Emergency

Question 1

Dosing for single most important action in anaphylaxis?

(Adult)

Answer 1

Administer intramuscular injection of adrenaline 0.5mg (500micrograms) in an autoinjector to the outer mid thigh immediately

Question 2

What is this?
(name the acute condition)

Patient has COPD

Answer 2

Right sided secondary spontaneous pneumothorax.

(secondary because the patient has an underlying lung condition)

Question 3

Define Hypertensive Urgency vs Emergency?

Answer 3

1. Urgency: BP >180/100mgHG

AND significant symptoms such as headache, dizziness or mild-moderate end organ damage.

2. Emergency BP > 220/140 AND associated end organ damage

Question 4

For hypertensive URGENCY what medications can you use to bring down the blood pressure?

Answer 4

Nifedipine IR 10mg, orally, stat

Catopril 12.5mg, orally, stat

Clonidine 100 Microg, orally, stat

Prazosin 2mg Orally, stat

Question 5

What is the triad of serotonin syndrome?

Answer 5

Neuromuscular excitation (e.g. hyperreflexia, hypertonia)

Autonomic effects (e.g. hyperthermia, tachycardia, sweating, flushing)

Central nervous system effects (e.g. agitation, confusion)

Question 6

What can you use to help treat a mild serotonergic toxidrome?

Answer 6

To help with agitation but if they are co-operative then..

diazepam 5 to 20 mg (child: 0.2 mg/kg up to 10 mg) orally; repeat after 30 minutes if required. Usually no more than 120 mg is required in 24 hours

Question 7

What medication might cause the following signs and symptoms, and what needs to be done?

Progressive hyperthermia
muscle rigidity
Sustained clonus
Seizures

Answer 7

SSRI, Certain TCAs, combination with MOAs or opioids, lithium

Medical emergency, send to ED to prevent life threatening multi-organ failure

Start rapid cooling techniques
with rehydration –> Cold IV fluid therapy
For seizures–> midazolam/diazepam IV
For rigidity or clonus–> may need sedation

Question 8

For a person with an eating disorder, what features on examination or investigations findings that would prompt an emergency admission?

Answer 8

• Heart rate <50 bpm
• systolic BP <80 mmHg or diastolic BP <40 mmHg
• Postural BP drop >10 mmHg
• ECG demonstrates any abnormalities, particularly prolonged QTc interval
• Temperature <35.5°C
• Weight <75% predicted ideal body weight (BMI <15)
• Electrolyte disturbance (eg. hypokalaemia)

Question 9

What is your immediate management of this in the GP setting?

(7)

Answer 9

1. Arrange urgent transfer to hospital in ambulance for management of STEMI
2. Insert 2 x large bore cannula into ACF
3. Give high flowOxygen in a non-breather mask if sats <94%
4. Give chewable aspirin 300mg, orally stat
5. GTN spray 400-800micrograms, every 5 minutes if needed

6.Administer Fentanyl 25mcg - 50mcg intravenously for pain relief

7. Place in a monitored area of the clinic/monitor vital signs for signs of deterioration

Question 10

What is the management for status epilepticus?

(6)

Answer 10

1. Apply oxygen through a hudson mask to ensure sats ? 94%
2. Obtain a fingerprick BGL
3. Arrange transfer to nearest ED department for management of status epilepticus
4. Continuing monitoring vital signs for signs of deterioration
5. Insert 2 x large bore cannular into each ACF
6. Administer one of
   a. Midazolam 10mg IV, stat
   b. if no IV access: midazolam 5-10mg buccally (or subcut if absolutely needed), Stat

Question 11

List up to 9 features of dehydration in a child

Answer 11

Withdrawn or straight comatose

Rapid weak pulse

Sunken fontanelle

Very Sunken eyes

No tears

Dry MM

Decreased Skin Turgor with TENTING

No urine for several hours

Greater than 10% weight loss

Question 12

What respiratory rates would make you worry in a child?

Answer 12

if between 6-12 months then RR>50

A chid over 12 months then RR> 40

Any age if RR > 60 ,thats a major warning sign.

Question 13

Steps in anaphylaxis management in clinic on a 3 year old child?

(6)
Include any dosing

Answer 13

1. Give 150 micrograms of adrenaline in autoinjector into the lateral thigh (doses for <1 year are not known, >5years or 20kg use 300microgam autoinjector)
2. Insert 2 large bore cannula into the ACF
3. Start fluid administration intravenously
4. Call ambulence for immediate transfer to the emergency department to treat anaphylaxis
5. Administer highest dose O2 until sats are between 94-98%
6. Keep patient laying flat

Question 14

What causes an Addisonian crisis ?

