A&E Flashcards

Question

Clinical features of acute LVF/HF

Answer 1

- Acute SOB - Looking/feeling unwell - Cough with pink/white sputum - Orthoponea - Type 1 resp failure (low O2, low/normal Co2) Signs: tachycardia, tachypnoea, reduced O2 sats, 3rd heart sound, bilateral basal crackles, hypotension (cardiogenic shock)

Answer 2

- Clinical assessment (Hx, examination and ABCDE if needed) - ECG (ischaemia and arrhythmias) - Bloods (anaemia, infection and kidney function), B-type natriuretic peptide, troponin if MI - ABG - CXR (cardiomegaly) - Echo (assess ejection fraction) ## Footnote BNP = hormone released from ventricles to relax smooth muscle in blood vessels when the myocardium is overstretched. High levels = heart is overloaded. Senesitive not specific. -ve = exclude HF, but can be raised in sepsis, PE renal impairment etc.

Answer 3

- Hospital admission - HDU/ICU if pulmonary oedema or cardiogenic shock - SODIUM mnemonic - S - sit up (oxygenate lungs, stop fluid spread) - O - oxygen (for < 95%, maintain 88 - 92% in COPD) - D - Diuretics (increases UO) - I - IV fluids stopped - U - Underlying cause = treat - M -monitor fluid balance Meds: positive inotropes (e.g. dobutamine) increases contractility, increases cardiac output and mean arterial pressure (MAP), e.g. after MI Vasoperssors (e.g. noradrenaline) = vasoconstriction = increase systemic vascular resistance + MAP = better BP and tissue perfusion

Answer 4

Abnormally elevated pressure witihn a fascial compartment, blood flow is cut off to the compartment. Fascial compartments = muscles, nerves and blood vessels surrounded by fascia (strong, fibrous connective tissue containing the comparmtent contents). Orthopaedic emergency, needs fasciotomy to relieve pressure and restore blood flow. Otherwise tissue neccrosis.

Answer 5

Often due to acute injury e.g. bone fractures, crush injuries, bleeding or oedema increases pressure within the compartment. Most often legs, but can affect forearm, feet, thighs and butt. 5Ps: - Pain **disproportionate** to underlying injury, worsened by passive stretching - Paraesthesia - Pale - Pressure (high) - Paralysis (late and worrying)

Answer 6

- Clinical diagnosis - Escalate to senior, remove dressing, elevate leg to heart level, good BP (no hypo) - Needle manometry - measure compartment pressure - Emergency fasciotomy - cut through fascia in compartment to relieve pressure + debride necrotic tissue

Answer 7

Associated with exertion, pressure in compartment rises with exertion and falls with rest. Pain, numbness and paraesthesia Needle manometry before, during and after to confirm diagnosis + fasciotomy

Answer 8

Rapidly worsening symptoms - Cough - SOB - Sputum - Wheezing - Triggers: viral or bacterial infection

Answer 9

ABG: Respiratory acidosis - Low pH - Low pO2 (respiratory failure) - Raised pCO2 - Raised bicarbonate (chronic retention of CO2) Other Ix: CXR (pneumonia), ECG, FBC (infection), U+E, sputum and blood culture (if suspected sepsis)

Answer 10

1st line - Regular inhalers or nebulisers (e.g. salbutamol and ipratropium) - Steroids (e.g. prednisolone 30 mg once daily for 5 days) - Abx if infection Severe: - IV amonphylline - Non-invasive ventilation (NIV) - Intubation and ventilation with ICU

Answer 11

- Right-sided HF due to respiratory disease - ↑ Pressure and resistance in the pulmonary arteries (pulmonary hypertension) = reduced blood into pulmonary arteries from RV, backlog in right heart - COPD = the most common cause - Early disease = asymptomatic - Clinical features: SOB, peripheral oedema, breathlessness on exertion, syncope, chest pain - Signs: hypoxia, cyanosis, raised JVP,parasternal heave, loud 2nd heart sound Management: - Diuretics for oedema - Manage COPD - Long-term O2

Answer 12

- Resuscitation (e.g., sepsis or hypotension) - Replacement (e.g., vomiting and diarrhoea) - Maintenance (e.g., nil by mouth due to bowel obstruction) Main types of IV fluids: - Crystalloids (water + salts or glucose) e.g. 0.9% NaCl, Hartmann's solution - Colloids = larger molecules remaining in intravascular space longer e.g. human albumin solution - unlikely to prescribe

