A&E Flashcards

Question

Initial ACS management

Answer 1

MONA Aspirin 300mg Oxygen (if <94% sats) Nitrates (sublingual/IV if pain, caution if hypotensive) Morphine if severe pain

Answer 2

Clinical symptoms >20 mins, with persistent (>20 mins) ECG features in 2 or more leads - 2.5mm ST elevation in V2-3 in men under 40, 2mm over 40. - 1.5mm ST elevation in V2-3 women - 1mm ST elevation in other leads - New LBBB

Answer 3

Aspirin 300mg straight away For patients presenting within 12 hours, is PCI possible within 120 mins? YES: Do PCI: - Give praugrel (P2Y12 inhibitor), radial access, give unfractioned heparin + bailout glycoprotein IIb/IIIa inhibitor (antiplatelet - e.g. Abciximab) - Give clopidogrel instead of praugrel if already on anticoagulation NO: Fibrinolysis AKA thrombolysis - Give alteplase (tissue plasminogen activator - binds to fibrin and converts plasminogen to plasmin, breaking down fibrin). - Give heparin with. - Ticagrelor given after. If >12 hours, medical therapy: - Dual antiplatelet (aspirin + P2Y12 inhibitor) - BB, ACEi, statins, nitrates - Anticoagulation - If ongoing ischaemia and pain you can do PCI

Answer 4

Aspirin 300mg (Fondaparinux if no immediate PCI planned) Estimate 6 month mortality - GRACE Score Low risk (<3%) - Ticagrelor High risk (>3%) - PCI - Give prasugrel or ticagrelor - Give unfractionated heparin - Drug-eluting stents should be used If patient high bleeding risk - Swap fondaparinux for alternative antithrombin - Swap prasugrel for ticagrelor/ swap ticagrelor for clopidogrel If on anticoagulants - Swap prasugrel/ticagrelor for clopidogrel

Answer 5

Global Registry of Acute Coronary Events - Age - Heart rate/BP - Cardiac and renal function (cardiac function measured with Kilip classification of heart failure - I - no signs, IV - Cardiogenic shock) - Cardiac arrest - ECG findings - Troponin levels

Answer 6

Immediate: If unstable (e.g. hypotensive) Within 72 hrs: GRACE>3% (intermediate, high, highest risk)

Answer 7

used to assess the severity of heart failure in patients presenting with acute myocardial infarction I - No heart failure II - Lung crackles, S3 sound III - Frank pulmonary oedema IV - Cardiogenic shock (80% 30 day mortality)

Answer 8

Ventricular fibrillation - most common cause of death following an MI. Leads to cardiac arrest. Cardiogenic shock - If large part of myocardium is damaged, ejection fraction is decreased such that heart cant pump to body's needs. Causes dropped BP, cold, clammy skin, confusion, low urine output, tachycardia and oedema. Bradyarrhythmias (AV block more common post inferior MI) Pericarditis - Common post transmural MI. Pain worse lying flat, pericardial rub can be heard and effusion seen on echocardiogram. - Dressler's syndrome, 2-6 weeks post MI, characterised by fever, pleuritic pain, pericardial effusion and raised ESR. Treat with NSAID

Answer 9

Occurs in 3% of MIs 1-2 weeks post MI, patient presents with acute heart failure, secondary to cardiac tamponade (raised JVP, pulsus paradoxus, diminished heart sounds)

Answer 10

Dual antiplatelet (Aspirin + antiplatelet (prasugrel etc)) ACEi BB Statin

Answer 11

Mediterranean diet Dont recommend omega 3 or oily fish Exercise 20-30 mins until slightly breathless Sex may resume after 4 weeks. PDE5 inhibitor (sildenafil) can be used 6 months post MI. Avoid if on nitrates

Answer 12

0.5-1.5 mL/kg/hr

Answer 13

95-100% on air Older: Depends on baseline, but 92-96% can be acceptable Chronic (COPD etc): 88-92%

Answer 14

Below 92 in most adults requires further assessment and oxygen therapy Below 88-90 in those with chronic respiratory disease, to avoid co2 retention Severe hypoxia <85%, urgent immediate intervention

Answer 15

Supplemental oxygen through nasal cannula, face mask, etc. Targets: Healthy adult: 94-98% COPD or CO2 retention: 88-92% Older adults: Individualised to baseline.

