A&E Flashcards by Sophia Chan

How do you calculate GCS?

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Describe an A-E

A = see if they reply, check for obstruction in mouth

B = resp exam, resp rate

C = cardio exam, hr, bp, put in 2 large bore IV access cannula (take bloods, give fluids etc), abg/vbg

D = avpu (alert, responds to voice, pain, unresponsive), pupil size, glucose, temperature, GCS

E = exposure

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What would you do if you suspect Sepsis?

Sepsis

Investigations
- Take Bloods (cultures, fbc, u&es, crp, lfts, clotting)
- Serial abgs or vbg for lactate
- Sputum and urine mc&s, swab wounds, lp?
Monitor urine output
Start broad spectrum antibiotics within 1 hour
Fluids if sbp<90, aki, lactate>2
- 500mls 0.9% NaCl over 15 mins
O2 until 94-98% or 88-92% for copd
Speak with critical care early

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How would you manage anaphylaxis?

Anaphylaxis management

Secure airway or intubate if necessary – inform ITU
Raise feet to help restore circulation
Adrenaline IM 0.5mg (1:1000)
- Repeat in 5 mins if needed
Get IV access and give Chlorphenamine 10mg IV and Hydrocortisone 200mg IV
Give 500ml 0.9% NaCl over 15 mins IV, give up to 2L
- If still hypotensive refer to ICU
- Ivi adrenaline may be needed +/- aminophylline and neb salbutamol (consult senior!!!)
Monitor with ecg
Continue chlorphenamine if still itching
Serum tryptase 1-6 hours after anaphylaxis
Educate about self injecting adrenaline
Skin prick IgE test to identify allergens and educate to avoid

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How would you manage a STEMI initially?

ACS (STEMI) Management

12 lead ecg + hx!!!
U&E, troponin, glucose, cholesterol, fbc, CXR

BNF Initial Management

O2 if necessary
Sublingual Glyceryl Trinitrate
5-10mg IV Morphine
10mg IV Metoclopramide
Aspirin 300mg + Ticagrelor 180mg
Refer for PCI
- Give unfractionated heparin or LMWH (enoxaparin)

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How would you manage a STEMI long term?

BNF Long term Management

Aspirin + clopidogrel
B Blockers eg. propranolol
- Diltiazem or verapamil if BB not appropriate
ACE I or ARB
Nitrates if angina
Statins

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How would you manage pulmonary oedema? (initially)

Pulmonary Oedema

Initial Management

Sit patient upright
High flow o2 if necessary
IV access
Monitor ECG
Run investigations (Cxr, ecg, U&Es, troponins, ABG, echocardiogram, BNP)
5mg Diamorphine IV slowly
40-80mg Furosemide IV slowly
2 puffs GTN spray
Can give further doses of 40-80mg furosemide
CPAP can help improve ventilation (get senior help)
Can start nitrate infusion if sbp>100mmhg

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How would you assess asthma severity?

Severe =
- RR>25
- HR>110
- PEF33-50%
- unable to complete sentences
Life threatening =
- PEF<33
- silent chest, cyanosis, confusion
- high pCO2 on abg

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How would you manage severe asthma?

Warn ICU if severe or life threatening
O2 until 94-98% (88-92 if copd)
5mg salbutamol nebs with o2 (SE = tremor, arrhythmia, low K+)
- Repeat salbutamol nebs every 15mins if PEF<75%
- Add ipratropium 0.5mg/6hours to nebs if severe/life threatening
100mg IV hydrocortisone or 40-50mg PO prednisolone
- Continue prednisolone 50mg PO OD for 5-7 days after
Monitor with ECG for arrhythmias
Single dose 1.2-2g MgSo4 IV over 20mins if unresponsive to prev therapy
If worse then refer to ICU!!!
If better monitor peak flow and o2
- Continue discharge if PEF>75% within 1 hour of treatment
- Otherwise must be…
  - stable on discharge meds for 24 hours
  - Inhaler technique checked
  - Peak flow>75% predicted or best
  - Steroid and bronchodilator therapy
  - Have a PEF meter and written management plan
  - GP appointment in 2 days
  - Resp clinic appointment in 4 weeks

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How would you manage a COPD exacerbation?

5mg/4h salbutamol neb + 500mcg/6h ipratropium neb
O2 aim for 88-92%, adjust using abg
200mg IV hydrocortisone and 30mg PO prednisolone (continue OD for 7-14 days)
Antibiotics if necessary eg. amoxi, clarithro, doxi
Physiotherapy for sputum
IV aminophylline if no response to nebs and steroids
Non invasive positive pressure ventilation if RR>30 or PH<7.35

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How would you manage a tension pneumothorax?

Large bore needle + syringe partially filled with 0.9% Nacl into 2^nd ICS mid clavicular line
Allow trapped air to bubble into syringe
Place chest tube, Then request CXR

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How would you manage a Secondary Pneumothorax?

SOB or rim of air>2cm on CXR = aspirate then do a chest drain if aspiration not successful
If rim of air <2cm or no Sob = discharge and outpatient review in 2 weeks

Chest drain = 4-5th intercostal space midaxillary line

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How would you investigate and manage a PE?

