Year 5 – Ortem – Emergency Medicine 2

Front 1

Algorithm for the management of seizure

Back 1

Front 2

What two groups of patients with asthma attacks should we admit?

Back 2

Life-threatening asthma

Severe asthma persisting after initial treatment

Front 3

Prednisolone in acute severe asthma should be given at a dose of 40-50mg but how often and for how long?

Back 3

OD for at least 5d and up to recovery

Front 4

39 year old male SOB has a PEF of 350. His previous best PEF is 750 and the PEF predicted for his age and height is 620. How would you characterise his asthma.

Back 4

Acute severe asthma (PEF < 50% best).

Best is more reliable than predicted.

Front 5

Name four features of the pain that evidence has demonstrated to make ACS more likely

Back 5

Front 6

When should troponin be taken in a patient with suspected ACS?

Back 6

Directly at presentation to have a baseline and then again later (some say 3h, some say 12h)

Front 7

What score can help you diagnose an ACS?

Back 7

HEART score (TIMI and GRACE help assess prognosis in established ACS)

Front 8

A patient with chest pain and vomiting has an ECG revealing ischaemic changes. Her previous ED attendance notes from 6 months ago show that her ECG changes are old, so her ischaemic heart disease is longstanding. Her initial troponin on admission is normal but her 3h troponin is raised. What is the exact diagnosis?

Back 8

NSTEMI

Front 9

When should ACEI be started in a patient with ACS?

Back 9

As soon as possible once renal function has been checked

Front 10

When should statins be started in a patient with ACS?

Back 10

As soon as possible once liver function has been checked

Front 11

What is meant by costochondritis?

Back 11

Usually wrongly used instead of idiopathic chest pain

Front 12

Patient has pneumothorax established on CXR. How do you manage her?

Back 12

Red flags

> 50

> 2cm rim at hilum

SOB

Suspected lung disease

Smoker or significant ex-smoked

0 red flag ⟹ Discharge and review in 2 weeks

1 red flag ⟹ Consult BTS guidelines but consider 14Ga cannula aspiration until < 2cm and not SOB
2+ red flags ⟹ US-guided chest drain and admit

Front 13

Name and describe one score can you use to assess the likelihood of PE

Back 13

Wells score for PE (≠ DVT)

Symptoms of DVT (+3)

Past DVT/PE (+1.5)

Haemoptysis (+1)

HR > 100 (+1.5)

Immobility/Surgery in past 4/52 (+1.5)

Malignancy (+1)

No alternative diagnosis (+3)

Front 14

Wells score for PE = 2. What do you do?

Back 14

D-Dimer to rule out

Front 15

Wells score for PE = 2. D-Dimer is elevated. What do you do?

Back 15

Start dalterparin and admit for a CTPA

Front 16

Initial management of a massive PE?

Back 16

MOT Heparin

Morphine 5-10mg IV

Oxygen 10-15L/min

Thrombolysis (alteplase 50mg bolus) if peri-arrest

Heparin (either LMWH or unfractionated as it has quicker effect)

Front 17

What will define the next step in the management of PE after MOT Heparin?

Back 17

SBP > 90 ?

Front 18

Patient with PE has had MOT Heparin and now has a SBP of 110. What do you do?

Back 18

Start warfarin loading (5–10mg PO)

Confirm diagnosis

Front 19

Patient with PE has had MOT Heparin and now has a SBP of 80. What do you do?

Back 19

Colloid fluid 500mL

ICU input

Dobutamine IV if BP still ➘
Noardrenaline IV if BP still ➘

Front 20

T/F: when starting warfarin in a patient with PE, you should stop the heparin

Back 20

False: heparin can be stopped once an INR of 2-3 has been achieved

Front 21

How long should you continue warfarin for after PE?

Back 21

At least 3 months and follow up in haematology to identify likely cause

Front 22

One bedside test that may be helpful in the diagnosis of aortic dissection. Is it specific or sensitive?