Answer 13

- NaCl 0.9%, Hartmann's solution, Plasma-Lyte 148 - ABCBE - Tx: initial 500ml fluid bolus < 15 mins (STAT) then ABCDE, repeat 250 - 500ml bolus if needed then reasses, then seek expert help if no improvement, particularly if >2L fluids - Paediatrics: 10ml/kg < 10 mins (smaller in <28d neonate) | Remember! No rapid bolus with K+, as K+ infusion can't exceed 10mmol/L

Answer 14

- If pt cannot tolerate oral fluids e.g. NBM or bowel obstruction NICE recommendations approx.: - 25 – 30 ml / kg / day of water - 1 mmol / kg / day of sodium, potassium and chloride - 50 – 100 g / day of glucose (this is to prevent ketosis, not to meet their nutritional needs) Daily monitoring to ensure correct Na, K, Ca2+, Mg, haemoglobin, haematocrit, clotting factors, platelets etc. | Based on ideal weight, NOT actual BMI ## Footnote Caution in elderly/frail pts, hyper/hyponatraemia, HF, renal/liver impairment

Answer 15

Most often originates from Kiesselbach's plexus in Little's area. Nasal mucosa at front of nose and very vascular. ## Footnote Common exam question is where is the most likely location of the bleeding?

Answer 16

- Nose picking - Colds - Sinusitis - Vigorous nose-blowing - Trauma - Changes in the weather - Coagulation disorders (e.g., thrombocytopenia or Von Willebrand disease) - Antiplatelets/anticoagulant medication (e.g., aspirin, DOACs or warfarin) - Snorting cocaine - Tumours (e.g., squamous cell carcinoma)

Answer 17

- Usually unilateral, bilateral might indicate posterior bleeding = increased risk of aspiration - If blood swallowed = vomit blood - Usually self-resolves, if > 10 - 15 mins, unstable, bilateral = ?admission - Ix underlying cause e.g. thrombocytopenia or clotting disorders. Advice: - Sit up, tilt head forward - Squeeze nostrils together for 10 to 15 mins - Spit blood out Spit any blood in the mouth out rather than swallowing Hospital tx: - Nasal packing - nasal tampons/inflatable packs - Nasal cautery - silver nitrate stick - Naseptin (chlorhexidine and neomycin) QDS for 10 days ↓crusting, inflammation and infection. CI peanut or soya allergy.

Answer 18

Usually self-resolving. Recurrent = Ix for thrombocytopenia/clotting disorder If bleeding > 10 - 15 mins/severe/bilateral/haem unstable = hospital for - nasal pack with nasal tampons/inflatable packs - Nasal cautery with silver nitrate sticks - Prescribe naseptin nasal cream to reduce inflammation

Answer 19

- Sit up and tilt the head forwards (tilting the head backwards is not advised as blood will flow towards the airway) - Squeeze the soft part of the nostrils together for 10 – 15 minutes - Spit out any blood in the mouth, rather than swallowing

Answer 20

A defect in the wall of the bowel, stomach or oesophagus that allows the contents to leak out.

Answer 21

Upper GI tract: - Oesophageal or gastric malignancies - Peptic ulcer disease Iatrogenic e.g. surgery/endoscopy Lower GI tract: - Colorectal cancer - Bowel obstruction - Colitis (e.g. inflammatory bowel disease) - Appendicitis - Iatrogenic e.g. colonoscopy - Mesenteric ischaemia - Metastatic disease

Answer 22

Symptoms - Acute abdomen (severe sudden abdo pain) - Nausea + vomit Signs - Peritonism+ - Shock (hypotension + tachycardia) - Tachypnoea - Fever | +guarding, rebound tenderness, ridgidity on palpation

Answer 23

- Blood gas - lactate + pH - Pregnancy test - Bloods: FBC, CRP, clotting screen and G+S in case of surgery, blood cultures if infection suspected - CT with contrast to identify and locate perforation

Answer 24

Conservative: NBM, urgent surgical review, ICU if organ failure due to sepsis - Medical: IV broad-spectrum abx, fluid resus, analgesia and antiemetic (maybe parenteral) - - Surgical - most cases need laparotomy (washout, identify cause and repair)

Answer 25

Core (rectal) temp < 35 - Mild: 32.2 - 35 (+/- shivering) - Moderate: 28 - 32.1 - Severe: < 28 (no shivering) Ensure low threashold of suspicion and low-reading thermometer

Answer 26

Combination of factors: - Impaired homeostasis e.g. age-related reduction in thermoregulation - Pathology affecting thermoregulation e.g. pneumonia, MI, HF - Autonomic neuropathy e.g. diabetic - Low room temp e.g. poverty, homeless

Answer 27

Symtoms: confusion, agitation, reduced GCS, coma Signs: brady, hypotension, arrhythmias (AF, VT, VF) Hx: fall with long-lie, homeless, alcohol/drugs use ## Footnote Rewarm + re-exam, many people have returned to life when warm despite no vital signs.

