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Emergency Medicine Flashcards

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1
Q

In status epilepticus what Rx should be given?

A

Lorazepam 2-4mg
10 mins
Lorazepam 2-4mg IV
Phenytoin

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2
Q

What is the definition of status epilepticus?

A

Seizures lasting 30 minutes or repeated seizures without intervening consciousness

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3
Q

Features of systemic inflammatory response syndrome? (SIRS)

A 
2 of:
HR >90
RR >20
Temp >38 or <36
WCC <4 or >11
Blood glucose >7.7 (not normally diabetic)

+ infection proven or suspected = sepsis

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4
Q

What features indicate a red flag sepsis rather than just sepsis?

A 
HR >131
RR >25
BP <90 or a fall of 40
MAP <65
on AVPU- V, P, or U

=start sepsis six

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5
Q

What is the difference between severe sepsis, red flag sepsis and septic shock?

A

Severe sepsis-objective lab evidence of end organ dysfunction:
Reduced urine output
Lactic acidosis
Rising creatinine, INR, aPTT, bilirubin
Dropping platelets

Red flag sepsis are bad signs that the sepsis six needs to be initiated
HR >130, RR >25, BP <90, MAP < 65, V/ P/ U

Septic shock is refractory hypotension

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6
Q

Summarise the Glasgow Coma Scale:

A 
M:
6- normal
5- localises
4- withdraws
3- flexes
2- extends
1- no response

V:
5- normal
4- confused
3- words
2- sounds
1- none

E:
4- normal
3- to voice
2- to pain
1- none
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7
Q

What can the respiratory pattern of a patient in a coma tell you?

A

Hyperventilation: acidosis, hypoxia, neurogenic
Cheyne-Stokes: deep and irregular, suddenly fast breathing (brainstem affected)
Ataxic/apneustic (breath holding): brainstem damage with grave prognosis

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8
Q

What do pupils indicate in a coma?

A

Normal direct + consensual reflexes: intact midbrain

Pinpoint + reactive: pons
Mid position + non reactive or irregular: midbrain
Unilateral dilated + unreactive: 3rd nerve compression
Unilateral constricted pupil: Horner’s, lateral medulla + hypothalamus, may precede uncal herniation

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9
Q

What is the ice water calorics test?

A

In comatosed patients, tests vestibulo-ocular reflex

Pour cold water into the ear, normal if eye deviates to cold side with nystagmus of other side

Indicates that brainstem from medulla to midbrain is fairly intact

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10
Q

What % blood loss is associated with different classes of shock?

A
  1. < 750mL or < 15%
  2. < 1500mL or < 30%
  3. < 2000mL or < 40% (low BP)
  4. > 2000 mL or > 40% (unreadable BP)
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11
Q

Rx for anaphylaxis:

A 
1 in 1000 0.5mL adrenaline IM 
   up to 5mLs
10mg chlorphenamine IV
200mg hydrocortisol IV
500mL saline
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12
Q

CI to thrombolysis:

A

Brain: stroke <6 months, intracranial haemorrhage or malignancy

Main: aortic dissection, major surgery/trauma

Hole: liver biopsy or lumbar puncture < 24 hours

Bowl: GI bleed < 1 month

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13
Q

Which anticoagulant is given in ACS with a STEMI or NSTEMI?

A

STEMI- bivalirudin (direct thrombin inhibitor)

NSTEMI- fondaparinux or LMWH but bivalirudin before PCI

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14
Q

Meds to write up for pulmonary oedema:

A

Furosemide 40-80mg IV
GTN 2 puffs SL
if BP >90mmHg

Isosorbide dinitrate 2-10mg/h IV
If BP >100mmHg

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15
Q

How does the use of aspirin and clopidogrel differ following MI and stroke/TIA?

A

Everyone gets Clopidogrel 75mg

But MI also gets Aspirin 75mg
Stroke has Aspirin 300mg for 2 weeks before Clopidogrel 75mg
TIA: just clopidogrel 75mg

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16
Q

Meds to write up for a haemodynamically stable broad complex tachycardia?