Back 22

Blood pressure difference between arms

A little specific (increases suspicion if positive)

Not sensitive at all

Front 23

What investigation should you do in a patient with suspected aortic dissection? What difficulty do you foresee?

Back 23

CT aortogram

Radiologists are reluctant to do it since many will be negative but aortic dissection is a rapid killer, so it's important to do it

Front 24

Management of aortic dissection

Back 24

Analgesia (regular and PRN)

Paracetamol and opioid

Blood pressure control

Aim for SBP between 100 and 120mmHg

Beta blockers or nitrates

Surgery

If Stanford Type A (Ascending and arch)

Front 25

What drives your decision to operate on aortic dissection?

Back 25

All Stanford Type A will

Front 26

What does ST depression imply?

Back 26

Ischaemia

Front 27

Name the 4 heart rhythms associated with cardiac arrest. Which are shockable and which aren't?

Back 27

Shockable

VFib

Pulseless VT

Non-shockable

Asystole

Pulseless Electrical Activity (PEA)

Front 28

Where do you place defibrillator pads?

Back 28

One below the right clavicle

One on the mid-axillary line at the position of V6

Front 29

What is surgical or subcut emphysema?

Back 29

Air trapped in the layer under the skin

Front 30

ALS algorithm

Back 30

Front 31

How does the management of shockable vs non-shockable rhythm differ?

Back 31

Only in the use or not of a defibrillator. The rest of it is exactly the same (including CPR sequences)

Front 32

What is the chain of survival in cardiac arrest?

Back 32

1) Early recognition and call for help to prevent cardiac arrest

2) Early CPR to buy time

3) Early defib to restart the heart

4) Post resuscitation care to restore QoL

Front 33

Energy to use for the shock

Back 33

150-360J biphasic

or 360J monophasic

Front 34

What should be done during CPR (5)?

Back 34

5A

Adjust reversible causes

Airway and Oxygen

Access (IV or intraosseous)

Adrenaline 1mg IV every 3-5min (after 3rd shock in shockable rhythms)

Amiodarone 300mg IV after the first 3 shocks

Front 35

What does a defibrillator do?

Back 35

Depolarises all cardiac muscle fibres simultaneously to reestablish synchronous rhythms and break re-entrant circuits

Front 36

The following are elements of the ALS. What takes precedence over what?

- Drugs

- Defibrillator

- CPR

Back 36

1) Defib should be given as soon as it arrives

2) CPR should be restarted directly after defib

3) Drugs should not delay defib and should be given alongside CPR

Front 37

How do you confirm cardiac arrest

Back 37

1) Shake and shout ➙ No response

2) Open airway

3) Check for normal breathing

4) Check for circulation (can be done with breathing assessment) ➙ No circulation

Front 38

Who do you contact when you call for help and how do you contact them?

Back 38

Resuscitation team 2222

Front 39

Describe adequate CPR technique

Back 39

Centre of chest

4-5cm deep (or 33% of chest depth)

100/min (Staying alive)

Front 40

No pulse

Back 40

Ventricular fibrillations – Shockable

Front 41

No pulse

Back 41

Asystole – Non-shockable

Front 42

No pulse

Back 42

Ventricular tachycardia - Shockable

Front 43

No pulse

Back 43

Pulseless electrical activity (PEA) - Non-shockable

Front 44

What methods of ventilation are possible during CPR (4)?

Back 44

1) Mouth to mouth

2) Pocket mask

3) Bag valve mask

4) i-gel supraglottic airway (picture)

Front 45

What buttons are always present on defib machines and what do they do?

Back 45

1 - Switches on

2 - Charges up

3 - Discharge

Front 46

How does the administration of adrenaline and the administration of amiodarone differ in ALS?

Back 46

Shockable rhythms

Amiodarone: Once after 3rd shock (hence only in shockable rhythm)

Adrenaline: Every 3-5 min. First shot with amiodarone, other shots every 2 cycles.