Answer 16

KDIGO criteria Stage 1 - Creatinine >26 or 1.5-1.9x baseline in <48hr - Urine output <0.5ml/kg/hr for 6-12 hours Stage 2 - >2-2.9x baseline creatinine - Urine output <0.5ml/kg/hr for >12 hours Stage 3 >353 or 3x reference creatinine <0.3ml/kg/hr for >24 hours or anuria for >12

Answer 17

DAAMN D - Diuretics A - ACEi/ARB A - Aminoglycosides (Gentamicin, Tobramycin etc) M - Metformin N - NSAIDs ACEi/ARB protective in Chronic

Answer 18

An acute reduction in renal function following an insult to the kidneys (usually physical not verbal). Pre renal Intra renal Post renal Prolonged pre or post can causes secondary intrarenal damage

Answer 19

Before blood reaches kidney -> low renal blood flow -> reduced GFR - Hypovolemia (haemorrhage, burns, vomiting, diarrhoea) - Hypotension/shock (sepsis, anaphylaxis, cardiogenic shock) - Renal artery issues (renal artery stenosis, thrombosis, aortic dissection) - Drugs (NSAIDs reduce prostaglandin mediated afferent dilation), ACEi, ARB (efferent constriction),

Answer 20

Problems within Kidney Tubular - Acute tubular necrosis (either ischaemic or nephrotoxic (toxins - Aminoglycosides, radiocontrast, cisplatin, myoglobin, haemoglobin) Interstitial - Acute interstitial nephritis (drug allergy, penicillin, NSAID, PPI, infection and autoimmunity) Glomerular - Post strep, IgA nephropathy, rapidly progressive GN Vascular - Thrombotic microangiopathies (HUS, TTP), malignant HTN, vasculitis

Answer 21

Outflow blockage - Renal pelvis/ureter blockage: Stones, clots, tumours - Bladder outlet obstruction: BPH, prostate cancer, bladder cancer, neurogenic bladder - Urethra: stricture, phimosis

Answer 22

Baseline bloods - U&E (renal function and electrolytes), FBC (haemolysis or anaemia), LFT (hepatorenal syndrome or systematic disease), Calcium, phosphate, albumin, CRP - Urinalysis (dipstick, MSU, blood = glomerulonephritis?, absence of abnormality means pre/post renal?) - Urine output monitoring (accurate fluid balance, oliguria (<0.5mL/kg/hour for >6 hrs) is used for AKI diagnosis

Answer 23

Renal USS within 24 hours if obstruction suspected or no identifiable cause - May find hydronephrosis, renal size, cortical thickness CT Urogram if stones or malignancy suspected. Renal doppler to assess vascular causes in select cases

Answer 24

- CKD - Other organ failure - History of AKI - Nephrotoxic drugs (DAAMN) - Iodinated contrast agents within past week - Age > 65

Answer 25

Main 2: Fluid balance, maintaining homeostasis - Reduced urine output (oliguria @ <0.5mL/kg/hr >6 hours) - Fluid overload - Rise in molecules that the kidney normally excretes/balances (K+, urea, creatinine)

Answer 26

Early - asymptomatic - Reduced urine output - Pulmonary and peripheral oedema - Arrhythmia (secondary to K+ and acid-base balance changes) - Features of uraemia (encephalopathy, pericarditis)

Answer 27

Paracetamol Warfarin Statins Aspirin (cardioprotective dose of 75mg) Clopidogrel Beta blockers

Answer 28

Worsen renal function - NSAIDs - Aminoglycosides - ACEi - ARBs - Diuretics Increased risk of toxicity - Metformin - Lithium - Digoxin

Answer 29

Stabilise cardiac membrane - IV Calcium gluconate Short term inward shift of potassium - Combined insulin/dextrose infusion, nebulised salbutamol Removal of potassium from body - Calcium resonium (oral or enema) - Loop diuretic - Dialysis

Answer 30

- Cause unknown or severe AKI - Where AKI is secondary to obstruction - Transplant - ITU patient with unknwon cause - (Where haemodialysis may be needed) patient not responding to treatment of complications - Stage 3 AKI - CKD 4 or 5 - Complications of AKI

