Gem's Crit Care: Emergency

Front 1

Acute O.D of paracetamol = >______ in single ingestion

Back 1

10g

Front 2

Acute O.D of paracetemol
Presentation

Back 2

GI: N+V, anorexia, RUQ pain
Mild coagulopathy (mild inc INR) in absence of liver failure (from direct inhibition of clotting factor by paracetamol)
Liver failure (rare): hypoglycaemia, metabolic acidosis, hepatic encephalopathy

Front 3

Mgmt Paracetamol O.D

Back 3

1. ABCs --> hydration/IV fluids
2. decontaminant: ACTIVATED CHARCOAL
3. ACETYLCYSTEINE (to prevent hepatotox) - administer w/i 8h of ingestion

Front 4

Pupils in opioid O.D

Back 4

miosis (pupil constriction)

Front 5

Antidote in opioid O.D

Back 5

Naloxone

Front 6

O.D on which drug/s:
hallucinations, seizures
hyperreflexia, tremor
hyperthermia, diaphoresis, flushing, mydriasis
tachycardia, HTN, arrhythmias
N+V+D
What is the Rx?

Back 6

amphetamines or cocaine or MDMA

aspirin, nitrates for ACS
benzos for agitation, Sz, HTN
Amiodarone for arrhythmias
IV fluids, icepacks for hyperthermia

Front 7

Pupils in amphetamine/cocaine/MDMA intoxication

Back 7

mydriasis (pupil dilation)

Front 8

What happens to temperature in opioid OD?

Back 8

hypothermia

Front 9

What do you worry about in opioid OD in terms of lungs? (4)

Back 9

respiratory depression
hypercapnoea
aspiration
pulmonary oedema (non-cardiogenic)

Front 10

Which drug O.D:
agitated, psychosis, hyperemesis
Rx?

Back 10

cannibis
anti-emetics
benzos
anti-psychotics

Front 11

In suspected AMI, ECG should be performed within ___mins of arrival

Back 11

10

Front 12

Initial therapy for chest pain (incl dose) (3)

Back 12

1. aspirin 300mg PO
2. nitrate spray 400mcg subling every 5 mins; usually 3 doses (i.e max 1200mcg)
3. morphine 2.5-5mg IV, titrate to effect

Front 13

ECG criteria for STEMI

Back 13

- ST elevation in 2 contiguous limb leads > or = 1mm
- ST elevation in 2 contiguous chest leads > or = 2mm
- new LBBB

Front 14

STEMI: reperfusion not recommended _____hrs after onset of symptoms if asymptomatic and haemodynamically stable

Back 14

12

Front 15

Do you give everyone with ACS oxygen?

Back 15

no, only those who are hypoxic (SpO2 <93%) or in shock

Front 16

What constitutes a significant increase in troponin levels?

What mgmt if it's less than this level?

Back 16

a increase of 30% of baseline

if <30% change => do exercise stress test

Front 17

3 adjuvant drugs for PCI/fibrinolysis

Back 17

1. aspirin
2. clopidogrel
3. heparin

Front 18

Antidote to heparin

Back 18

protamine

Front 19

Dose: LMWH (therapeutic)

Back 19

enoxaparin : 1 mg/kg up to 100 mg SC, twice daily
or 1.5mg/kg daily

Front 20

Dose: unfrac heparin

Back 20

unfractionated heparin 1000 units/hour IV infusion, adjusted according to APTT

Front 21

STEMI: which Beta-blockers (2)?

Back 21

1. atenolol
2. metoprolol tartate

Front 22

Subsequent Rx for STEMI (7) (Hint: mneumonic)

Back 22

ABCDE

A: aspirin, ACEi
B: beta blocker
C: clopidogrel, cholesterol (Statin)
D: diuretic (spirinolactone): if HF
E: enoxaparin and warfarin (if large MI)

Front 23

ECG characteristics of pericarditis

Back 23

ST elevation most prominent in V5, V6, I
PR depression II, aVF, V4-V6

Front 24

The most serious complication of pericarditis = ?
Think of it when associated with ________________

Back 24

pericardial tamponade

malignancy

Front 25

What is Beck's triad?
Seen in what?

Back 25

1. hypotension
2. JVP distention
3. muffled heart sounds

Pericardial tamponade

Front 26

What are the clinical Fx of pericardial tamponade? (4)

Back 26

Beck's triad: hypotension, JVP distention, muffled heart sounds
and
pulsus paradoxis

Front 27

Mgmt of uncomplicated pericarditis

Back 27

NSAIDs

Front 28

What is aortic dissection:
blood violates the ____________ and dissects between the ____________ and the _____________

Back 28

intima
intima
adventitia

Front 29

3 branches of aortic arch (from patient's RHS -> LHS)

Back 29

1. brachiocephalic (--> R sublavian and R common carotid)
2. L common carotid
3. L subclavian

Front 30

Stanford classification of aortic dissection

Definitive mgmt of each?