Non-shockable rhythms

No amiodarone

Adrenaline: First shot asap, other shots every 2 cycles.

Front 47

What do you do after every 2min of CPR (outline different pathways)?

Back 47

Stop CPR to assess rhythm

1) If shockable rhythm, give a shock

2) If asystole, start CPR again

3) If organised electrical activity check for pulse

3.1) If no pulse, start CPR again

3.2) If pulse, start post-resucitation care

Front 48

8 reversible causes of cardiac arrest

Back 48

4H and 4T

Hypoxia

Hypovolaemia

Hypo/HyperK, HypoCa, Hypoglycaemia, acidaemia and other metabolic disorders

Hypothermia

Tension pneumothorax

Tamponade cardiac

Toxins (mostly TCA in the UK)

Thrombosis (coronary or pulmonary)

Front 49

Most common reversible cause of cardiac arrest in kids

Back 49

Hypoxia

Front 50

Name two devices that may be used to secure the airway

Back 50

Endotracheal tube

Supraglottic airway device (eg i-gel, laryngeal mask airway)

Front 51

What changes in the ALS algorithm if the airway has been secured?

Back 51

Compressions no more need to be interrupted by ventilations

Front 52

T/F: Hyperventilation is not so much a concern in ALS

Back 52

False: Hyperventilation ⟹ Air trapping ⟹ Reduced venous return

Front 53

MOA of adrenaline useful in ALS

Back 53

α-agonist: arterial vasoconstriction ⟹ Raise systemic vascular resistance ⟹ Raise cerebral and coronary flow

β-agonist: raise heart rate, raise force of contraction, but also raise myocardial O2 demand

Front 54

How can we monitor that the endotracheal tube was correctly placed during ALS

Back 54

Capnography (waveform)

Front 55

What does larger values on capnography signify?

Back 55

Usually mean that things are working as they should:

1) Endotracheal tube is in the trachea (or bronchus)

2) There is no hyperventilation

3) Depth of compression is high enough

4) Perhaps return of spontaneous circulation (ROSC) has occurred.

Front 56

T/F: Adrenaline should no more be given if there are signs of ROSC during CPR

Back 56

True

Front 57

T/F: Amiodarone is perceived as a anti-arrhythmic during ALS because it only has a mild negative inotrope effect

Back 57

True

Front 58

What is part of the post-resuscitation care in cardiac arrest?

Back 58

ABCDE

12 lead ECG

Treat precipitating cause (MI, PE, pneumothorax, tamponade, ...)

Manage T°C to be 36°C or lower

Front 59

Define SIRS criteria and the new two criteria added by the surviving sepsis campaign (pre 2016 era)

Back 59

SIRS

◾ T°C > 38.3°C or < 36°C

◾ HR > 90

◾ RR > 20

◾ WBC > 12 or < 4 or > 10% immature forms

Addition

◾ Glucose > 6.66mM in the absence of DM

◾ Acutely altered mental status

Front 60

What defines severe sepsis (pre 2016 era)?

Back 60

End-organ dysfunction as testified by:

◾ Low BP (CV failure)

◾ High lactate (CV failure)

◾ Low urine output (renal failure)

◾ High creatinine (renal failure)

◾ High bilirubin (liver failure)

◾ High INR (liver failure)

Front 61

What defines septic shock (pre 2016 era)?

Back 61

Severe sepsis with hypotension not responding to fluid

Front 62

What is the sepsis six bundle and who should receive it?

