access (after 3-4 minutes) – take bloods o FBC, U+E, LFT, Ca2+, glucose, blood cultures, anticonvulsant levels. * Check glucose: if <3.5mmol/L give 100ml of 20% glucose STAT

Answer 190

* Call for senior help and attach cardiac monitor * Consider airway adjunct but do not force teeth apart * If IV access: lorazepam 4mg IV over 2 min, repeat at 10 min if no effect * If no IV access: diazepam 10mg PR, repeat every 10min if no effect up to 30mg total * Ask ward staff about history/check notes * If alcoholism/ malnourished give Parbinex 2 pairs IV over 10min if not already given this admission

Answer 191

Ischaemia – 85% - AF, carotid stenosis Haemorrhage – 15%

Answer 192

Posterior Circulation Strokes (POCS) Affect territory of verterbrobasilar artery (occipital lobes, brainstem + cerebellum) Anterior Circulation Strokes (TACS, PACS, LACS) Internal carotid artery territory, which supplies all the rest of the brain.

Answer 193

All of: * Motor/sensory deficit in 2 or more of face, arm or leg * Homonymous hemianopia * Higher cortical function

Answer 194

``` Either * 2 out of 3 of TACS criteria met Or * Higher cortical dysfunction alone Or * Isolated motor deficit not meeting LACS criteria ```

Answer 195

Motor and/or sensory deficit affecting 2 or more of face, arm, leg No higher cortical dysfunction or hemianopia

Answer 196

Any of: * Ipsilateral cranial nerve palsy + contralateral motor/sensory deficit * Bilateral motor/sensory deficit * Disordered conjugate eye movement * Cerebellar dysfunction * Isolated hemianopia or cortical blindness

Answer 197

Bloods – Acute - FBC, U+E, LFT, lipids, glucose, cardiac markers, clotting, G+S ECG CXR CT head – urgent if within thrombolysis window, GCS persistently low, on oral anticoagulants/known bleeding disorder, severe headache at onset of stroke or evidence of ↑ICP; otherwise within 24h. Echo/carotid Doppler/24h ECG – if anterior circulation stroke.

Answer 198

Call for senior help ABCDE * 15 L/min O2 via NRBM * Monitor O2 sats, RR, HR, cardiac trace, temp and BP * Venous access + take bloods (FBC, ESR, U+E, LFT, lipids, glucose, cardiac markers, clotting, G+S) * NBM + start IV fluids for hydration (0.9% saline at 100ml/h) * ECG looking for atrial fibrillation/arrhythmia * Take a focused history * Examine the patient (RS, CVS, abdo + neuro exam – document exact neurological deficits). * Request urgent CT scan * Consider thrombolysis OR aspirin 300mg PO STAT after CT excludes haemorrhage * Reassess - ABCDE

Answer 199

* Age <80 - <4.5 hours from start of symptoms * Age >80 - <3 hours from start of symptoms * Non-haemorrhagic stroke (excluded by CT) * Significant symptoms and not improving

Answer 200

Active bleeding, CNS trauma, neoplasms or arteriovenous malformations, previous intracerebral haemorrhage, ischaemic stroke in previous 6mths, major trauma/surgery in past 3wk, non-compressible punctures in past 24hrs (LP etc).

Answer 201

* If no thrombolysis – aspirin 300mg/24h PO/PR for 14d (provided no haemorrhage on CT) * Assess safety of swallow; if concerns, keep NBM + IV fluids and request SALT assessment. * Admit to stroke ward for early mobilisation and rehabilitation with multidisciplinary team.

Answer 202

History - Rapid onset (<2 min), severe, continuous (>2h) headache; often occipital (‘hit around back of head’), vomiting, dizziness; may have had seizures. Exam - Neck stiffness, drowsy, photophobia, focal neurology, ↓GCS

Answer 203

CT Head – URGENT LP – (>12 hours after onset) - if CT normal, as CT may miss small bleeds. Looking for xanthochromia

Answer 204

15 L/min O2 Analgesia (codeine 30mg PO or 5mg morphine IV) and anti-emetic (metoclopramide 10mg IV/IM). Refer urgently to neurosurgeon for endovascular coiling or neurosurgical clipping and consider transfer to ICU if ↓GCS. Lie patient flat and advise not to get up or eat. Reassess often and request neuro obs. Nimodipine (60mg/4h PO) prevents vasospasm and improves outcome. Keep systolic <130mmHg, using IV β-blockers, unless lethargic (suggests vasospasm; may require permissive hypertension).

Emergency Medicine Flashcards

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