A

300mg Amiodarone IV (over 20 minutes)

CI if long QT

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17
Q

4 H’s + 4T’s to correct in cardiac arrest?

A

Hypoxia
Hypothermia
Hypo/hyperkalaemia/ calcaemia
Hypovolaemia

Tamponade
Tension pneumothorax
Toxins
Thrombosis

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18
Q

How are shockable and non-shockable rhythms managed differently?

A

VF + VT every 2 minutes, check rhythm + shock

After 3 shocks:
Adrenaline, then every 3-5 minutes
Amiodarone 300mg

Asystole + PEA
No shocks + adrenaline once IV access obtained

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19
Q

What adverse signs indicate synchronised DC cardioversion is required?

A

Chest pain, heart failure
Systolic BP < 90mmHg
HR > 150bpm
Ischaemia on ECG

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20
Q

Which broad complex tachycardia’s can you use synchronised DC cardioversion for vs non-synchronised DC cardioversion?

A

VT- has an R wave so synchronised

VF- no R wave, non-synchronised

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21
Q

Meds to write up for narrow complex tachycardia:

A

Vagal manoeuvres
Adenosine 6mg bolus, 12mg, 12mg

Verapamil

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22
Q

Asthmatic patient with SVT Rx:

A
  1. Vagal manoeuvres
  2. Verapamil 2.5mg over 2 mins IV (rather than adenosine)
  3. If not unstable: IV metoprolol, IV amiodarone or digoxin IV may be tried
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23
Q

What extra meds need to be given if life-threatening features of asthma present?

A

For severe asthma would have given
5mg Salbutamol, 100mg Hydrocortisone IV

For life threatening add in:
500 micrograms Ipratropium
MgS04 1.2g IV over 20 minutes

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24
Q

In exacerbations of COPD what are the indications for non-invasive positive pressure ventilation vs intubation and ventilation?