Back 62

For patient with severe sepsis

1) IV ABx (as per local guidelines)

2) IV fluid boluses

3) Oxygen (aiming for Sats > 94% or 88-92% in COPD)

4) Measure FBC and lactate

5) Measure urinary output (consider catheter)

6) Take blood cultures (prior to ABx)

Front 63

UK Sepsis Trust criteria to suspect sepsis in a child

Back 63

Suspected infection and ≥2 of the following

T°C

> 38.5°C or < 36°C

HR

> 160 (under 1yo)

> 150 (1-2yo)

> 140 (2-5 yo)

Altered mental state

Sleepy, irritable, floppy

Reduced peripheral perfusion

Mottled, cold limbs, cap refill > 3s

Front 64

Management of septic child

Back 64

Paediatric sepsis six

1) IV or IO ABx

2) IV Fluid boluses (20mL/kg x 2)

3) Oxygen

4) Blood culture, FBC, lactate, CRP, glucose

5) Inform senior clinician immediately

6) Inotropic support if still hypoperfused after 2 fluid boluses

Note: compare to sepsis six:

1) Give 3 is the same

2) Take 2 are the same (urine output is dropped)

3) Take CRP and glucose

4) Inform 1 (senior clinician)

Front 65

Which require ABx?

Back 65

Diverticulitis

Pyelonephritis

Cellulitis

UTI

For tonsilities, Centor ≥3/4 is required

For abscess, first incision and drainage

Front 66

Define syncope

Back 66

Rapid loss of consciousness followed immediately by a return to baseline (within minutes)

! Not syncope if they have not returned to baseline

Front 67

What is the common mechanism of transient loss of consciousness

Back 67

Cannot get O2 and glucose from heart to brain

Front 68

Outline an effective system to classify causes of transient loss of consciousness

Back 68

◾ Before the heart (eg blood pooling)

◾ In the heart (eg arrhythmia)

◾ In arteries (eg dissection)

◾ In the brain (eg intra-cranial haemorrhage)

Front 69

5 causes of TLOC before the heart

Back 69

◾ IVC compression (pregnancy, tumour…)

◾ Pooling of blood in the leg

◾ Not enough circulating blood (haemorrhage, GI bleed, AAA, dehydration, diuretics, sepsis…)

◾ Vasodilation (sepsis, warmth, drugs…)

◾ Increased intra-thoracic pressure (cough, breath holding…)

◾ Combination: getting up of bath ⟹ Vasodilation (due to hot T°C) then postural hypotension

Front 70

5 causes of TLOC at the heart

Back 70

PE (outflow obstruction)

MI

Vasovagal ⟹ HR ➘ (psychological, pain, …)

Arrhythmia

Aortic stenosis

Obstruction (eg obstructive cardiomyopathy)

Negative chronotropes (beta blockers…)

Myxoma

Front 71

5 causes of TLOC in the arteries

Back 71

Aortic dissection

Carotid stenosis

Carotid sinus massage (eg old man extending neck and shaving)

Aortic regurgitation

Vasodilation (eg sepsis)

Front 72

5 causes of TLOC in the brain

Back 72

TIA/Stroke

High ICP

Hypercapnia (vasodilation and low O2)

CO poisoning

Intra-cranial haemorrhage

Hypoglycaemia

Front 73

29 year old female has TLOC during exercise. It's the first time that it happens and her DH and PMH are otherwise unremarkable. What one question would you like to ask that patient?

Back 73

Has anyone in the family died young?

You suspect obstructive cardiomyopathy and arrhythmias

Front 74

Why can urinating cause TLOC?

Back 74

PNS activation

Front 75

29 year old female has TLOC at rest. It's the first time that it happens and her DH and PMH are otherwise unremarkable. What two bedside test would you want to do?

Back 75

ECG

hCG

Front 76

Diagnoses not to miss

TLOC + Headache

TLOC + Neural deficit

TLOC + Confusion

TLOC + Chest pain

TLOC + back pain in older patient

TLOC + abdo pain in older patient

TLOC + positive hCG

Back 76

TLOC + Headache – Subarachnoid or intracranial haemorrhage

TLOC + Neural deficit – TIA/Stroke

TLOC + Confusion – Seizure

TLOC + Chest pain – MI, PE or aortic dissection

TLOC + back pain in older patient – AAA

TLOC + abdo pain in older patient – AAA

TLOC + positive hCG – Ectopic pregnancy

Front 77

Long QT syndrome

Definition

Aetiology

Precipitants

Management

Back 77

Definition – QTc > 440ms (♂), > 460ms (♀)

Aetiology – Congenital

Precipitants – Drugs

Management – Avoid exercise, no driving

Front 78

Two ECG features of WPW

Back 78

Short PR

Delta waves

Front 79

How is WPW managed?