Answer 14

Adrenal Crisis (more formal name) is caused when somebody has addison’s disease or primary adrenal insufficiency. Usually precipitated by acute stress or sudden cessation of glucocorticoids.

There is not enough glucocorticoids to go around.

Question 15

How do you immediately treat Adrenal Crisis?

Answer 15

Give immediate glucocorticoid

Nb: if no previous diagnosis of Addison’s disease, take bloods to measure plasma cortisol, adrenocorticotrophic hormone (ACTH) and renin concentrations but
do not wait for lab results

1. hydrocortisone 100 mg intravenously, initially, then 50 mg intravenously, every 6 hours until stable and tolerating oral intake.

if no IV access/hard to obtain then

2. prednis(ol)one 40 mg orally.

Question 16

In this general condition, what factors would make you seek urgent attention for the patient?

(5)

Answer 16

This is AF on the ECG with a slow ventricular response

This ECG itself (slow V response) is not an indication for Emergency management. But the following are

1. Rest angina (obviously)
2. AF with rapid ventricular response
3. Syncope or presyncope
4. Clinical signs of heart failure
5. Hypotension (haemodynamically unstable- which could happen with a slow response like this)

Question 17

What is the NEXUS criteria for neck pain?

(5)

Answer 17

Following trauma, cervical spine injury cannot be excluded if any of these criteria are present:

midline cervical tenderness

altered mental status

focal neurologic deficit

evidence of drug or alcohol intoxication,

presence of other injury considered painful enough to distract from neck pain.

Question 18

For low risk, alert and stable trauma patients, what would exam finding with necessitate imaging?

As per Canadian C spine rules

Answer 18

not able to ROTATE neck 45 degrees

using a CT for trauma

Question 19

What are signs and symptoms of a potential PE?

(8)

Answer 19

New onset worsening SOB
RR > 20
Chest pain, can be pleuretic or restrosternal (like angina)
HR > 100
Haemoptysis
Syncope
sBP < 90
Crepitations

Question 20

What steps do you take if suspecting a PE based on symptoms and risk factors?

two different risk categories?

Answer 20

1. Do a wells score for everyone
2. A. high risk on wells score proceed directly to CTPA and treatment

B. Interderminant or low risk, do a D Dimer
If D-Dimer is positive then proceed to CTPA, if negative, no further investigation

Question 21

What medication do you use to treat a PE? and for how long

Answer 21

Apixaban 5mg, orally, 12 hourly

If caused by a provoking factor then 3 months of treatment, if off course the provoking factor is now removed.

If NO provoking factor than longer than 3 months. No exact guidance on when to stop.

Question 22

What are features of a severe asthma exacerbation?

Answer 22

unable to complete a sentence

Increased WOB (accessory muscles- tracheal tug, intercostal recession, excessive abdominal breathing, chest wall recession in children)

Obvious respiratory distress

Sats <94% RA (if below 90% then it’s life threatening)

Question 23

Treatment of severe Asthma exacerbation in a GP setting/ED?

Adults vs Children

Answer 23

Anyone over 6 years old

Salbutamol 12 actuations of 100micrograms pMDI via spacer repeated as needed
PLUS
ipratropium 21 micrograms, 8 puffs, repeated as needed
PLUS
within an hour
dexamethasone 0.6mg/kg up to 16mg given orally followed by a single dose the next day
OR prednisolone 1mg/kg- up to 50mg, oral, daily for 5-10 days

Anyone < 6 years old
Salbutamol is 6 puffs every 20 minutes if needed
and Ipratropium is 4 puffs every 20 minutes if needed
Plus prednisolone or dexamethasone

Note if oral medication isn’t tolerated then use hydrocortisone 4 milligrams per kg up to 100 mg intravenous 6 hourly for 24 hours. Then switch to an oral steroid if tolerating it. If not then continue IV therapy but reduced to 12 hourly

Question 24

What are aspects of a secondary assessment in asthma that will determine severity?