Answer 28

- Rectal temperature reading - 12 lead ECG: core temp 32 - 33 = ST elevation and J waves - FBC - U+E (particularly K+, as risk of hypokalaemia) - Blood glucose - ABG - Coagulation screen - CXR

Answer 29

- ABCDE, ensure safe airway - Warm, humidifed O2 - Ventilation if reduced GCS, reduced pO2 and increased pCO2 - Slow rewarming = blankets or hot air duvet, aim core temp increase of 0.5C/h - Monitor HR, BP, RR. Increase HR, decrease BP = shock - Rapid rewarming if CV instability/arrest, warm fluid lavage + intravascular warming - Monitoring for arrhythmia | Rewarming too quickly = peripheral vasodilation + shock

Answer 30

Range of conditions featuring hypersensitivity of the immune system to allergens. Aka atopy - predisposition to atopic conditions e.g. allergic rhinitis, eczema, asthma and food allergies Often type-1 hypersensitivity reactions - IgE mediated.

Answer 31

- Urticaria - Angioedema (eyes, lips, mouth, throat) - SOB + wheeze - Itchy skin/eyes - Sneezing - Rhinorrhoea - Worsening asthma/eczema

Answer 32

Detailed hx is most accurate way to establish dx! - Timing afrer exposure to allergen - Previous + subsquent exposure and reaction to allergen - Symptoms of rash, swelling, breathing difficulty, wheeze and cough - Previous personal and family history of atopic conditions and allergies ## Footnote Used zero to finals paediatric allergy page as could not find any other source.

Answer 33

- Skin prick test - RAST test - blood tests for total and specific IgE Both test for sensitation NOT allergy! Unreliable and misleading. - Patch testing in allergic contact dermatitis - Gold standard is food challenge testing! Limited availibility and resource intensive

Answer 34

- Avoid triggers - Regular hoovering, sheet + pillows change in house mite allergy - Prophylactic antihistamines useful in unavoidable contact e.g. hayfever - Adrenalin auto-injector for pts at risk of anaphylaxis - Immunotherapy at specialist centres, where patients are gradually exposed to increasing allergen levels to build tolerance Post-exposure: - Antihistamines (e.g. cetirizine) - Steroids (e.g. oral prednisolone) - IM adrenalin - Monitor for progrression to anaphylaxis

Answer 35

- Rapidly progressive infection of the deep fascia > subcutaneous tissue necrosis. - Mainly group A beta-haemolytic strep (strep pyogenes), but often polymicrobial - Systemically very unwell (very high inflamm, markers + lactate) despite resus, disportionate to wound apperance, intense pain in affected area + muscles Mx: urgent radical debridement +/-amputation in theatre and IV abx (e.g. benylpenicillin and clindamycin (check local guidelines).

Answer 36

Physical harm inflicted on a child or as a result of the caregiver failure to protect them from this harm. Risk factors include: - DV, previous child maltreatment - Caregiver substance/alcohol misuse - Poverty - Children in care system - Children and young people with disabilities

Answer 37

- Inconsistencies in caregiver narrative e.g. changing stories, severity/type of injury not matching with story - Delayed presentation - Unwitnessed injury Examination: - Injuries of varying ages - Burns, scalds, bruises - Retinal/subconjunctival haemorrhage - FGM - Torn frenum - head injury/force feeding

Answer 38

- Detailed history + body map - Comprehensive radiological skeletal survey to identify rib/clavicle/finger fractures, metaphyseal corner fractures (twisting limb) - Bloods for dffierentials e.g. clotting disorders or haematological malignancies

Answer 39

- Report to senior and safeguarding lead - Measures: admit child for safeguarding while Ix continue - Clear documentation - Social care liaison

Answer 40

Intentional injuries, cuts or alterations to female genitals without medical indication. Illegal in the UK Contact 999 if you suspect a patient is at immediate risk of FGM, or calll 101 (police or NSPCC if not immediate

Answer 41

Reduction in all major cell lines: red, white, platelets. Causes: 1) Reduced marrow production: aplastic anaemia, infiltration in leukaemia/lymphoma, megablastic anaemia 2) Increased peripheral destruction in hypersplenism