Answer 31

Fluid overload - Pulmonary oedema, peripheral oedema - Hypertension Electrolyte disturbance - Hyperkalaemia - Hyponatraemia (fluid overload or inappropriate use of IV fluid) - Hyperphosphataemia, hypocalcaemia (reduced vit D activation and phosphate retention) Acid-base imbalance - Metabolic acidosis - reduced cardiac contractility, K+ shifts, bone demineralisation Uraemic - Encephalopathy - Pericarditis - Nausea/vomiting/anorexia/pruritus Hyperkalaemia and pulmonary oedema most life threatening

Answer 32

Fluid restriction Loop diuretics (furosemide) (only used in AKI IF secondary fluid overload) Supplemental oxygen - NIV (CPAP, BiPAP) Sit them upright. IF hypertensive and stable, can give nitroglycerin (vasodilator)

Answer 33

Inflammation of renal interstitium - 25% of drug induced AKI Normally immune mediated hypersensitivity to drugs but can also be due to infection or autoimmunity Mainly antibiotics - Penicillin - Rifampicin But also: - NSAIDs - Allopurinol - Furosemide - Systemic disease (SLE, Sjogrens, Sarcoidosis) - Infection (hantavirus, staph)

Answer 34

- Fever, maculopapular rash, athralgia - Eosinophilia! (increased eosinophil WBCs) - Mild renal impairment and hypertension

Answer 35

Sterile pyuria White cell casts

Answer 36

TINU usually occurs in young females. Symptoms - Fever - Weight loss - Painful, red eyes Urinalysis - Leukocytes and protein

Answer 37

Acute tubular necrosis Necrosis of renal tubular epithelial cells severely affects the functioning of the kidney. Reversible at early stage.

Answer 38

Ischaemia (Shock, sepsis) Nephrotoxins - DAAMN drugs - Myoglobin secondary to rhabdomyolysis - Radiocontrast agents - Lead

Answer 39

Raised Urea, creatinine and potassium Muddy brown casts in urine

Answer 40

Casts are formed when proteins or cellular elements take the shape of the renal tubules, where they form. Usually Tamm-Horsfall protein which precipitates in acidic urine. Suggests an intrarenal cause of AKI

Answer 41

Tubular epithelium necrosis - Loss of nuclei and detachment from basement membrane - Dilation of tubules - Necrotic cells obstruct tubule lumen

Answer 42

Skeletal muscle fibre breakdown, releasing intracellular contents (Myoglobin, CK, potassium) into bloodstream. This can lead to AKI as myoglobin is filtered by the kidney, precipitates in the tubules and causes AKI

Answer 43

- Collapse (especially in an older person) - Seizure - Ecstasy - Crush injury - McArdle's syndrome - Statins (especially if co-prescribed with clarithromycin)

Answer 44

- AKI with high CK >5000. (AKI risk at >15000) CK 5x Baseline - Myoglobinuria (dark/reddish-brown colour) - Hypocalcaemia (myoglobin binds to calcium) - Elevated phosphate - Hyperkalaemia - Metabolic acidosis Urine dip is positive for blood but microscopy shows no RBCs

Answer 45

IV fluids and fuckin lots of em

Answer 46

Urine normal/bland sediment in PRU. Brown granular casts in ATN Urine Sodium PRU: Low ATN: High Urine osmolality PRU: >500 ATN <350 Serum urea:creatinine ratio PRU Raised ATN Normal

Answer 47

Airway - Patent? Talking? Stridor? Noisy breathing? Obstruction (vomit, blood etc) Breathing - Look: Resp rate, IWOB, Chest expansion, cyanosis, O2 sats - Listen: Wheeze, crackles, stridor - Feel: Trachea, chest wall movement, percussion Circulation - Look: Colour, cap refill, sweating, obvious bleeding - Feel: Pulse, temperature of peripheries - Measure: BP, HR, ECG, Urine output, IV access, bloods Disability - GCS Scale - Pupils - Blood glucose Exposure - Expose patient, maintain dignity and warmth - Look for rashes, bleeding, trauma, surgical wounds etc

Answer 48

Airway - Head tilt/chin lift, jaw thrust, suction, airway support, call anaesthetics Breathing - Oxygen, nebulisers, physio, ventilation support Circulation - IV fluids, stop bleeding Disability - Correct hypoglycaemia, protect airway Exposure - Remove exposure

Answer 49

Rapid onset of airway breathing circulation symptoms A - Swelling of throat and tongue (hoarse voice, stridor) B - IWOB, wheeze, dyspnoea, cyanosis, reduced O2 sats C - Hypotension, Tachycardia, reduced consciousness Also pruritus, widespread urticaria