Answer 24

Conscious level. alert, alert, reduced consciousness

Ability to speak: full, incomplete, not

Skin colour/cyanosis

Mobility: walking, tripoding, collapsed

Respiratory distress: non, some, severe

HR: normal, tachy, up to arrhythmia or arrest

Sats >94, 90-94, <90

ABG: not needed, yes needed, definitely needed –> corresponding to sat level above

Question 25

Which parameters would indicate a patient with CAP needs ICU? (Respiratory failure 3) (Organ failure 5)

Answer 25

Signs of respiratory insufficiency: -RR>30Br/m -O2 <90% RA, PaO2 <60mmHg -Multilobar or rapid progression of infiltrate on CXR Signs of organ failure: -Hypotension <90mmHg -Acute onset confusion -Poor peripheral perfusion -Acute oliguria, elevated creatinine or uraemia -Blood lactate 2mmol/L

Question 26

What are some causes of Acute Pulmonary Oedema? (8)

Answer 26

Not all causes are due to Chronic Cardiac Failure, though that is one. Non compliance with CCF medications. Could be MI/ACS Arrhythmia Valve dysfunction Endocarditis Drugs: NSAIDS, CCB AKI or failure PE

Question 27

1 Definitive management and 3 other cornerstones of management for APO?

Answer 27

1. Frusemide 20-80mg, IV given stat and repeated after 20 minutes if needed 2. GTN Spray or Infusion 400micrograms, given SL, every 5 minutes, goal to maintain sBP>100mmHg (DO NOT USE if a PDE5i has been used in the last 48 hours). 3. Oxygen in a reservoir mask 10-15L in a hudson mask and reservoir bag. And if GTN and Frusemide aren't working then 4. CPAP

Question 28

In APO, apart from Frusemide, Oxygen, CPAP and GTN sprays, what other management steps might you start? (4)

Answer 28

*Morphine for anxiety 1-2mg, IV. (also reduces respiratory work) Enoxaparin 40 (or 20)mg subcut Spironolactone 25-50mg, oral, stat, in a volume overloaded patient not responding to frusemide. *Make sure to sit patient in an upright posture *=more important

Question 29

What are the parameters that define severe croup?

Answer 29

Persistent stridor at rest Increasing fatigue Markedly increased RR Markedly decreased AE Tachycardia

Question 30

Emergency or community (whilst awaiting T/F) medical management of severe croup ? (2)

Answer 30

Adrenaline 1:1000 (1mg/1ml) solution 5ml inhalation via nebuliser. Repeated after 30 minutes PLUS EITHER of prednisolone 2mg/kg up to (50mg), orally, stat then 1-2mg/kg (max 50mg) 24 hours later OR dexamethasone 0.6mg/kg (up to 12mg), orally, stat or IV or IM if child is vomiting. once only.

Question 31

In a presentation of severe croup, consider discharge once there is no ______ at ______. And plan a follow up in __ ____.

Answer 31

stridor at rest 24 hours

Question 32

What symptoms differentiate a stroke from a SAH?

Answer 32

Usually the stroke has deficits (neurological) without a headache and the SAH has a sudden onset harsh headache without focal neurological deficits. Also full loss of consciousness is not likely to be a stroke

Question 33

What is the ABCD2 score?

Answer 33

It's the scoring system used to help determine stroke risk in those with a TIA Age > 60 +1 BP - hypertensive (140/90) +1 Clinical. If unilateral weakness +2, if speech impaired without weakness +1, if other symptoms =0 Duration of symptoms: <10 minutes =0, 10-59 min = +1, >60min = +2 Diabetes +1 Scores 0-3 low risk 4-5 moderate risk 6 and over, high risk

Question 34

What is the immediate management steps for a stroke?

Answer 34

1. Keep monitored 2. Urgent Hospital management for A. CT scan B. thrombolysis with alteplase (within 3 hours) 3. Aspirin 300mg to be commenced within 48 hours. Don't do this prior to the CT. 4. Placed on a stroke specific ward

Question 35

What should be done in a patient who has stroke symptoms for over 24 hours?

Answer 35

Urgent referral to tertiary hospital with specialist stroke services. If they had a symptoms within 3 hours then urgent referral to centre that offers thrombolysis.

Question 36

A 10 year old boy was climbing a tree in his backyard during summer and was bitten by a black spider about 2 hours ago. He described it as "really big," and he's currently having abdominal pains. What is the management from here?

Answer 36

Treat any big black spider and a funnel web spider (this is the most dangerous type) 1. apply a pressure bandage around the bite site 2. Apply the pressure bandage along the whole limb 3. Immobilise the limb and patient 4. Arrange transport to the nearest hospital with anti-venom (5. antivenom needs to be administered in a critical care or resus area with readily available adrenalin and resuscitation equipment)

Question 37

What are the directions of applying a pressure bandage to a spider bite?

Answer 37

apply a 15cm pressure bandage around the bite site then wrap distally and proximally around the whole limb. For the pressure bandage to work the limb and patient need to be completely immobilised.