Investigations

U&Es, fbc, clotting
Ecg (s1q3t3 or af or rbbb etc)
Cxr
Abg
D dimer
Ctpa or v/q scan
Lower limb us doppler for dvt
Wells score

Management

15L o2 if needed
10mg morphine IV + 10mg metoclopramide IV
LMWH or fondaparinux
If low bp, give 500ml NaCl IV over 15 mins
- Get ICU input
- Consider vasopressors like dobutamine or noradrenaline if still low bp (aim for sbp>90)
If haemodynamically unstable give thrombolysis eg. 10mg alteplase IV bolus then 90mg/2hrs IVI
If haemodynamically stable, commence long term anticoagulation eg. apixaban (doac)

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How would you manage an Upper GI Bleed?

A-E
- 2 large bore cannula = fbc, u&es, lft, glucose, clotting, crossmatch
Keep NBM
IV fluids
Transfuse blood if hb low
adrenaline injection
Varices = endoscopic banding, terlipressin and broad spec antibiotics
Correct clotting problems = vitamin K, ffp, platelet concentrate
Consider referral to ICU or HDU
Catheterise and monitor urine output

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How would meningitis/ meningococcal septicaemia present?

Meningitis = neck stiffness, photophobia but no shock
Meningococcal septicaemia = symptoms + shock (long CRT, DIC, low bp) + non blanching rash

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How would you manage meningitis?

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Blood cultures
Lp within an hour if no sign of shock, rash, high icp
Give empirical antibiotics eg. ceftriaxone
Give dexamethasone 10mg/6hrs IV for meningism
If signs of high icp (papilloedema, seizures, etc)
- Airway support
- Fluid resus
- Keep at 30 degrees
Give ciprofloxacin for prophylaxis

How would you manage encephalitis?

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Blood cultures, serum for viral pcr (and throat swab and msu)
Contrast ct
Lp
Eeg
Management = aciclovir asap, phenytoin for seizures

How would you manage status epilepticus?

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A-e and secure airway!
- O2 and suction as required
- Bloods = u&es, lfts, fbc, glucose, ca2+, toxicology screen, anticonvulsant levels
IV bolus of 4mg Lorazepam
- Give 2^nd dose of Lorazepam in 10mins
- Can also use buccal midazolam or rectal diazepam
IVI of phenytoin in a different line to lorazepam
- Monitor ecg and bp
250mg IV thiamine if alcohol or malnourishment suspected
50mls 50% glucose IV if needed
Fluids for hypotension
ICU help!!! (may need propofol infusion and ventilation with continuous EEG monitoring)

What are some signs of a raised ICP?

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Papilloedema
Pupil changes
Decreased visual acuity
Altered gcs eg. drowsy, coma, irritable
Headache worse on coughing and leaning forward
Vomiting
Low hr, high bp (cushings response)
Cheyne-stokes respiration

How would you manage high ICP?

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A-e, treat seizures etc
Elevate head to 30 degrees
Hyperventilate cause cerebral vasoconstriction
Mannitol
Dexamethasone for high icp due to oedema surrounding tumours
Monitor

How would you diagnose DKA?

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Acidaemia (ph<7.3)
Hyperglycaemia (glucose>11)
Ketonaeima >3 or ketonuria >2+ on dipstick

How would you manage DKA?

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A-e
- 1L 0.9% nacl over 1 hour (if sbp<90 then give resus 500ml over 15mins etc)
- VBG, glucose, ketones, u&es, fbc, crp, cxr, ecg
add 50 units insulin to 50ml 0.9% nacl and infuse at 0.1 units/kg/hr
check cap blood glucose and ketones hourly
check vbg every 2 hours
continue fluids, assess need for K+
monitor urine output, consider catheter or ng tube
start on LMWH
when glucose <14mmol/L start 10% glucose at 125ml/hr too to prevent hypoglycaemia

How would you manage a thyrotoxic storm?

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a-e
- bloods t3,t4, cultures incase infection
- iv access for fluids, ng if vomiting
propranolol 60mg/4hours PO
high dose digoxin can help slow heart but makes sure they have been started on BB already. Cardiac monitoring
carbimazole PO
after 4 hours give Lugols solution (aqueous iodine oral solution)
Hydrocortisone IV or dexamethasone PO to prevent conversion of T4 to T3
Treat suspected infection with coamoxi

How would you manage an addisonian crisis?

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A-e
- Bloods for cortisol and ACTH, u&es (may have high K+, low Na+)
Fix high K+ with calcium gluconate and do ecg
Fix low Na+ with rehydration and steroids
Hydrocortisone 100mg IV stat
Fludrocortisone potentially needed if underlying adrenal disease (ask senior)
Search for underlying cause eg. infection, trauma, surgery, missed meds - if so educate!

What is basic management for poisoning?

* A-E * Bloods and specific for levels of poison * Empty stomach if appropriate * Specific antidote or **activated charcoal** * Search on **toxbase**!!! * Continue to monitor eg. catheter, icu if necessary, cardiac monitor, etc * Proper hx and psychiatric assessment. **Risk assess**!!!