Back 30

Stanford
Type A: Dissection involves the ascending aorta
--> urgent surgical referral

Type B: Dissection does not involve the ascending aorta. Predominantly involves only the descending thoracic (distal to the left subclavian artery) and/or abdominal aorta.
--> medical mgmt

Front 31

4 main RFs for aortic dissection

Back 31

1. HTN
2. Marfan's (particularly during pregnancy)
3. bicuspid aortic valve (disturbs blood flow distal to aortic valve)
4. Ehler's Danlos

Front 32

Diagnostic test of choice for aortic dissection

Back 32

CT

Front 33

Mgmt aortic dissection (3)

Back 33

1. analgaesia
2. control HTN --> beta blockers
3. Stanford A --> surgery. Stanford B --> medical mgmt

Front 34

Pulse pressure in aortic stenosis: wide or narrow?

Back 34

narrow

Front 35

Oesophageal rupture: what do you see on CXR?
What Ix for Dx?

Back 35

pneumomediastinum
(though may be normal)
CT or endoscopy

Front 36

Electrical alternans on ECG (alternating sizes of QRS) suggests what?

Back 36

pericardial camponade

Front 37

Direction of tracheal deviation in tension pneumothorax

Back 37

away from side of PTX

Front 38

CXR in PE is usually normal.
What features could it have? (5)

Back 38

1. atelectasis
2. elevated hemidiaphragm
3. pleural effusion
4. Hampton's hump (wedge-shaped pleural-based density = infarction)
5. Westermark's sign = distension of pulmonary vasculature prox to embolism w/ loss of vascular markings distally (rare)

Front 39

What is Hampton's hump?

Back 39

wedge-shaped pleural-based density = infarction
P.E

Front 40

What is Westermark's sign

Back 40

= distension of pulmonary vasculature prox to embolism w/ loss of vascular markings distally (rare)
(P.E)

Front 41

ECG in P.E is usually sinus tachy.
What else could you see? (4)

Back 41

1. R axis deviation
2. RBBB
3. AF w/ rapid ventricular response
4. S1Q3T3 (not specific for PE)

Front 42

What would D-Dimer show in aortic dissection?

Back 42

positive

Front 43

If going to perform imaging with IV contrast, which Ix do you want to do first?

Back 43

EUCs to look for high baseline creatinine which would indicate renal insufficiency

Front 44

Troponin: takes _____ to rise, peaks in _____ hrs and returns to baseline in _______

Back 44

3-6
18-24
14 days

Front 45

CK : takes _____ to rise, peaks in _____ hrs and returns to baseline in _______

Back 45

6-8
24-36
3-4 days

Front 46

When giving GTN in chest pain, what do you have to watch?

What would you do in someone who has chest pain and this parameter is < what it should be?

Back 46

bp
SBP must be >90mmHg

If SBP <90, steer clear of GTN. Give aspirin and morphine and figure out the cause of shock.

Front 47

How do you calculate rhythm on an ECG when it's irregular?

Back 47

number of QRS in the 10 second strip; x6

Front 48

What is the normal cardiac axis on ECG
- in degrees

Back 48

-30deg to +90deg

Front 49

left axis deviation:
lead I :
aVF:

Back 49

positive
negative

Front 50

right axis deviation:
lead I :
aVF:

Back 50

negative
positive

("right is tight" so they point towards each other)

Front 51

extreme R axis deviation:
lead I :
aVF:

Back 51

both negative

Front 52

What is P mitrale?
What does it look like on ECG?

Back 52

L atrial enlargement
notched P wave

Front 53

What is P pulmonale?
What does it look like on ECG?

Back 53

R atrial enlargement
peak P wave (>2.5mm) in inferior leads

Front 54

What is the PR interval normally?

Back 54

120-200ms
i.e 3-5 small squares

Front 55

QRS complex is normally ____ms

Back 55

<120ms
i.e <3 small squares

Front 56

LV hypertrophy on ECG:

Back 56

S (downward) wave in V1 or V2
+
R (upward) wave in V5

= >35mm

Front 57

RV hypertrophy on ECG

Back 57

R > S in V1
RAD

Front 58

What does Digoxin do to ST segment?

Back 58

depression
(reverse tick)

Front 59

What constitutes a new Q wave on ECG in AMI?

