medical emergencies

Question 1

adrenaline doses in anaphylaxis

Answer 1

IM doses of 1:1000 adrenaline (repeat after 5 min if no better)
• Adult 500 micrograms IM (0.5 mL)
• Child more than 12 years: 500 micrograms IM (0.5 mL)
• Child 6 -12 years: 300 micrograms IM (0.3 mL)
• Child less than 6 years: 150 micrograms IM (0.15 mL)

Question 2

management of anaphylaxis

Answer 2

ABCDE
- raise patient's legs and call for help
- adrenaline (IM unless someone with IV experience present)
- establish airway
- high flow O2 regardless of sats
- peripheral venous access
- fluid challenge
- IV/IM chlorphenamine 10mg and hydrocortisone 200mg
- monitor:
     > sats
     > ECG
     > BP

Question 3

how does anaphylaxis cause hypotension

Answer 3

histamine causes:

• widespread vasodilation (reduced TPR = hypotension)
• capillary leakage (fluid from intravascular to extravascular space = reduced circulating volume)

Question 4

discharge advice for pneumothorax

Answer 4

• NEVER scuba dive

- no flights for at least 6 weeks (or when cleared by doctor)

Question 5

management of pneumothorax

Answer 5

primary or secondary?
- primary and >2cm and/or SOB = cannula aspiration
> If successful, discharge and review in 2-4 weeks
> if unsuccessful chest drain and admission
- primary and <2cm and not breathless = consider discharge with follow up in 2-4 weeks
- secondary and >2cm and/or SOB = chest drain and admission
- secondary and 1-2cm = cannula aspiration
> if successful, admission and 24hrs monitoring
> if unsuccessful, chest drain and admission
- secondary and <1cm = admission for 24hs monitoring

Question 6

PE Wells score

Answer 6

3 points:

• clinical signs and symptoms of a deep vein thrombosis (DVT)
• no alternative diagnosis is more likely than a PE
  1. 5 points:
• tachycardia (heart rate >100 beats/minute)
• immobile for more than 3 days or has had major surgery within the last month
• previous PE or DVT

1 point:

• haemoptysis
• active malignancy

Question 7

management of PE

Answer 7

ABCDE

• oxygen, fluids, analgesia may be required
• anticoagulation with DOAC when suspected or confirmed
• LMWH then warfarin if DOAC not suitable eg. renal failure, triple + antiphospholipid
• anticoagulation should last at least 3 months (provoked = 3mo, unprovoked = 6mo)
• thombolysis eg. alteplase is indicated in massive PE
• IVC filter an option in recurrent

Question 8

PESI score

Answer 8

assesses mortality risk of PE
severe PE risk factors
- male
- cancer patient
- heart failure
- chronic lung disease
- HR >110bpm
- BP <100
- RR >30
- O2 < 90% OA
- temp <36.0 
- altered mental state

Question 9

heart failure management

Answer 9

Acute: 
- IV Furosemide
- O2
Chronic: 
- ACEI +BB
- Spironolactone 
- Specialist stuff (hydralazine, nitrates, ivabradine, sacubitril valsartan)

Question 10

A B C D E of heart failure CXR

Answer 10

• Alveolar oedema
• kerley B lines
• Cardiomegaly
• upper lobe Diversion
• pleural Effusions

Question 11

monitoring of heart failure

Answer 11

• daily weights

- fluid balance

Question 12

diagnosis of heart failure

Answer 12

BNP

TTE = HFpef or HFref

Question 13

Glasgow Blatchford score

Answer 13

screening tool to assess likelihood a person with an acute upper GI bleed will need to have medical intervention such as a blood transfusion or endoscopic intervention.
The tool may be able to identify people who do not need to be admitted to hospital after a UGIB.

Question 14

acute management of ACS (STEMI)

Answer 14

• MONA
• presented within 12h of symptoms?
  > PCI available in 120mins? Give prasugrel (clopidogrel if on anticoagulant) with unfractionated heparin and do PCI
  > PCI not available in 120mins? thrombolysis with alteplase in STEMI, give ticagrelor after

Question 15

acute management of ACS (NSTEMI/UA)

Answer 15

• MONA
• give fondaparinux if no immediate PCI planned
• use GRACE to assess 6-month mortality risk
  > low risk = conservative mx = ticagrelor
  > high risk (>3%) = offer PCI, give prasugrel (clopidogrel if on anticoagulant), unfractionated heparin

Question 16

reversible causes of cardiac arrest

Answer 16

4Ts
- tamponade
- tension pneumothorax
- toxins eg. medications
- thrombosis
4Hs
- hypoxia
- hypovolaemia
- hypo/hyperkalaemia/electrolyte imbalance
- hypothermia

Question 17

shockable and non-shockable heart rhythms

Answer 17

SHOCKABLE
- VF
- pulseless VT
NON-SHOCKABLE
- PEA
- asystole

Question 18

medication given during CPR

Answer 18

• adrenaline 1mg IV/IO every 3-5mins

- amiodarone 300mg IV/IO after 3 shocks

Question 19

management of diabetic ketoacidosis

Answer 19

1) . IV 0.9% NaCl approx 1L/hr
2) . 50units insulin in 50mls NaCl 0.9% at a rate of 0.1unit/kg/hr
3) . Hourly VBG (glucose, HCO3- and K+) Add K+ to IVI as required
4) . Add 10% glucose IV once BM <14mmol/l to run alongside NaCl

Continue Insulin until ketones <0.3mmol/L, pH >7.3 and pt eating and drinking

Question 20

management of epileptic seizure/status epilepticus

Answer 20

ABCDE

• Secure airway
• High flow O2 and suction if required
• IV lorazepam 4mg slow bolus if cannulated (buccal midazolam 5mg or rectal diazepam if not)
• Repeat after 10 mins if seizure continues.
• If seizures continue or recur in 30mins = Status Epilepticus
• Phenytoin infusion 1-2g slow IVI (monitor BP and ECG)
• ICU for intubation if lasting >60mins.

Question 21

management of hyperkalaemia

Answer 21

1) . Calcium Gluconate (10ml of 10% over 10min)
2) . IV Insulin (10units) in IV dextrose (50mls of 50%)
3) . salbutamol nebuliser (extracellular –> intracellular K+)
4) . calcium resonium enema (slow working - not for emergency mx - aids K+ excretion)
5) . haemodialysis if persistent

Regular monitoring of BMs and hourly K+ via bloods/VBG

Question 22

blood tests for reversible causes of confusion

Answer 22

FBC - anaemia, WCC
U+E = urea/electrolyte imbalance
LFT = hepatic encephalopathy
TFT = hyper/hypothyroid
glucose = hypoglycaemia/hyperglycaemia
calcium = hypocalcaemia/hypercalcaemia
CRP/ESR 
B12 deficiency