Answer 50

1. Remove exposure 2. 500mcg adrenaline, IM, anterolateral aspect of middle third of thigh 3. IV Fluid challenge with crystalloid (500-1000mL in adults, 10mL/kg in children)

Answer 51

Adult/child >12 years - 500 mcg 6-12 years - 300 mcg 6 month- 6 years - 150 mcg <6 months - 100-150 mcg Can be repeated every 5 mins. Usually done on the anterolateral aspect of the middle third of the thigh. Always done at 1mg/mL

Answer 52

When symptoms persist despite 2 doses of IM adrenaline

Answer 53

1. Establish IV access and seek expert help so they can do IV adrenaline infusion 2. Rapid fluid bolus (Crystalloid e.g. 0.9% sodium chloride) 3. Keep giving IM adrenaline every 5 mins till infusion started. Give high flow oxygen and monitor If BP goes crazy high, may indicate adrenaline overdose

Answer 54

Non sedating oral antihistamines Serum tryptase to confirm anaphylaxis (stay raised 12 hours post anaphylaxis) Refer to allergy clinic Give adrenaline injector (epipen) and train on use

Answer 55

1) CPR 30 compressions:2 breaths 2) Assess rhythm 3) If rhythm shockable (VF or pulseless VT), 1 shock then 2 mins of CPR If not shockable (PEA or asystole) continue for 2 mins before assessing again

Answer 56

Vaginal bleeding post 24 weeks

Answer 57

Placental abruption - Shock out of keeping with visible loss - Constant pain - Woody, hard, tender, tense uterus. Firm and constant tone all round - Normal lie and presentation - Fetal heartbeat absent or distressed - Have coagulation issues Praevia - Shock in proportion to visible loss - No pain - Non tender uterus - Lie and presentation abnormal - Fetal heart normal - Dont normally have coagulation issues - Small bleeds before large

Answer 58

Praevia - When the placenta lies wholly or partly over the cervical os. Major cause of mortality and morbidity, and is indication for C section. It is a worse version of a low lying placenta, as low lying placentas usually resolve upwards. Abruption - When compromise of the vascular structures supporting the placenta separate from the wall of the uterus causing bleeding into the new space under attachment site. Causes a solid woody feeling abdomen

Answer 59

Pasteurella multocida Cleanse, (Dont suture puncture wounds), co amoxiclav Wound should undergo irrigation and debridement, and be left open 3-5 days if no infection. Tetanus status should be checked.

Answer 60

Organisms: - Streptococci - Staph aureus - Eikenella - Fusobacterium - Prevotella HIV and Hep C risk Treated with co amoxiclav

Answer 61

Spirochaete infection (Borrelia burgdorferi), spread by ticks. <30 days Erythema migrans - Bullseye rash typically at site of tick bite - 1-4 weeks after initial bite - Painless, >5cm, slowly increases Systemic features - Headache - Lethargy - Fever - Arthralgia

Answer 62

>30 days Cardiovascular - Heart block - Peri/myocarditis Neurological - Facial nerve palsy - Radicular Pain - Meningitis

Answer 63

Diagnosed clinically if erythema migrans present, start antibiotics ELISA antibodies to Borrelia burgdorferi first line test. If negative but suspected, repeat in 4-6 weeks. If positive, immunoblot test. Treat with doxycycline. Amox as alternative, ceftriaxone if disseminated.

Answer 64

If the tick still present, best way to remove is with tweezers, grasping as close to the skin as possible. Wash following, abx not needed

Answer 65

Fever, rash, tachycardia after first dose of antibiotics (more commonly in syphilis but also in lyme disease) Rash is sometimes worsening of maculopapular rash (classically secondary syphilis) and sometimes urticarial/erythematous Resolves in 24 hours

Answer 66

Assess Total Body Surface Area (TBSA). The surface of your palm is equivalent to ~1% Wallace's Rule of 9s - Head and neck = 9% - Anterior or posterior chest = 9% each - Each arm = 9% each - Anterior or posterior leg = 9% each - Anterior or posterior abdomen = 9% each Lund and Browder chart (more precise and better in children)

Answer 67

1) First degree - Superficial epidermis - Red and painful with no blisters 2) Second degree - Partial thickness (superficial dermal) - Pale pink, painful, blistered, slow cap refill 2.5) Second degree - Partial thickness (deep dermal) - Typically white but may have patches of non blanching erythema. Reduced sensation and painful to deep pressure. May or may not need grafting. Heals in 2-3 weeks. 3) Third degree - Full thickness - White (Waxy)/Brown (leathery)/ black, no blisters and no pain (nerve endings destroyed). Requires grafting. 4) Affects tendon, muscle, bone. May require debridement, amputation etc.