Back 59

>40ms and 1/3 height of R wave

Front 60

2 causes of peaked T waves

Back 60

hyperkalaemia
hyperacute MI

Front 61

4 causes of flat or inverted T waves

Back 61

myocardial ischaemia
infarction
hyperventilation
adrenergic stimulation

Front 62

PE often has no specific examination findings but what ight you see? (7)

Back 62

1. tachycardia
2. hypoxia
3. parasternal heave
4. pleural rub
5. loud P2
6. hypotension (obstructive shock)
7. signs of DVT

Front 63

Well's criteria (7)

Back 63

1. clinical S+S of DVT (3)
2. alt Dx deemed less likely than PE (3)
3. HR >100 (1.5)
4. immobilisation or surgery past 4 weeks (1.5)
5. previous DVT or PE (1.5)
6. haemoptysis (1)
7. cancer (current or treated in prev 6mo) (1)

Low: <2 points
Int: 2-6 points
High: >6 points

Front 64

False +ve D-Dimer (2)

Back 64

1. trauma/bruising
2. aortic dissection

Front 65

V/Q scan or CTPA:
which has superior sensitivity?

Back 65

V/Q

Front 66

When suspect PE, when do you do a V/Q and when do you do CTPA?

Back 66

normal CXR -> V/Q
abnormal CXR -> CTPA

Front 67

2 contraindications to CTPA

Back 67

1. contrast allergy
2. renal dysfunction

Front 68

2 populations that are at risk of spontaneous pneumothorax?

Back 68

1. tall thin males
2. Marfan's

Front 69

CXR: what do you see deep sulcus sign in ?
(supine film)

Back 69

pneumothorax

Front 70

CXR: what do you see subcutaneous emphysema in?

Back 70

pneumothorax

Front 71

Estimating pneumothorax size on CXR:
If >___cm from the apex, then size = >____%
If >___cm from lateral wall, then size is _______, at least ____%

Back 71

3; 20
2, large, 50

Front 72

Chest tube insertion can go anteriorly at 2nd ICS MCL
or in the axillary above ____ ICS ___________ __________ line
surface landmark for this = ______

Back 72

5th
anterior axillary
above or in line with nipple

Front 73

ABG in PE :
hypoxia common, but can be normal
What else?

Back 73

respiratory alkalosis with metabolic compensation
elevated A-a gradient suggestive of VQ mismatch

Front 74

"Cardiac assessment" = Triage Category __

Back 74

2

Front 75

Normal troponin level
Critical level

Back 75

N <15
critical >100

Front 76

Normal CK level
Critical level

Back 76

N 55-170
critical > 400

Front 77

Which troponin is most Sn?

Back 77

T

Front 78

When is the first troponin reading diagnostic of MI?

Back 78

when it's >100

(if <15 it's normal; if 15-100, need to repeat in 6h)

Front 79

Some other causes of raised troponin (there's heaps)

Back 79

 Tachyarrhythmia
 DC cardioversion
 Sepsis
 Aortic dissection
 PE or resp failure
 Pericarditis/ myocarditis
 Renal failure
 Neurological insult (SAH/CVA)

Front 80

When do you see a see-saw abdomen?

Back 80

obstructed airway

Front 81

(2) Rx of mild anaphylaxis

Back 81

oral antihistamines
corticosteroids if prolonged urticaria

Front 82

(2) Rx of mod-severe anaphylaxis

Back 82

1. high dose O2 via face mask
2. ADRENALINE 0.01mL/kg of 1:1000 solution IM anterolateral thigh
may repeat IM dose
If unresponsive, consider Ad infusion

Front 83

Rx anaphylaxis if laryngeal oedema (2)

Back 83

1. adrenaline neb 5mg
2. surgical airway preparation

Front 84

Mgmt anaphylaxis if wheezy or Hx asthma (2)

Back 84

1. hydrocortisone 200mg IV
2. salbutamol 5mg neb

Front 85

Mgmt anaphylaxis if hypotensive (3)

Back 85

1. supine with elevated legs
2. N/S bolus 20mL/kg
3. consider glucogon/other vasopressor

Front 86

Mgmt choking (6) (in hospital)

Back 86

1. high flow O2
2. clear foreign material: suction or McGill's forceps
3. Allow coughing/compensatory positioning
4. back blows/chest compressions
5. laryngoscopy/ETT
6. bronchoscopy

Front 87

2 typical causes of CAP

Back 87

strep pneumoniae
H. influenza

Front 88

3 atypical causes of CAP

Back 88

1. chlamydia pneumoniae
2. mycoplasma pneumoniae
3. legionella

Front 89

2 viral causes of pneumonia

Back 89

1. influenza
2. varicella

Front 90

What scores on CURB-65 constitute
PO ABx
IV ABx
ICU/HDU consult

Back 90

0-1: PO ABx
2: IV ABx
3-5: HDU/ICU consult

Front 91

What sort of valve disease is common in APO?