Question 38

What are features of DKA (diabetic ketoacidosis)? Apart from the obvious hyperglycemia (3)

Answer 38

1. polyuria 2. polydipsia 3. tachypnoea Others 4. deep sighing respiration 5. breath smelling like acetone 6. Nausea and vomiting 7. abdominal pain 8. Confusion 9. drowsiness

Question 39

What is the criteria for DKA diagnosis?

Answer 39

There is no specific criteria typically.. pH is 7.3 or less serum bicarb <15mmol/L positive ketones in urine BGL is usually > 14 (but can be less if on an SGLT2i) use the clinical presentation + in room findings to decide.

Question 40

DKA needs to be managed in hospital by an emergency team, what aspects of management should be addressed? dosing not needed. (4)

Answer 40

1 Aggressive fluid replacement 2. Correction of hyperglycemia and ketone production with insulin 3. Correction for potassium disturbance 4. Thorough investigation and management of concurrent infection or other precipitating conditions (MI, CVA, VTE)

Question 41

What is the main difference in treating adult vs. children in DKA?

Answer 41

Do not use the same protocol Avoid giving excess fluid if intravenous rehydration is started for a child or adolescent with DKA. Excess fluid replacement can cause significant harm.

Question 42

What is HHS? what is is characterised by?

Answer 42

Hyperosmolar Hyperglycemic Syndrome? 1. severe hyperglycemia 2. little or no ketoacidosis 3. Dehydration 4. Altered Mental state

Question 43

HHS like DKA requires specialist management in E.D. One aspect is fluid resuscitation, over what time course should this be done? How do you correct the hyperglycemia in HSS?

Answer 43

Replace approximately 50% of estimated fluid loss within the first 12 hours and the remainder in the following 12 to 36 hours Unlike in DKA, insulin is not needed to correct the hyperglycemia, fluid resuscitation and time should be enough. However still monitor potassium and correct if needed

Question 44

What are patients with HHS at high risk of developing? (1-2)

Answer 44

There is high risk of developing arterial and venous thrombosis so use prophylactic anticoagulation

Question 45

If working in the ED and suspecting bowel obstruction what investigations should you order? (6)

Answer 45

Imaging. Preferrably CT, but abdominal XRAY has been the standard- though is more useful for identifying perforation than obstruction itself FBC (anaemia might suggest malignancy) EUC Serum lactate - ischemia PT Group and Save These should happen pretty much simultaneously with starting treatment.

Question 46

What is the mainstay of treatment in LBO? (4)

Answer 46

1. Nasogastric tube if severe distention and vomiting 2. Volume resuscitation 3. Timely surgical consult 4. Initiation of preoperative antibiotics.

Question 47

In a patient with ______(a) _______, their BMI is under ___(b)__ due to a fear of gaining weight. You can use the __(c)____ questionnaire to help determine the patient's risk of actually having an eating disorder. When consulting the patient, assessing them for _______ (d) _______, dehydration and ___(e)_______ ________( especially ___f____) is vital and can be lifesaving.

Answer 47

a. anorexia nervosa b. 18 c SCOFF d. Comorbid conditions e. dehydration and metabolic disturbances f. hypokalemia

Question 48

List at least 5 acute/emergency complications of the extensive list of complications from anorexia nervosa?

Answer 48

Acute Pancreatitis Hypokalemia Mallory-Weis tear (not always an emergency, but needs an emergency evaluation) Arrhythmias Suicide

Question 49

What is the most serious complication-syndrome that can arise when treating anorexia nervosa

Answer 49

Refeeding syndrome During starvation, intracellular electrolytes become depleted from fat and protein catabolism. Upon refeeding insulin secretion stimulates intracellular glucose and electrolyte uptake leading to: - Derangement of serum electrolytes (PO4, Mg, K) - Vitamin deficiencies (Thiamine, B12, folate) - Sodium and fluid retention RFS can be life-threatening leading to complications such as cardiac failure, arrhythmia, delirium and seizures.

Question 50

What are the four main drug induced dermatological emergencies ? What is the management of them?

Answer 50

Steven Johnson Syndrome -SJS Acute generalised exanthematic pustolosis (AGEP) Toxic Epidermal Necrolysis (TEN) Drug rash with eosinophilia and systemic symptoms (DRESS) Management: Transfer all suspected cases to the nearest emergency department, if suspecting TEN then arrange transfer to nearest hospital with a burns unit.