Answer 68

- All deep dermal and full thickness burns - Superficial dermal burns of the hands, face, feet, perineum, genitals or flexures. - Inhalation injuries - Electrical, chemical burns - non accidental injury

Answer 69

Local progressive tissue loss and release of inflammatory cytokines Fluid loss due to increased capillary permeability and plasma leakage into interstitial space. Leads to a hypovolaemic state causing reduced stroke volume and cardiac output, burn shock, vasodilation and increased vascular permeability, compensatory tachycardia, organ dysfunction Immunosuppression +- bacterial translocation from gut, which can cause sepsis, the major cause of death in burns.

Answer 70

Parkland formula - 4mL x Body weight (kg) x %TBSA burned Use crystalloid (Ringer's lactate), with half in the first 8 hours since the burn and half in the following 16 Burn is major if >10% TBSA in children, or >15% in adults

Answer 71

Airway (smoke inhalation causes oedema) - early intubation if deep burns to head/neck Urinary catheter + analgesia Complex burns should go to burns unit 1st or 2nd degree can be managed conservatively, will heal in 2 weeks. Excision not done due to infection risk Escharotomy indicated in circumferential full thickness burns to torso or limbs. Careful division of encasing band will improve ventilation or relieve compartment syndrome

Answer 72

MVE Motor - 6. Obeys - 5. Localises to pain - 4. Withdraws from pain - 3. Abnormal flexion to pain - 2. Extending to pain - 1. No response Verbal response - 5. Orientated - 4. Confused - 3. Words - 2. Sounds - 1. Nothing Eye opening - 4. Spontaneous - 3. To speech - 2. To pain - 1. None

Answer 73

Dry mucous membranes Loss of skin turgor Sunken eyes Tachycardia Hypotension Delirium

Answer 74

Bradycardia - Atropine Give glucagon if resistant

Answer 75

BLAST Barbiturates Lithium Alcohol Salicylates Theophyllines

Answer 76

Assess with ABCDE - O2 sats (give if less than 94), IV access, monitor ECG, identify cause Life threatening features? - Shock (hypotension <90 systolic, pallor, sweating, cold, clammy, confused), syncope, Myocardial ischaemia, heart failure. If yes, Synchronised DC shocks, up to 3 shocks. If no, is QRS Narrow (<0.12 s/120ms) If no (broad complex), and regular QRS. - VT possible, give amiodarone 300mg bolus IV over 10-60 mins. If non regular QRS - If irregular and not AF Polymorphic VT give magnesium 2g over 10 mins. If yes (narrow complex) and regular QRS, Vagal manoeuvres. If ineffective, give adenosine 6mg rapid IV bolus, increasing by 6mg up to 18 every time its ineffective. Finally, beta blocker or verapamil if doesn't work. If narrow complex and irregular, possible AFIB. Control rate with BB. Digoxin or amiodarone if heart failure. Anticoagulate if >48 hours.

Answer 77

Broad = >120ms QRS Regular rhythm - Assume VT unless previously confirmed SVT with bundle branch block. Loading bolus of 300mg of IV Amiodarone over 10-60 mins, followed by 900mg IV over 24 hours.

Answer 78

4 H - Hypoxia - Hypovolaemia - Hypo/hyperkalaemia - Hypothermia 4 T - Tension pneumothorax - Tamponade - Toxins (drug overdose, poisoning) - Thrombosis (PE, MI)

Answer 79

Initial O2 target of 88-92, due to hypercapnia risk. 1) before ABG, 28% Venturi mask at 4L/min. If pCO2 normal, increase target to 94-98 2) If type 2 resp failure (high CO2 and low O2), then NIV. BIPAP used with initial settings (EPAP 4-5cm H2O, IPAP 10cm H2O)

Answer 80

Increase frequency of bronchodilator use and consider nebuliser. Give prednisolone 30mg for 5 days Oral amoxicillin or clarithromycin or doxycycline if sputum prurulent or clinical signs of pneumonia

A&E Flashcards

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