Back 91

acute MR

Front 92

APO mgmt steps (7) (incl Ix)

Back 92

1. High flow O2 15L non-re-breather
2. airway support
3. ECG monitoring
4. IV access x2
5. GTN (beware hypotension)
6. morphine
7. CPAP

Front 93

3 contraindications of CPAP in APO

Back 93

1. GCS < 12
2. absent airway reflexes
3. copious secretions

Front 94

What do you think of with abdo pain + lying completely still w/ avoidance of movement?

Back 94

peritonitis

Front 95

5 DDx of hypotension and sudden abdo pain

Back 95

1. inferior MI
2. pancreatitis
3. ruptured AAA
4. ectopic
5. mesenteric infarction (get metabolic acidosis w/ bloody diarrhoea)

Front 96

2 DDx of hypotension and gradual onset abdo pain

Back 96

1. peritonitis
2. urosepsis

Front 97

What is the AMPLE Hx in secondary survey?

Back 97

Allergies
Meds
Past med Hx; Pregnancy
Last meal
Environment/events related to injury

Front 98

Where does pain caused by liver and gallbladder disease refer to?

Back 98

T7-8
= inferior angle of R scapula

Front 99

Colicky pain (e.g renal colic) makes the patient ___________

Back 99

restless

Front 100

Surgical acute abdo
and
Gastritis/gastroenteritis
and
peritonitis, perforation of viscus
and
Intestinal obstruction and ileus

-- which comes first; pain or N+V?

Back 100

surgical: pain then N+V

gastritis/o: N+V then pain

peritonitis, perforation of viscus, obstruction: vomiting at onset of pain

Intestinal obstruction and ileus: vomiting hours after onset of pain

Front 101

Clear vomit = obstruction ______ to _______ of ______ (2nd part of duodenum)

Back 101

proximal
sphincter of oddi

Front 102

Bilious vomit = obstruction ______ to _______ of ______ (2nd part of duodenum)

Back 102

distal
sphincter of oddi

Front 103

Where is the obstruction if vomit is brown and faeculent?

Back 103

distal colon

Front 104

What 2 things do you think of w/ diarrhoea alternating with constipation?

Back 104

1. diverticular disease
2. colonic Ca

Front 105

When you percuss the abdomen and there is loss of liver dullness, what do you think of?
(this is in the setting of abdo pain)

Back 105

perforated viscus

Front 106

Absent bowel sounds = ?
Tinking bowel sounds = ?

Back 106

paralytic ileus or late bowel obstruction
mechanical bowel obstruction (e.g adhesions)

Front 107

What is psoas sign and what is it +ve in (2)?

Back 107

abdo pain in response to passive hip extension

retrocaecal or pelvic appendicitis
psoas abscess

Front 108

What is obturator sign and what is it +ve in (2)?

Back 108

abdo pain to passive flexion and internal rotation of R hip to 90deg w/ Pt supine

appendicitis
psoas abscess

Front 109

What is the sign in appendicitis when pain in RLQ elicited on palpating LLQ?

Back 109

Rovsing's sign

Front 110

Bowel obstruction is usually colicky pain (but not necessarily)
Where is it felt if:
small intestine
large intestine

Back 110

small: peri/supra umbilical

large: hypogastrium

Front 111

Which "colic" does not have colicky pain?

Back 111

biliary colic

Front 112

Where do you feel acute distension of the gallbladder?

And of the common bile duct?

Back 112

GB: RUQ pain --> R posterior region of thorax or tip of R scapula

CBD: epigastric pain --> upper part of lumber region

Front 113

The possibility of _________________ disease must be considered in every Pt w/ abdominal pain, esp if in upper part of abdo

Back 113

intrathoracic

i.e AMI, Pulm infarction, pericarditis, pneumonia, oesophageal

Front 114

Dx:
wax/waning post-prandial epigastric/RUQ pain
No fever
WBCs and LFTs normal

What is the cause?

Back 114

Cholelithiasis (biliary colic)
= transient cystic duct obstruction by stone

Front 115

Dx:
persistent RUQ pain +/- fever
incr WBCs, incr LFTs
Murphy's sign +ve

What is the cause?