Question 51

What medications are implicated in causing this? 5As

Answer 51

This is Toxic Epidermal Necrolysis Infact SJS and TEN are just variants of the same condition. Both include sheet like skin and mucosal loss. Medications include 40% of the time Antibiotics: penicillins, cephalosporins, Co-trimoxazole Anticonvulsants- lamotrigine, carbamazepine, phenytoin, phenobarbitone Acetominophin; paracetamol and Aspirin/NSAIDs Allopurinol

Question 52

What is the clinical course in developing SJS/TEN?

Answer 52

1. Before the rash there is usually a flu like prodrome (fever of 39+, conjunctivitis, rhinorhoea, cough, aches and pains) 2. Rash Usually develops 1 week after starting an antibiotic or 1-2 weeks after antiepileptic up to 1 month for other drugs Then there is a rapid abrupt initiation of red skin rash, that for some reason doesn't affect the scalp, soles or palms. The lesions can be either Macules Purpura Diffuse erythema Targetoid (like in erythema multiforme) Blisters 3. The blisters then merge to form sheets of skin detachment, exposing red, oozing dermis. The Nikolsky sign is positive in areas of skin redness. This means that blisters and erosions appear when the skin is rubbed gently.

Question 53

What are 4 signs of sepsis or impending septic shock?

Answer 53

Tachypnoea (RR >22) Hypotension (sBP < 90mmHg) Altered consciousness Blood Lactate >2mmol/L

Question 54

What are some life threatening features, when presented with a probably sepsis, indicated organ failure? (5)

Answer 54

Poor peripheral perfusion Mottled skin Acute oligouria or raised serum creatinine Raised billirubin Low platelet count

Question 55

If hospital management is likely to be delayed by over an hour for sepsis, what antibiotic can you start?

Answer 55

ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously or intramuscularly given immediately Use ceftriaxone even if there is mild-moderate reaction/hypersensitivity as treating sepsis is more important. However don't make things worse if the person is known to have a SEVERE reaction to ceftriaxone.

Question 56

In the management of Sepsis in the ED, what steps are important to take?

Answer 56

1. Measure blood lactate 2. Obtain blood samples for culture 3. Collect other samples as soon as possible, but not if it will delay treatment 4. Administer broad spectrum antibiotics 5. Begin rapid administration of IV fluids to manage hypotension or a blood lactate concentration more than 2 mmol/L 6. Give a vasporessor IF NEEDED to maintain a MABP of 60mmHg

Question 57

What is the defining factor between non severe and severe hypoglycaemia and what is the treatment for non severe hypoglycemia?

Answer 57

If the patient is conscious and able to self administer oral treatment, it is non severe. If not able to treat themselves, even if not unconscious, then it is severe. This can be because patient has altered mental status because of the hypo or is generally incapable. Non severe Basically needs to eat/drink glucose. < 5 years old AND under 25kg then 5grams of glucose 6 years and older or > 25kg then 10grams of glucose for an adult then 15grams It takes about 10-15 minutes for the glucose to arise. When it does rise to normal then longer acting carbohydrate should be consumed to prevent recurrence. If BGL < 4.4 or if child is vomiting and cannot eat/drink then you can give a minidose of glucagon approx 10micrograms per year of age up to 150micrograms or 15 years old (then everyone gets 150micrograms)

Question 58

How do you treat severe hypoglycemia?

Answer 58

First Glucagon less than 25 kg: 0.5 mg subcutaneously or intramuscularly 25 kg or more: 1 mg subcutaneously or intramuscularly. If the patient hadn't eaten and has run out of glucose stores in the liver, then the patient will need IV glucose. In a 10% glucose solution over 20 minutes. Once glucose concentration >4mmol/L then can start a regular 5% glucose with NaCl 0.9% solution. remember to warn of the implications for driving.

Question 59

When is acute mania an emergency?

Answer 59

Acute mania is an emergency with severe symptoms: no insight and risk taking behaviour likely to cause harm to themselves or others (physical, financial, reputation destroying behaviours).

Question 60

What medications would you use to treat acute severe mania? MAniA

Answer 60

Antipsychotic (quetiapine or olanzapine) + Mood stabliser (lithium or valproate) + Anxiolytic like a benzo

Question 61

What is the paediatric dose of adrenaline for management of anaphylaxis?

Answer 61

150microgram dose for children weighing 7.5-20kg (about 1-5 year olds)

Question 62

Apart from adrenalin when managing anaphylaxis what else should you do? (4)

Answer 62

1. Monitor HR, bp, RR and O2Sat 2. Give oxygen and or airway support if needed 3. Obtain IV access. Consider larger bore cannula if hypotensive 4. Administer normal saline rapidly 20ml/kg if hypotensive.