Answer 42

Absence of granulocyte (neutrophils, basophils or eosinophils) production > risk of fatal infection Causes: clozapine, carbimazole etc. Pts often present with fever or sore throat (wcc ≤ 0.5 x 10^9L) = NEUTROPENIC SEPSIS - A MEDICAL EMERGENCY! Stop drug, start neutropenic sepsis regimen (including sepsis 6) and consider granulocyte colony stimulating factor G-CSF) | From Oxford Handbook of Clinical Medicine

Answer 43

Three tests: - Serum lactate - Blood cultures - Urine output Three treatments: - Oxygen therapy (94-98%) or 88-92% in COPD) - Empirical broad-spectrum antibiotics - IV fluids

Answer 44

- Sepsis in someone with neutrophil count < 0.5x10^9/L - Temp > 38 in pt undergoing cancer or immunosuppressant tx is this until proven otherwise - Causes: chemo, methtrexate (RA), sulfasalazine (RA), infliximab etc. - Tx: follow local neutropenic sepsis policy, broad spectrum abx e.g. piperacillin with tazobactam (tazocin), other tx same as sepsis but closer monitoring and lower threshold for escalation | From zero to finals

Answer 45

When the body launches a large immune response to an infection > systemic inflammation + organ dysfunction

Answer 46

Macrophages, lymphocytes and mast cells identify pathogens and release cytokines = immune activation: - Vessel endothelial lining = leaky = oedema of extracelluar spaces > hyoperfusion of organs - Activation of coagulation pathways, fibrin deposits and blood clots throughout circulation = hypoperfusion and DIC+ - Tissue undergo anaerobic respiration > increased lactate and metabolic acidosis | +Blood clots in vessels > DIC = thrombocytopenia and haemorrhage

Answer 47

- Very young/old (<1 or >75) - Chronic conditions e.g. COPD, diabetes - Chemo, immunosuppressants, steroids - Surgery, trauma or burns - Pregnancy and childbirth - Cathethers and central lines

Answer 48

NEWS2 score to identify acutely unwell patients: temp, HR, RR, O2, BP and consciouness - Possible source of infection - Reuced urine output - Mottled skin - Cyanosis - Arrhythmia e.g. new AF - Non-blanching rash (meningococcal septicaemia - Tachypnoea = early sepsis sign - Elderly pts usually non-specific e.g. confusion, drowsiness ## Footnote Neutropenic/immunosuppressed pts can have normal obs but be life-threateningly unwell

Answer 49

- FBC for WCC and neutrophils - U+Es for AKI - LFTs for liver infection - CRP - Blood glucose - Clotting for DIC - Blood cultures for bacteraemia - ABG for lactate, pH and glucose For source of infection: urine dipstick and culture, CXR, CT if intra-abdo infection suspected, LP for meningitis/encephalitis

Answer 50

- Each hospital has sepsis protocol and pathway - Escalate to senior - HDU/ICU if needed NICE stratifies into low, med and high risk patients - High risk - urgent attention and mx - Moderate risk = mx in community if safe + safety-netting Suspected sepsis = assessment and tx within 1 hour, sepsis six (see card)!

Answer 51

Twisting of spermatic cord with rotation of the testicle Urological emergency! Delay = ischaemia, necrosis, infertility

Answer 52

- Typically teenage boy after playing sports - Unilateral testicular pain - Abdominal pain (sometimes only symptom) - Vomiting Examination: firm swollen, retracted testicle, absent cremasteric reflex, abnormal testicular lie (horizontal - Bell-Clapper deformity)

Answer 53

- NBM - Analgesia - Urgent senior urology assessment - Surgical exploration of scotum - Orchiopexy (correcting testicle position and fixation) - Orchidectomy if surgery delayed or necrosis ## Footnote Scrotal USS to confirm dx, but don't delay tx!

Answer 54

ABCDE A – Airway: Ensure the patient’s airway is patent and secure. B – Breathing: work of breathing, SpO2, RR (tachyponea often first indication of serious illness), auscultation, O2 therapy if needed C – Circulation: BP, HR, heart sounds, CRT, IV access, take bloods, IV fluid bolus if needed D – Disability: ACVPU or GCS, blood glucose level E – Exposure: temp skin (swelling, rash, bleeding), abdomen, wounds, calves (often recorded as soft, non-tender SNT if normal) | P on AVPU roughly equalvant to GCS 8

Answer 55

- Highly toxic, binds to haemoglobin, ↓ O2 carrying capacity - Headache, N+V, vertigo, altered conciousness - Ix: carboxyhaemoglobin concentration ABG/VBG, > 30% = severe - Mx: 10 to 15L/min 100% O2 via rebreather mask

A&E Flashcards

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