Back 115

Acute cholecystitis
= acute GB inflammation due to cystic duct obstruction

Front 116

Dx:
RUQ pain
Jaundice
fever
Can --> septic shock

Back 116

Cholangitis

= infection within the bile ducts, usually due to obstruction of common bile duct

Front 117

What is Charcot's triad and which disease do you see it in?

Back 117

1. fever
2. RUQ pain
3. jaundice

Cholangitis

Front 118

What 2 things make up the common hepatic duct?

Back 118

R and L hepatic ducts

Front 119

What 2 things make up the common bile duct?

Back 119

cystic duct (from GB)
common hepatic duct

Front 120

5 categories of life threatening causes of abdo pain

Back 120

1. exsanguination (ruptured AAA, ectopic)
2. perforated hollow viscus (perf peptic ulcer)
3. necrosis of viscus (ischaemic colitis)
4. intra-abdominal septic focus (cholangitis)
5. extra-abdominal causes: AMI, PE, thoracic aortic dissection, DKA, opiate w/d, toxins (paracetamol, iron), vertebral neoplasm or infection

Front 121

Which prophylactic ABx do you give for peritonitis caused by perforated viscus/viscus necrosis? (hint: mneumonic)
What ABx class do they belong to?

What do you have to do before giving ABx?

Back 121

"GAM"
Gentamicin (aminoglycoside)
Ampicillin (beta-lactam)
Metronidazole (nitroimidazole)

These are broad spectrum and cover aerobic and anaerobic bowel flora

Take blood cultures first

Front 122

Abdo pain: ECG is mandatory in anyone >____ years old

Back 122

50

Front 123

4 red flags in the context of abdo pain

Back 123

1. elderly (symptoms may be mild - get senior opinion)
2. immunocompromised: DM, steroids, AIDs, chemo (can rapidly progress to sepsis)
3. abnormal vitals
4. can't eat or drink at time of planned d/c

Front 124

What is the first step when assessing someone with AMS?

Back 124

SAFETY to patient and staff

security, scheduling, physical/chemical restraint required?

Front 125

Rx AMS when BSLs are LOW?

Back 125

50% dextrose 20-30mL IV
(antecubital fossa vein, not hand (hand vv --> superficial thrombophlebitis)

Front 126

Antidote to benzodiazepine O.D?

Back 126

Flumazenil

Front 127

Rx alcohol w/d (3)

Back 127

1. benzo
2. thiamine
3. rehydration

Front 128

Rx hepatic encephalopathy

Back 128

lactulose

Front 129

Rx cerebral vasculitis

Back 129

high dose steroids

Front 130

In AMS, you do primary survey and resus then what is the next step?

Back 130

check BSL!

Front 131

When would you do an LP in AMS?

Back 131

if non-trauma, no focal neurology, no metabolic cause found, CT is normal
then do LP

Front 132

What do you do in AMS if you do a CT and it's abnormal?

Back 132

urgent neurosurg r/v

Front 133

5 most common causes of life-threatening AMS presenting to ED

Back 133

1. SAH
2. intracranial mass lesion --> raised ICP
3. hypoxia
4. sepsis
5. delirium tremens

Front 134

CT: crescent shaped bleed
Dx?

Back 134

subdural haematoma

Front 135

CT: biconvex shaped bleed
Dx?

Back 135

extradural haematoma

Front 136

Dx: fluctuating LOC, sleepiness, H/A
LATE onset focal neuro Sx (unequal pupils, hemiparesis)

Back 136

subdural haematoma

Front 137

Vessels involved in subdural?

Back 137

bridging vv

Front 138

Vessel usually involved in extradural haematoma?

Back 138

middle meningeal vessels

Front 139

Dx:
LUCID interval hours-days before raised ICP causes decreased LOC

Back 139

extradural haematoma

Front 140

4 clinical signs of basal skull #

Back 140

1. raccoon eyes
2. CSF rhinorrhoea
3. haemotympanum
4. bruises on mastoid process

Front 141

Rx acute subdural haematoma that's <10mm and no sig. neuro dysfunction (4)

Back 141

1. observation and monitoring (GCS <9 needs ICP monitoring + EEG for Sz)
2. prophylactic anti-epileptics
3. stop/reverse antiplatelets/anticoagulants
4. lower ICP by raising bed head to 30deg (reverse Trendelenburg), analgaesics and sedation or hyperventilation

Front 142

Methods to lower ICP (4)

Back 142

1. raise bed head to 30deg (Reverse Trendelenburgs)
2. analgaesics and sedation (since pain can incr raised ICP)
3. hyperventilation to pCO2 30-35
4. (2nd line) = osmotics: 3% hypertonic saline or mannitol

Front 143

Rx acute subdural haematoma that's >10mm, or expanding or causing significant neuro dysfunction

Back 143

SURGERY
- Burr hole craniotomy
or
- Hemicraniectomy + duraplasty

Front 144

Dx of SAH?

