Emergency medicine/surgery

Question 1

What do you hear on auscultation/percussion with effusion

Answer 1

Auscultation- absent breath sounds

Percussion- stony dullness

Question 2

Acute severe asthma vs life threatening asthma

Answer 2

Acute severe: 
33-55% of best PEF 
Can't complete sentences 
Resp >25/min 
Pulse>110 beats/min

Life threatening asthma:
PEF <33% of best 
SpO2 <92% 
Silent chest, cyanosis, or feeble respiratory effort
Arrhythmia/hypotension
Exhaustion, altered consciousness

Question 3

What is an important piece of info about an asthmatic in a&e

Answer 3

if they’ve ever been intubated… this means they were at the point of dying before so it is a big risk factor and you don’t want to send them home

Question 4

Info to ask for asthma attack

Answer 4

Previous ITU
Other medical conditions
Allergies
Any infective symptoms

Question 5

Pathophsiology of asthma

Answer 5

Reversible airway disease
Hyper reactivity
Airflow limitation

Question 6

Clinical presentation of asthma

Answer 6

Wheeze?
-Other things which also cause wheeze. Not specific for asthma

Breathless?

Tachycardic?

Question 7

Treatments for asthma

Answer 7

Nebulised salbutamol
IV salbutamol
Nebulised adrenaline
Nebulised magnesium
Oral steroids
IV steroids
 (IV magnesium if they are terrible)

Question 8

What would you give if he is an acute asthmatic

Answer 8

Give them whatever is in the nebuliser IV (if they’re not breathing properly it probably won’t go in)

Call for specialist help

Question 9

What is the difference between severe vs life threatening asthma

Answer 9

Decompensation

Unable to maintain adequate PO2 and PCO2

Drowsy due to rising PCO2, hypotension or exhaustion (note co2 should be low in asthma!)

Need intubation

Question 10

What should CO2 be in an acute asthmatic

Answer 10

LOW (because they blow it off)

If co2 is normal you worry,

if it’s high then this is very bad

Question 11

What is included in asthma review

Answer 11

How pathology creates the clinical signs
How physiology is explained- compensation vs decompensation
Treatment
Started to understand how history, examination and treatment might fit together in one package

Question 12

What is special about meningitis rash

Answer 12

It is a vasculitic rash…. it is nonblanching

Question 13

What will happen if you press on an uritcarial rash

Answer 13

It will go away (i.e. blanching)

Question 14

Pathophsyiology of anaphylaxis

Answer 14

IgE mediated activation of mast cells leading to mediator release and airway airway obstruction

Question 15

What is the treatment for anaphylaxis

Answer 15

Adrenaline
500mcg
0.5ml 1;1000 (IM not IV as it can predispose to arrythmia)

Lie flat and put legs in the air

Piriton

Hydrocortisone

Fluids

Question 16

How does adrenaline help you in anaphylaxis

Answer 16

α1 – vasoconstriction and relaxation of GI tract

α2 – platelet aggregation and reduction in noradrenaline release from nerve terminals

β1 – inotropic and chronotropic cardiac effects and relaxation of GI tract

β2 – bronchodilatation, increase in noradrenaline release from nerve terminals, increase in intracellular cyclic adenosine monophosphate (cAMP) production in mast cells and basophils, reduction in the release of cellular mediators

Question 17

Priorities for MI

Answer 17

1. Call for help
2. Open his airway and start rescue breaths
3. Get IV access
4. Get a 12 lead ECG

You need to check for a pulse first (because an ECG could be normal despite no pulse and thus death)

Question 18

What pulse should you check

Answer 18

Carotid pulse (close to the heart)

Question 19

2 algoriths in CPR

Answer 19

Shockable or non-shockable rhythm

Question 20

Which rhythms are shockable

Answer 20

VF or pulseless VT (check this)

Question 21

What rhythms are non-shockable

Answer 21

PEA and asystole

Question 22

Reversible causes of cardiac arrest

Answer 22

Hs:
Hypoxia
Hypovolaemia
Hyper/hypokalamemia (& other electrolyte disturbance)
Hypothermia

Ts:
Tension pneumothorax
Cardiac tamponade
Toxins
Thromboembolic

Question 23

Learn to recognise cardiac tamponade on echo!

Answer 23

……

Question 24

What do you do for a cardiac tamponade

Answer 24

An emergency pericardiocentesis (ultrasound guided)

Question 25

What is the correct dose of adrenaline in anaphylaxis

Answer 25

0.5 1 in 1000

Question 26

Primary survey for trauma

Answer 26

``` Catastrophic Haemorrhage? Airway with c spine control Breathing Circulation Disability Exposure ‘C-ABC’ ```

Question 27

When do you get a dilated pupil What should you do

Answer 27

It means the brainstem is being pushed through the foramen magnum which compresses crainial nerves affecting pupils. Usually 1 eye first and then the second Before survery give mannitol

Question 28

How to differentiate between subural and extradural

Answer 28

Subdural looks like banana | Extradural is convex

Question 29

ED management of extradural haemorrhage

Answer 29

``` Optimise oxygenation -A, B, C Keep CO2 normal -A,B Maintain cerebral perfusion -(CPP= MAP-ICP) Make sure nothing more life threatening takes priority -Primary survey Neurosurgical input & theatre ```

Question 30

Primary survey

Answer 30

Systematic approach C- ABC Treat life threatening problems as you find them Trauma team – lead by a senior doctor Simultaneous action But we teach it in order so you remember the priorities

Question 31

What is the strongest predictor of injury

Answer 31

Mechanism of injury is the strongest predictor of injury Applies to all trauma- minor and major Create a mental picture of events in your head

Question 32

What do you want to know about airway

Answer 32

Are they breathing? Is it normal or noisy? - Noisy = obstructed - Obstructed = do something! Do they need a ‘definitive airway’

Question 33

Palpate for surgical emphysema

Answer 33

You have an airway leak going into the surrounding tissue

Question 34

Assessment of circulation

Answer 34

Pulse, BP, capillary refill time | General appearance

Question 35

Source of haemorrhage

Answer 35

'On the floor and 4 more': Abdomen (spleen and liver) Into leg (femur can bleed lots) Chest Pelvis

Question 36

What fluid should you give to hypertensive patients

Answer 36

Transfusion | red cells+platelets+FFP

Question 37

Circulation with haemorrhage control

Answer 37

``` Turn off the tap Fluids (blood) Warfarin Coagulopathy to correct TXA (within 1hr) ``` Damage control surgery

Question 38

Assessment of disability

Answer 38

GCS- Glasgow Coma Score level of consciousness Pupils Blood sugar Limb movements

Question 39

Potential injuries for burns

Answer 39

``` Direct Burns Inhalation Injury Smoke Inhalation Carbon Monoxide Poisoning Cyanide Poisoning Trauma ```