A

NIPPV: RR >30 or pH < 7.35

Intubation: pH <7.26 or PaCO2 rising

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25
Treatment for meningitis and the therapy that is not required for pure septicaemia rather than meningitis:
Rx: 2g cefotaxime + dexamethosone 4mg over 6hr IV if meningitic Not needed for septicaemia
26
How do viral and TB meningitis look different on lumbar puncture?
Viral- clear, low protein | TB- fibrinous web, high protein (bacterial walls contribute)
27
How do the causes of encephalitis differ from encephalopathy?
Encephalitis- infectious prodrome of fever, rash, lymphadenopathy etc Viral: HSV 1+2, EBV, CMV, Varicella, HIV, MMR, Jap B encephalitis TB, bacterial, malaria, listeria, Lyme, legionella, aspergillosis, cryptococcus, schistosomiasis Encephalopathy- low glucose, hepatic cencephalopthy, diabeteic ketoacidosis, hypoxic brain injury, uraemia, SLE, beri beri
28
Tests for encephalitis:
Blood cultures, viral PCR, toxo IgM titre, thick + thin blood films Contrast enhanced CT Lumbar puncture Urgen EEG- diffuse abnormalities
29
What are the indications for immediate CT head vs CT head within 8 hours of injury?
``` Immediate: GCS <13 GCS <15 after 2 hours post injury Vomited more than once Focal neurology Post-trauma seizure Open or depressed skull fracture Basal skull fracture signs- panda eyes, battle sign, CSF leak ``` In 8 hours if loss of consciousness or amnesia with any RF: Age 65 + Clotting disorders or anti-coagulated Dangerous mechanism of injury- fall, RTA 30 minutes retrograde amnesia (before the accident) If any head injury and warfarin: CT within 8 hours
30
What are the three types of cerebral hernia that may occur:
Uncal herniation: uncus of the temporal lobe gets pushed through the tentorium putting pressure on the midbrain Signs- CN III palsy, hemiparesis, coma Cerebellar tonsil: cerebellar tonsils through foramen magnum Signs- ataxia, 6th nerve palsy, upgoing plantars, irregular breathing, coma Subfalcian herniation: median frontal lobe (cingulate gyrus) forced under falx cerebri Signs- silent or anterior stroke
31
How is plasma osmolarity determined?
GUNN Glucose + urea + 2[Na]
32
Signs of severe DKA:
EHx: GCS <12 Obs: O2 sats <92%, HR >100 or <60, BP <90 IHx: pH below 7.1, bicarb <5, anion gap >16, K+ < 3.5 on admission GCS <12 Dehydrated
33
What are the exact parameters of DKA?
Glucose > 11 PH < 7.3 Bicarbonate < 15 Ketones > 3 or ++ on dipstick
34
Management of hypoglycaemia? | Which patient group won't this work in?
Oral glucose drink 10% dextrose IV Glucagon 1mg IV/IM won't work in drunk patients (no sugar reserve)
35
What is hyperosmolar hyperglycaemic state and what are the dangers of it?
Type 2 diabetics, over 1 week who can't switch on ketosis Dehydrated, glucose >35, osmolality >350 Hyperviscosity + occlusion: focal CNS signs, chorea, DIC, leg ischemia, rhabdo Hydrate slowly, gradual K+ add in
36
Rx for thyroid storm:
1. Propranolol or short acting b-blocker if low CO 2. Carbimazole 3. Lugol's solution (high iodine blocks T4 release) 4. Hydrocortisone prevents T4 conversion to T3
37
Meds to write up for phaeochromocytoma:
IV a blocker: phentolamine 2-5mg (Short acting) PO a blocker: phenoyxbenzamine 10mg (Long acting, once BP controlled) B1 blocker (atenolol, metoprolol)
38
Meds to write up for hyperkalaemia:
10mL 10% calcium gluconate 10 units actrapid in 50mL of 20% glucose Saline 500mL over 30 minutes
39
When is dialysis needed urgently in hyperkalaemia:
Refractory hyperkalaemia or patient remains oligouric Refractory pulmonary oedema Uraemic complications (pericarditis) Severe acidosis <7.2
40
Name 3 drugs that cause an irregular pulse if OD-ed on:
1. Salbutamol (B1 agonist) 2. Antimuscarinics 3. Tricyclics (anticholinergic actions, reduces parasympathetic input)
41
2 drugs that cause respiratory depression and how an overdose of each may be distinguished:
Opiates: constricted pupils Benzodiazepines
42
Drug overdoses that will result in dilated pupils:
Cocaine Amphetamines Tricyclics (anticholinergic)
43
Drug overdoses that cause metabolic acidosis:
Alcohol, ethylene glycol, methanol Paracetamol, salicylates (respiratory alkosis initially) CO poisoning, cyanide (binds Fe in cytochromes preventing aerobic respiration)
44
Which overdoses are likely to require haemodialysis?
Ethylene glycol, methanol Lithium, sodium valproate Salicylates Phenobarbitol
45
Antedote for benzodiazepines:
Flumazenil | Suspect if respiratory depression
46
Antedote for beta blockers:
Indications: severe bradycardia or hypotension Atropine 3mg IV Consider glucagon, phosphodiesterase inhibitors or pacing
47
Rx for moderate to severe cyanide poisoning:
100% oxygen (cyanide binds Fe, preventing aerobic respiration) Sodium nitrite/sodium thiosulfate Also 50% glucose or hydrocobalamin
48