Question 63

What analgesia would you use acutely to treat cardiac suspected chest pain?

Answer 63

Fentanyl 25-50micrograms IV, repeated 5-10 minutes if needed While Morphine makes up the "MONA" approach to treatment, it can reduce the amount of anti-platelet agents absorbed

Question 64

What dose of Aspirin and GTN do you give in acute chest pain?

Answer 64

Aspirin 300mg chewable aspirin. Chewed or dissolved. GTN spray 400-800micrograms, sublingual, every 5 minutes if needed. max 3 doses

Question 64

What dose of Aspirin and GTN do you give in acute chest pain?

Answer 64

Aspirin 300mg chewable aspirin. Chewed or dissolved. GTN spray 400-800micrograms, sublingual, every 5 minutes if needed. max 3 doses OR GTN tablet 300-600mg, sublingual, every 5 minutes if needed for pain, max 3 doses

Question 65

When is oxygen needed/should be applied during a suspected ACS event?

Answer 65

if sats <94%

Question 66

What are sore throat conditions that NEED hospitalisation?

Answer 66

Acute epiglottitis Retropharyngeal abscess SEVERE EBV infection SEVERE croup Peritonsillar abscess and peritonsillar cellulitis Pharyngeal diphtheria

Question 67

What are findings with HHS? (hyperosomolar hypergylcaemic syndrome) (4)

Answer 67

Dehydration Altered mental State Severe hyperglycaemia No or little ketoacidosis

Question 68

What is the usual cause for HHS?

Answer 68

Related to medications omitting or forgetting glucose lowering medication Starting medication or drugs that cause hyperglycemia discontinuing antihyperglycemics

Question 69

What is the mainstay of treatment for Hyperosmolar Hyperglycemic Syndrome?

Answer 69

Fluid resuscitation but this shouldn't be done too aggressively The aim of treatment should be to replace approximately 50% of estimated fluid loss within the first 12 hours and the remainder in the following 12 to 36 hours Also need anticoagulants, and they are in a prothrombotic state Potassium can be monitored, but isn't as much of an issue. There is NO acidosis (DKA), so there shouldn't be large intracellular shifts.

Question 70

When doing CPR, when do you administer adrenalin and how much?

Answer 70

If rhythm is shockable then give after the 2nd shock If the rhythm is not shockable then give after the first cycle/AED rhythm check. Give 1mg of Adrenalin

Question 71

In a shockable rhythm what other medication should be administered, and when?

Answer 71

Amiodarone 300mg IV after the third shock

Question 72

What are the 4 T's and 4H's for cardiac arrest?

Answer 72

Toxins Tamponade Tension Pneumothorax Thrombus Hypovolemia Hypoxia Hyper/hypokalemia or other metabolic Hypothermia/hyperthermia

Question 73

What are treatment options for this?

Answer 73

This is an SVT, fast rhythm, no visible P waves, but regular. Try Vagal manoevres Can give Adenosine STAT (fast push)

Question 74

How do you immediately treat a tension pneumothorax?

Answer 74

needle decompression using a 16 gauge needle into the second intercostal space, midclavicular line.

Question 75

What needs to be done immediately after a needle decompression for a tension pneumothorax?

Answer 75

Insert an underwater chest tube and drain. Why? the needle decompression causes a simple pneumothorax, and the lung could collapse so needs a way to stay open

Question 76

What is beck's triad and what is it potentially an indicator of?

Answer 76

Neck vein distention Hypotension Muffled heart sounds It is not super reliable , but can indicate cardiac tamponade. Best use an U/S.

Question 77

what does this show?

Answer 77

NSTEMI sinus tachycardia with right bundle branch block and inferolateral ST depressions and T wave inversions.

Question 78

When suspecting a ACS event, what treatments should be initiated?

Answer 78

Analgesia with opioids GTN Oxygen if sats <94% Aspiring 300mg (chewable preferrably) Arrange t/f to tertiary centre

Question 79

What are the main treatment steps in hypothermia?

Answer 79

Drying and insulation (e.g. removing wet clothes and insulating patient) Fluid resuscitation (usually because they are hypovolemic). Can heat the fluid to about 40-42dC. Active rewarming if between 28 to 32dC. via hot air enclosures. If <28dC, needs CORE rewarming; inhalation, IV infusion, Lavage.

Question 80

What are ECG changes expected with Hyperkalemia?