Back 79

Cardiology follow up

No exercise until cleared by cardiology

Front 80

Aetiology of Brugada syndrome and ECG features

Back 80

Sodium channel disorder causing syncope

ST elevation followed by T wave inversion or ST saddle back type often with RBBB

Front 81

Most likely cause of TLOC in a 25, a 55 and an 85 year old

Back 81

25 – Vasovagal

55 – Vasovagal and arrhythmias

85 – Orthostatic due to drugs

Front 82

Most important questions to ask in the history of a TLOC

Back 82

Before

Any warning?

Any precipitant?

Any recent trauma?

During

How long was the TLOC?

Tongue biting, muscle contraction, urinary or faecal incontinence?

After

How was the recovery? Spontaneous? Confused for a while?

Front 83

For the following 3 common aetiologies of TLOC, outline the before, during and after of TLOC: epilepsy, vasovagal, arrythmia

Back 83

Front 84

How informative is the presence of incontinence in identifying the aetiology of TLOC?

Back 84

Not really informative but for exam purposes, it usually suggests seizures

Front 85

T/F – Convulsions and jerks during TLOC is a specific sign of epilepsy

Back 85

False: twitching may also occur in vasovagal and arrhythmia

Front 86

What mostly distinguish vasovagal from arrhythmic causes of TLOC?

Back 86

Prodrome (sweating, pallor, nausea) and precipitant present in vasovagal but absent in arrhythmia

Front 87

Recurrent unprovoked TLOC in a 37 year old with no awareness of it and no prodrome, sometimes with a twitch. Episodes last for a few minutes after which she is fine apart from headaches sometimes.

Back 87

Non-epileptic seizures (ask for PMH of anxiety and depression)

Note: stereotyped episodes and post-ictal confusion is characteristic of epileptic seizures, not non-epileptic seizures.

Front 88

42 year old man with multiple episodes of TLOC mostly when he runs or rushes. Prodrome: sweating. Complete recovery within seconds. No tongue biting. Normal ECG and bloods. Two differentials.

Back 88

Aortic stenosis (bicuspid valve)

Hyperthrophic cardiomyopathy (HOCM)

Front 89

How is the diagnosis of epilepsy confirmed?

Back 89

Clinical diagnosis

EEG, CT and MRI are all taken but the diagnosis can be made even if these are negative.

Front 90

Define seizure.

Back 90

Transient excessive electrical activity with motor, sensory, orcognitive manifestations discernible to the patient or an observer

Front 91

Define a classification of seizures in two categories

Back 91

Generalised – Electrical activity affects the whole brain from the start

Partial – Electrical activity starts focally (but may then affect the whole brain)

Front 92

6 classes of generalised seizures

Back 92

Tonic-clonic

Rigid first, then convulsions

Absence

LOC and unresponsive

Atonic

Loss of tone causing fall

Tonic

Rigid

Clonic

Convulsions

Myoclonic

One very brief muscle jerk (< 0.1s)

Front 93

2 classes of partial seizures

Back 93

Simple – No impaired consciousness

Complex – Impaired consciousness

Front 94

Name 4 causes of TLOC that may lead to sudden cardiac death in a young individual and athletes. How can they be treated?