Back 144

CT scan

if -ve, but clinical suspicion of SAH, do LP

Front 145

Mgmt of SAH

Back 145

surgery
clipping or coiling (endovascular -- better)

Front 146

What can cause morbidity/mortality w/i 72h post-SAH?
Mgmt?

Back 146

Vasospasm --> cerebral ischaemia

hypervolaemic and hypertensive therapy to improve cerebral perfusion
and
NIMODIPINE

Front 147

SAH: what is Kernig's sign?

Back 147

hip flexion
pain on knee extension

Front 148

SAH: what is Brudzinski's sign?

Back 148

involuntary lifting of legs when supine

Front 149

Hypertensive encephalopathy caused by malignant HTN:
SBP>_____
DBP>______

Back 149

190
120

Front 150

Hypothermia:
S+S if >32deg

Rx?

Back 150

pallor
apathy
shivering

Rx: dry and allow to shiver

Front 151

Hypothermia:
S+S if <32 deg

Rx?

Back 151

arrhythmia
AMS
no shivering; muscle tone increases

Rx: dry and re-warming

Front 152

Ix for hypothermia (5)

Back 152

EUCs
BSLs
potassium
CK
ECG

Front 153

When might you see J (or Osborne) waves on ECG?

Back 153

hypothermia

Front 154

Heat stroke:
= core body temp >____deg
S+S (4)?
Rx?

Back 154

40

1. AMS
2. (usually) hot, dry skin
3. tachy
4. tachypnoea
5. muscle aches --> rhabdo

Rx: cooling

Front 155

Ix in heat stroke (4)

Back 155

potassium (incr)
CK (incr)
EUCs (impaired kidney fn)
U/A (myoglobinuria)

Front 156

What do pupils do in critical hypoxia?

Back 156

dilate

Front 157

Plucking at the air or bedding is associated with ___________, esp during __________________________________________________________

Back 157

delirium
drug intoxication or withdrawal

Front 158

Dx (2 possible):
AMS
bradypnoea
pinpoint pupils

Back 158

opioid xs
or
brainstem lesion

Front 159

If you're not diabetic, what other disease can cause hypoglycaemia?

Back 159

liver failure

Front 160

What happens to pupils in raised ICP?

Back 160

dilated

Front 161

When, in raised ICP, do you give dexamethasone?

Back 161

when the cause is BRAIN TUMOUR

Front 162

What are the 3 categories in GCS?

Back 162

Eye opening
Verbal response
Motor response

Front 163

How many points available in Eye opening in GCS?
What are they?

Back 163

4

4: spontaneously
3: to speech
2: to pain
1: none

Front 164

How many points available in Verbal response in GCS?
What are they?

Back 164

5

5: orientated
4: confused
3: inappropriate
2: incomprehensible sounds
1: none

Front 165

How many points available in Motor response in GCS?
What are they?

Back 165

6

6: obeys commands
5: localises to pain
4: withdraws from pain
3: flexion
2: extension
1: none

Front 166

What is GCS in mild, mod, severe

Back 166

mild: 14-15
mod: 9-13
severe: 3-8

Front 167

AMS:
Order urgent CT if.... (4)

Back 167

1. headache
2. possible head trauma
3. warfarinised
4. lateralising neurological signs

Front 168

Alcohol w/d symptoms generally come on _____hrs after last drink and typically last _____.
What sort of tremor?
What Rx (2) do you give?

Back 168

6-24h
72h
fine

1. diazepam
2. thiamine

Front 169

Delirium tremens comes on _____hrs after last drink.

What sort of hallucinations do they get?
What sort of tremor?

Back 169

72

tactile
gross

Front 170

What can you check if a coma is a psych cause, i.e somatisation of 'pseudo-coma'

Back 170

eyelash and corneal reflexes in tact

Front 171

CVP is equivalent to ____ pressure.
It reflects the ___________________.
What is it in each form of shock and why?