How would benzo poisoning present and be managed?

* Agitation, euphoria, slate grey cyanosis, slurred speech, blurred vision * **Flumazenil** 200mcg over 15s then 100mcg at 60s intervals if needed

How would opiate poisoning present and be managed?

* Constricted pupils, resp depression, etc * **Naloxone** eg. 2mg IV * Can result in opiate withdrawal symptoms eg diarrhoea and cramps * Give **diphenoxylate and atropine** * High dose opiate misusers may need methadone to combat withdrawal

How does neuroleptic malignant syndrome present and is managed? (neuroleptic malignant syndrome occurs with drugs that cause dopamine receptor blockade eg haloperidol and other antispychotics)

* Hyperthermia, rigidity, extrapyramidal signs, autonomic dysfunction, confusion, coma, etc. * Manage with **dantrolene IV** or **bromocriptine and amantadine**

How would anticholinergics poisoning present? How would you manage it?

* Sludge BBB= * Salivation * Lacrimation * Urination * Diaphoresis (excess sweating) * GI upset * Emesis * Bradycardia * Bronchospasm * Bronchorroea * Give **atropine**

How would carbon monoxide poisoning present? How would you manage it?

* Reduced reflexes, tachycardia, pulmonary oedema, shock, met acidosis, flushed cherry pink skin * Give **hyperbaric oxygen**

How would you manage sympathomimetics (cocaine, amphetamines) overdose? How would they present?

* _Tachycardia_, _dilated pupils,_ insects crawling, agitation, _arrhythmias_, tremor * Give **activated charcoal** * Monitor bp, ecg, temp for 12 hours * Monitor urine output and U&Es for aki, lfts, ck, fbc, coagulation for dic * **IV lorazepam** for anxiety * **Metoprolol IV** for narrow complex tachycardias * **Nifedipine PO** for HTN * Try to cool for hyperthermia

How would paracetamol overdose present? How would you manage it?

* Nausea, vomiting * Hepatic necrosis= jaundice, RUQ pain, encephalopathy, hypoglycaemia * Metabolic acidosis, oliguria, renal failure * 150mg/kg in adults can be fatal * Give **activated charcoal 1g/kg** * glucose, U&Es, lfts, inr, abg, fbc, hco3-, **abg for met acidsis** * **blood paracetamol level at 4 hours post ingestion** (plot on graph) * If \<8hours after ingestion * **Activated charcoal** if \<2hours after ingestion * **Acetylcysteine** * If \>8hours after ingestion * **Acetylcysteine + 5% dextrose** * 5% patients will have an allergic rash * Toxbase! * next day do **inr, u&es, lft** * refer to liver specialist if deterioration

How would aspirin (salicylate) poisoning present and be managed?

* mild symptoms = _tinnitus_, _lethargy, dizziness_, vomiting * Severe symptoms = sweating, bounding pulse, _deafness_, breathless, hypo/hyperglycaemia, confusion (pulmonary oedema and met acidosis in fatal) * Do salicylate conc, U&Es, glucose, K+ (usually hypoK), ABG, urine and blood pH, ECG * Management * **Activated charcoal** if \>125mg/kg ingested \<1hr ago * **Gastric lavage if \>500mg/kg ingested \<1hr ago** * Aggressive **rehydration**!!! * Glucose if necessary * **Sodium Bicarbonate if \>500mg/kg ingested** * Monitor urine pH (should be 7.5-8.5) **Haemodialysis** for severe eg. plasma salicylate \>700mg/kg

How would serotonin syndrome present? How would you manage it?

(SSRIs, TCAs, ecstacy, tramadol, etc) Presentation = altered mental state, hyperthermia, autonomic dysfunction, rhabdomyolysis, tremor, clonus, hyperreflexia, sweating, mydriasis Management - IV fluids - benzodiazepines - severe cases = serotonin antagonists like cyrpoheptadine or chlorpromazine

How would you manage burns?

* **Lund and Browder charts** to assess size * Burn depth ie partial thickness (painfull/red/blistered) or full thickness (painless/grey/white) * A-E * Flexi bronchoscopy/laryngoscopy useful to investigate eg. if hot gases inhaled or hx of fire or smoke inhalation etc. * Involve anaesthetists early incase of intubation * Parkland formula to decide fluid replacement * **Simple saline gauze or paraffin gauze** * Titrate **morphine IV** for analgesia * Ensure **tetanus** immunity * **Skin grafts** for major full thickness burns etc

How would you investigate hypothermia? Rectal Temp \<35C

* Shivering = mild. Not shivering = severe * U&es, plasma glucose, amylase, tfts, fbc, blood cultures * Abg * Ecg may show j waves

How would you manage hypothermia?

* A-e * **Warm humidified o2** * Remove wet clothing and slowly rewarm using **blankets or active external warming (aim for 0.5C/hour)** * **Warm IVI** * Cardiac monitoring * Antibiotics to prevent pneumonia * Monitor renal function (consider catheter)

A&E Flashcards

(37 cards)