Answer 80

Widening QRS first increased PR interval then absence of p waves Peaked T waves (early on)

Question 81

Treatment for moderate to severe hyperkalemia? (6.0 + mmol/L)

Answer 81

Give IV insulin and glucose Calcium Gluconate 10mg over 10 minutes IV Can try inhaled beta2 agonist at a high dose as an adjunct (don't use in MI) Consider haemodialysis if treatments are ineffective

Question 81

What are ECG changes with hypokalemia?

Answer 81

Flattening T waves ST segment sagging U wave elevation

Question 82

What is severe hypokalemia and what is the treatment?

Answer 82

usually below 3.0mmol/L and with symptoms IV replacement of potassium. 40mmol. but slowly at 10mmol per hour.

Question 83

Signs and symptoms you might expect with hypertensive emergency?

Answer 83

Symptoms you may expect SOB Chest pain Stroke symptoms: numbness or weakness, difficulty speaking Severe headache Visual changes Signs Pulmonary creps Retinal hemorrhages Peripheral swelling (hands and feet)

Question 84

What factors may increase the risk of complications in someone with hypertensive urgency, that may warrant a visit to the E.D rather than community work up?

Answer 84

1. Extreme BP elevation not due to missed meds 2. coagulopathy 3. Anticoagulant or antiplatelet therapy 4. Pregnancy 5. kidney impairment 6. recent or imminent fibrinolysis 7. aortic dissection suspected 8. Recent vascular procedure 9. suspicious of an aneurysm

Question 85

In a patient with suspected sepsis, what are features of life threatening organ dysfunction? (4+4)

Answer 85

1. Impaired consciousness 2. RR >22 3. sBP <90mmHg 4. Blood lactate >2mmol/L Note that HR and Fever are not on here Other features include 5. poorly perfused and mottled skin 6. Acute oliguria 7. Low platelet count 8. Elevated serum bilirubin from baseline

Question 86

If hospital management for sepsis is likely to be delayed by over an hour, what steps can you initiate in the community? Dosing for antibiotic (6 +1)

Answer 86

Start resuscitation ABC Determine Advanced care plan for appropriate situations Keep in a monitored area Take blood for cultures. Take other cultures/samples ASAP but not to delay Abx administration. Start fluid administration if hypotensive or raised lactate Start antibiotic ceftriaxone 2 g (child 1 month or older: 50 mg/kg up to 2 g) intravenously or intramuscularly If patient cannot maintain their BP with fluid administration or just after, consider giving a vasopressor

Question 87

What is the qSOFA score and what does it compromise of?

Answer 87

used when suspected sepsis and shock. It stands for quick sequential organ failure assessment If 2 or more of: RR > 22 BP > 100mmHG Altered mentation Then proceed to further investigation for sepsis.

Question 88

With an acute/active seizure what are the first 3 things to consider doing?

Answer 88

1. Placing in the left lateral position 2. Protect the airway 3. Remove dangerous objects (Can also start a timer)

Question 89

After initially ensuring the safety of the patient, what 5 further steps can you take to manage an acute seizure?

Answer 89

Take finger prick BGL Maintain Oxygen saturation above 94%, can use a hudson mask to provide oxygen Keep in a monitored area Insert 2 x large bore cannula if able Take bloods if able

Question 90

What is the first line agent to give during status epilepticus? What is status epilepticus?

Answer 90

Definition: A seizure > 5 minutes Or no recovery between seizure attacks Treatment Administration of a benzo (midazolam) With IV accss Midazolam 10 mg (child: 0.15 to 0.2 mg/kg up to 10 mg) intravenously, over at least 2 minutes Without IV access First line: midazolam 10mg (adult or child > 40kg), given Intramuscularly, immediately (Child dose child: 0.15 to 0.2 mg/kg up to 10 mg) Second line: midazolam 5 to 10 mg (child: 0.2 to 0.3 mg/kg up to 10 mg) buccally or intranasally

Question 91

Advice to give regarding seizures in a child e.g. febrile seizures (8)

Answer 91

It is important to stay calm Ensure child is in a safe position, on a soft surface, lying on his side or back Remove any objects from around the child to ensure his safety Time how long the convulsion lasts for Watch or video carefully the movements that take place during the convulsion so you can inform medical staff later Do not try to restrain him Do not put anything in his mouth Do not put him in a bath to lower his temperature

Question 92

What is the definition of a minor burn?

Answer 92

superficial in depth (eg painful, moist, brisk capillary return) less than 10% total body surface area in adults and less than 5% total body surface area in children.