Back 171

RA
amount of blood returning to the heart

Hypovolaemic: decreased circulating volume => CVP LOW (=> body compensates by vasoconstriction => systemic resistance increases)

Cardiogenic: tachycardia (unless bradyarrhymia) => CVP RAISED (and the body compensates the tachy by vasoconstriction => systemic resistance increases)

Distributive: vasodilation i.e decreased systemic resistance and also there is leakage of fluid from capillaries => CVP is LOW

Obstructive: CVP usually markedly RAISED

Front 172

Neurogenic shock (e.g SCI)
= anatomic interruption of _____________ output
=> __________cardia
and ___________tension

Back 172

sympathetic
brady
hypo

Front 173

Primary survey:
Once identified, deal with a problem BEFORE moving on in your assessment (this is encapsulated by the mantra “FIND the bleeding, STOP the bleeding”).
After any intervention, return to the _______ of the primary survey.

Back 173

start

Front 174

How much oxygen do you give trauma Pt during primary survey?

Back 174

High flow oxygen 15L/min via non-rebreather mask

Front 175

6 killer conditions to be picked up on primary survey (hint: mneumonic!)

Back 175

"ATOM FC"
Airway obstruction/disruption
Tension pneumothorax
Open pneumothorax
Massive haemothorax

Flail chest
Cardiac tamponade

Front 176

What happens to neck vv in tension pneumothorax?

Back 176

distended

Front 177

What does silent chest with paradoxical chest movement indicate?

Back 177

complete airway obstruction

Front 178

What is a sucking chest wound?
What is the Rx?

Back 178

open pneumothorax
occlusive 3 sided dressing --> 'flutter valve' that allows air through wound but prevents air from sucking in
Then you need to but a formal catheter in a separate intercostal space
Formal exploration is needed prior to closing

Front 179

Massive haemothorax = ______mL blood w/i thoracic cavity.
Rx?

Back 179

>1500

drainage and restore blood vol @ same time --> immediate intercostal catheter insertion
Haemostatic resus (activate massive transfusion protocol)
Thoracotomy

Front 180

Define flail chest.
How can you tell it's a flail chest (2xS+S)?
Rx?

Back 180

# 2 or more ribs in 2 or more locations.

1. paradoxical movement -- segment moves in on inspiration as rest of chest expands
2. boney crepitus

Rx: 15L/min O2
Analgaesia (panadol, NSAIDs, IV opiates, regional anaesthetic...)
Keep monitoring SaO2 and resp effort and ABGs and if deteriorate --> ETT

Front 181

Define pulsus paradoxis
What do you see it in?

Back 181

SBP decreases >10mmHg on inspiration

cardiac tamponade

Front 182

Rx cardiac tamponade

Back 182

15L O2
needle pericardiocentesis (ultrasound guided)

Front 183

What bloods to you take during primary survey? (6)

Back 183

1. cross-match
2. FBC
3. EUCs
4. coags
5. BSLs
6. VBG (lactate and Hb)

Front 184

Resus fluid:
want to resus which 2 spaces

Back 184

1. blood volume (i.e intravascular)
2. extracellular fluid

Front 185

3 options for resus fluids

What temp should they be?

Back 185

1. normal saline
2. Hartmann's
3. plasmalyte (best but most $$$)

WARMED in an attempt to improve hypothermia

Front 186

Problem with using N/S as resus fluid

Back 186

depletes HCO3- => become acidotic

Front 187

ECF made up of which 2 components

Back 187

interstitial fluid (80%)
plasma (20%)

Front 188

What is the tertiary survey?

Back 188

Repetition of 2ndary survey:
repeated top to toe evaluation, laboratory data, radiographic study review
This may occur on multiple occasions over the days following injury.

Front 189

3 adjuncts to primary survey (in the order in which you do them)

What do you add if the Pt is haemodynamically unstable?

Back 189

1. CXR
2. pelvic Xray
3. C-spine Xray

If haemodynamically unstable, add DPL OR FAST
(otherwise, these are part of secondary survey)

Front 190

Resus fluids:
Normal Saline or Hartman’s Solution — _____L STAT. Change to _________ if remains _______________ _____________ after ____ L of crystalloid, or earlier if obvious signs of major bleeding

Back 190

1-2L

blood

haemodynamically unstable

2

Front 191

Maintenance fluids:
How much Na+ and K+ is required per day?

Back 191

Na+: 2mM/kg/24h

K+: 1mM/kg/24h

Front 192

BLUNT ABDO TRAUMA:
If they're haemodynamically stable, what are the next steps?

Back 192

complete secondary survey
then do FAST

If FAST +ve ----> CT

(if -ve, observe)

Front 193

BLUNT ABDO TRAUMA:
If they're haemodynamically UNstable, what are the next steps?