When are digoxin-specific antibody fragments indicated for digoxin poisoning:
Serious arrhythmias | Correct hypokalaemia's first
49
Antidote for opiates:
Naloxone, repeating every 2 minutes until breathing is adequate May precipitate diarrhoea + cramps as it precipitates opiate withdrawal- may need atropine + diphenoxylate (form of opioid) or methadone
50
Management of phenothiazine poisoning (like chlorpormazine antipsychotic) + signs of it:
Signs: dystonia, torticollis, opisthotonus Procyclidine ``` If neuroleptic malignant syndrome hyperthermia, rigidity, extrapyramidal signs, mutism autonomic dysfunction- sweating, labile BP, urinary incontinence Confusion High WCC + CK ``` Rx: cool + dantrolene can help
51
Why does salicylate overdose have the effects it does?
It uncouples oxidative phosphorylation causing anaerobic metabolism Like you've exercised too much: sweating, vomiting, dehydration Resp alkalosis- due to direct stimulation of central respiratory centres Vertigo + tinnitus
52
Rx of salicylate poisoning:
IV fluids If plasma salicylate >500mg/L or severe metabolic alkalosis: Alkalinize urine with sodium bicarbonate IV If plasma salicylate >700 or AKI/HF or pulmonary oedema, seizures, confusion, severe acidosis: Dialyse
53
Patient has dropped GCS and become confused and weak after 3L of 5% dextrose, what blood test is it important to check?
U+Es As glucose is used, a hypotonic solution is left, diluting Na+ levels, may be hyponatraemic Need to exclude pseudohyponatraemia causes: high glucose, high lipids or protein
54
What three tests help delineate cause of hyponatraemia?
Tonicity = 2Na + glucose + urea Isotonic- hyperlipidaemia or high protein Hypertonic- high glucose Hypotonic- true low sodium Then need volume status + urine Na/osmolality to delineate hypotonic causes
55
Patient is hypotonic (2Na + urea + glucose), what are the causes in a hypovolaemic, euvolaemic and hypervolaemic patient?
Hypovolaemia + pissing Na: Addison's, diuretics, raised glucose Hypovolaemia + not pissing Na: Extra-renal loss like burns, D+V, fistulae, CF Euvolaemia + concentrated urine: SIADH, diuretics Euvolaemia + dilute urine: Hypothyroid, low cortisol, Beer potomania/psychogenic polydipsia Hypervolaemia: The failures- heart, kidney, liver
56
If trying to correct hyponatraemia, what rate of Na+ increase should not be exceeded?
15mmol in a day if chronic low Na Or 1mmol/L per hour if acute low Na Risk of central pontine myelinolysis = subacute lethargy, confusion, psuedobulbar palsy, paraparesis, locking in syndrome, coma
57
What level of K+ is considered normal and what level would worry you?
3.5-5mmol >6.5 = emergency
58
A patient has a high K+ on U+Es, you get the ECG machine but are not sure if it's an artifactual result- what can you ask to determine if they are being affected?
Chest pain Palpitations, fast/irregular pulse Weakness Light headed
59
Rx of non-urgent hyperkalaemia:
Review medications | Polystyrene sulfonate resin PO (binds K+ in gut)
60
What is calcitonin a marker for?
Thyroid medullary cancer
61
Two tests for hypocalcaemia:
Trousseau's sign: inflate the cuff- wrist + finger flex Chvostek's sign: tapping the facial nerve over the parotid gland causes the corner of the mouth to twitch Low Ca+ causes neuromuscular hyperexcitability or irritability as it increases permeability of neuronal membrane to Na+ causing depolarisation
62
Rx for urate stones?
Urate is formed by purine breakdown which precipitates in tubules Low-purine diet, avoiding shellfish and red meats Alkalinize urine with potassium citrate or potassium bicarbonate
63
Questions to ask to assess risk of osteoporosis:
Age PC: immobility, BMI <22, (2) low Ca intake PMH: rheumatoid arthritis (2) hyperparathyroidism, hyperthyroidism, hypercalcaemia (2) early menopause (2) myeloma, antiandrogen ca prostate (2) diabetes type 1, malabsorption DHx: steroid use FHx: osteoporosis SHx: 4 units alcohol a day, smoking
64
Medical Rx of osteoporosis:
Bisphosphonates (SE jaw osteonecrosis) Strontium- those intolerant of bisphosphonates Raloxifene: selective oestrogen modulator (blocks RANK ligand) Teriparatide: recombinant PTH (if fracture) Denosumab: antibody against RANK ligand (twice yearly) HRT, Testosterone
65
What are the signs of a severe paracetamol overdose?
PC: vomiting within a few hours of ingestion Abdominal pain More than 150mg/kg IHx: Liver failure- abnormal LFTs within 12 hours, AST > 10000, hyperbilirubinaemia, prolonged INR Paracetamol level
66
When would you give NAC to a patient who presents 24 hours after a paracetamol overdose?
``` If severe (liver failure, abdo pain) Or high risk OD (taking phenytoin, carbamazepine, existing liver impairment or HIV +) ```
67
Which antidepressant causes arrhythmias in overdose?
Tricyclic antidepressants

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