Question 93

When should you refer a burn to a specialist centre?

Answer 93

burns greater than 10% total body surface area in adults burns greater than 5% total body surface area in children full thickness burns greater than 5% total body surface area burns to the face, hands, feet, genitals, perineum, major joints and circumferential limb or chest burns with inhalation injury electrical burns chemical burns burns in patients with pre-existing illness burns associated with major trauma burns at the extremes of age—young children and the elderly burns in women who are pregnant intentional burns (assault and self-inflicted).

Question 94

What is the wallace rule of 9 regarding burns?

Answer 94

Determines the surface area of the burn and hence need for specialist management. Applies to > 10 years old

Question 95

In descending order of deep, these are the burn categories Epidermal burn Superficial dermal burn Mid dermal burn Deep dermal burn Full thickness burn Which can be managed without consideration of a burns specialist?

Answer 95

Epidermal burns and superficial dermal burns can be managed in a GP setting

Question 96

What is this? Why? and how can it be treated?

Answer 96

This is an epidermal burn Because the epidermis is damaged but intact, appears pink/red and painful. Example: sunburn management Cool showers or compress to manage warmth and pain. Ensure adequate hydration and moisturise skin. If pain is significant use a hydrogel to soothe and provide analgesia. A secondary dressing is generally not needed.

Question 97

What type of burn is this? Can it be managed in a GP setting?

Answer 97

Superficial dermal burn Yes it can

Question 98

What is the recommended treatment for a superficial dermal burn?

Answer 98

Can be managed in GP setting Provide first aid and analgesia. Ensure adequate hydration. Deroof blisters and debride as required. Advice Significant exudate is often produced in the first 72 hours. Appropriate dressings include a silicone foam dressing and, if contaminated, silver-based dressings (eg Acticoat or AquacelAg) -If there is minimal exudate, use a moisture retention dressing (eg a clear acrylic dressing)

Question 99

First aid management of thermal burns? (6)

Answer 99

If on fire: stop drop and roll Remove clothing NOT stuck to the burn Remove all jewellery and watches Run under cold water for 20 minutes *useful for up to 3 hours after the burn DO NOT try to induce hypothermia DO NOT use ice Cover the burn with cling wrap but not wrapped circumferentially

Question 100

Fluid resus dose in major burns?

Answer 100

Adults: 0.5 – 1.0 ml/kg/hr Children <30kgs: 1ml/kg/hr

Question 101

First aid points for chemical burns (5)

Answer 101

Remove contaminated clothing from patient Powdered agents should be brushed from the skin whilst protecting care giver Areas of contact should be irrigated with copious amounts of cool running water Avoid washing chemical over unaffected skin If an eye is affected always ensure the unaffected eye is uppermost when irrigating to avoid contamination

Question 102

For a non contaminated burn, what dressings can be used when 1. Absorption is the goal 2. Balance of dry/wet conditions is ok 3. When area is dry

Answer 102

Question 103

For a CONTAMINATED burn, what dressings can be used when 1. Absorption is the goal 2. Balance of dry/wet conditions is ok 3. When area is dry

Answer 103

Question 104

When inspecting a epidermal burn, does the percentage of burned surface area need to be assessed the same way as other burns?

Answer 104

no Epidermal burns are NOT included in the assessment of % total body surface area burnt.

Question 105

What analgesia can be given for severe burns?

Answer 105

Question 106

Apart from IV access, analgesia and fluid resuscitation, what else should you consider in your management of a severe burn?

Answer 106

1. Preventing heat loss. cover the burn. cover the patient with warm blankets or bear huggers. remove wet dressigns 2. Tetanus status and booster 3. Measuring urine output 4. Elevate the burnt area 5. Make sure to manage or monitor the airway

Question 107

How do you treat sustained VT? (2 scenarios)

Answer 107

One: Unstable VT- DC cardioversion Two: Stable VT- can consider DC cardioversion at some stage, other options medical amiodarone intravenous infusion or lidocaine infusion

Question 108

What is paraphimosis and how can you attempt to treat it without surgical intervention?

Answer 108

It is when the foreskin is left in a retracted position and becomes oedematous, then tight and cannot be reduced over the glans Steps Give oral analgesia and reassurance Wrap a firm compression bandage (ideally 1 inch, for example Coban, pictured) over the oedematous area, starting at penile tip Leave bandage for 10-15 minutes (use a timer) Remove bandage and attempt to reduce foreskin over the glans. If unsuccessful, repeat bandage for further 15 minutes and re-attempt If manual reduction fails, obtain urgent surgical consult