Back 193

FAST or DPL

If +ve ------> LAPAROTOMY

(if -ve, complete secondary survey and then repeat FAST)

Front 194

PENETRATING ABDO TRAUMA:
Next step in mgmt:
haemodynamically unstable

Back 194

laparotomy

Front 195

PENETRATING ABDO TRAUMA:
Next step in mgmt:
haemodynamically stable, but wound is on anterior or lateral abdo and it's a gunshot, frank peritonitis, evisceration

Back 195

laparotomy

Front 196

PENETRATING ABDO TRAUMA:
Next step in mgmt:
haemodynamically stable, but wound is on anterior or lateral abdo and it's NOT a gunshot, frank peritonitis, evisceration

Back 196

do a diagnostic laparoscopy

if that's +ve => do laparotomy

Front 197

PENETRATING ABDO TRAUMA:
Next step in mgmt:
haemodynamically stable, and wound is on flanks or back

Back 197

CT

If this is +ve --> laparotomy

(if -ve, observe)

Front 198

Which wounds should be considered potential penetrating abdominal wounds?

Back 198

Any wound between the nipple line (T4) and the groin creases anteriorly, and from T4 to the curves of the iliac crests posteriorly.

Front 199

Abdo trauma:
What do you do if penetrating object is still in situ?

Back 199

laparotomy
(since removal can cause bleed)

Front 200

Cardiac arrest:
compression-ventilation ratio

Back 200

30:2

Front 201

Cardiac arrest:
What are the 2 shockable rhythms?

Back 201

pulseless VT

VF

Front 202

Cardiac arrest:

What are the 2 non-shockable rhythms?

Back 202

Pulseless electrical activity (PEA)

Asystole

Front 203

Cardiac arrest:
Shockable rhythms: what sort of shock?
What follows the shock?
What drugs should be used and when?

Back 203

200J biphasic shock
followed by 2 mins of CPR then re-assess rhythm/pulse

ADRENALINE 1mg after 2nd shock and then every second loop
AMIODARONE 300mg after 3rd shock

Front 204

Cardiac arrest:
Non-shockable rhythm---then what?

Back 204

Give 1mg ADRENALINE immediately (repeat every 2nd loop)
followed by 2 mins CPR

Front 205

Reversible causes of cardiac arrest:
4 Hs

Back 205

Hypoxia --> intubate (continue bag and mask til experienced person arrives)
Hypovolaemia --> Rx resus fluids
Hypo/erkalaemia
H+ (acidosis)

Front 206

Reversible causes of cardiac arrest:
4 Ts

Back 206

Tamponade (cardiac)
Tension pneumothorax
Thrombosis (P.E or AMI)
Toxins

Front 207

When you suspect AAA and the pt is haemodynamically stable, which Ix do you do?

Back 207

CT abdo

Front 208

When you suspect mesenteric ischaemia, what Ix do you do?

Back 208

angiogram/CT angiography

Front 209

Best Ix to diagnose gas in the peritoneal cavity?

Back 209

CXR

(!!! not AXR)

Front 210

Cause of extra-luminal gas (i.e gas that's not in the GIT) (5)

Back 210

1. perforation of a viscus
2. gallstone ileus
3. cholangitis (gas forming organisms)
4. abscess
5. post abdo surgery/ERCP

Front 211

What are the 4 commonest causes of small bowel obstruction?

Back 211

1. surgical adhesions
2. herniae
3. intraluminal masses (e.g small bowel lymphoma or gallstone ileus)
4. Crohn's --> stricture

Front 212

How do you tell the difference between small and large bowel on AXR?

Back 212

the haustra of large bowel only extends a third of the way across the bowel from each side

the valvulae conniventes of the small bowel traverse the complete distance

Front 213

What is it called when there is calcium WITHIN the medulla of the renal parenchyma?

Name a cause.

Back 213

Nephrocalcinosis.

hyperparathyroidism

Front 214

Abdo pain, distension and fevers.
Abdo rigid, tender and resonant on percussion.

What initial imaging will you do?

Back 214

CXR

Front 215

Is renal colic a true colic?

Back 215

no

Front 216

Is biliary colic a true colic?

Back 216

No

Front 217

Bile stained vomit must come from beyond what?

Back 217

Sphincter of Oddi

Front 218

What does a high specific gravity on UA mean?

Back 218

dehydration

Front 219

4 causes of large bowel obstruction

Back 219

1. CANCER
2. volvulus
3. diverticulitis
4. faecal impaction

Front 220

1st line Rx for sigmoid volvulus?
(provided there is no peritonitis)

Back 220

colonoscopy to detorsion
then insertion of a rectal tube

Front 221

1st line Rx for caecal volvulus?

Back 221

surgery
(laparotomy)