Back 94

◾︎ Hypertrophic cardiomyopathy

◾︎ Long QT

◾︎ Brugada syndrome

◾︎ Arrhythmogenic right ventricular dysplasia

Treatment: implantable cardioverter and beta blockers

Front 95

Pattern recognition

TLOC while turning head

Back 95

Carotid sinus hypersensitivity

Front 96

How does the prodrome in vasovagal and cardiac causes of TLOC differ?

Back 96

Vasovagal – Few minutes

Cardiac – Few seconds

Front 97

6 red flags in TLOC. What should you do if you encounter a patient with TLOC and any of them?

Back 97

Refer within 24h for specialist CV assessment

◾ ECG abnormality (Long QT, Brugada, MI...)

◾ Hx of heart failure

◾ TLOC during exertion

◾ FHx of young sudden cardiac death

◾ New or unexplained SOB

◾ Heart murmur

Front 98

Normal PR interval

Back 98

200ms

Front 99

Diagnosis and management

Back 99

Normal, possibly first degree heart block (PR > 200ms) but may be normal given that he is young and asymptomatic. So no need to do anything.

Front 100

Diagnosis and first line management

Back 100

Mobitz Type 1

Atropine 500mcg IV

Front 101

Diagnosis and first line management

Back 101

Mobitz Type 2

Atropine 500mcg IV (even if there was no syncope)

Front 102

Diagnosis and first line management

Back 102

Complete heart block

Atropine 500mcg IV (even if there was no syncope)

Front 103

One advantage and one disadvantage of transcutaneous pacing

Back 103

✔ Quick (can be done before transvenous pacing is available)

✘ Uncomfortable for patient

Front 104

What should be done before transcutaneous pacing (3)?

Back 104

Skin dry

Chest hair shaved

IV sedation/analgesia

Front 105

How is transcutaneous pacing achieved?

Back 105

Same machine as defibrillator

1) Connect pads

2) Select pacer mode

3) Choose rate between 60 and 90 (and in any case, higher than the patient's HR)

4) Start at a low current and gradually increase. You will see spikes at the rate selected in (2). Once each spike is followed by QRS (usually between 50 and 100mA), stop increasing.

5) Check that mechanical capture has been achieved too by checking the pulse

Front 106

Should "sync" be on or off for pacing?

Back 106

Off (it's "on" for shocks)

Front 107

T/F: Adenosine should be administered as centrally as possible

Back 107

True: it has a very short half life

Front 108

Name two airway opening manoeuvres

Back 108

Chin lift

Jaw thrust

Front 109

Assessment of airway in ATLS (ABCDE)

Back 109

◾ Hold patient's head with both hands

◾ "Hello can you hear me?"

◾ Look in the mouth

◾ Ear against mouth: looking (chest expansion), listening (stridor) and feeling (air to cheeks)

◾ Give O2 15L via non-rebreatheable mask

◾ Triple immobilisation of the C-spine

Front 110

Name 3 adjuncts airway that you may consider in a patient with trauma

Back 110

Nasopharyngeal tube

Oropharyngeal tube

Bag and mask

Front 111

Two contraindications of nasopharyngeal tube in a trauma patient

Back 111

Basal skull fracture (look for Panda eyes and Battle's sign)

Broken nose

Front 112

Who can help if there are problems achieving appropriate airway in a trauma patient?

Back 112

Anaesthetist

Front 113

How do you assess breathing in ALTS (ABCDE)

Back 113

◾ Pulse oximeter (nurse)

◾ Neck: abnormalities, injury (blood on gloves), steps over C-vertebrae

◾ Trachea: central and crepitus

◾ Expose chest: look for injuries

◾ Put hands on chest symmetrical breathing

◾ RR

◾ Feel around the flank and back and look for blood on gloves

◾ Percussion of 6+2 areas

◾ Auscultation of 6+2 areas + heart

◾ Order CXR and pelvic X-ray (can be kept for C but easier to do them both together)

Front 114

Who can help if there are problems restoring breathing in a trauma patient?

Back 114

Surgeon

Front 115

Name 3 actions that may be taken to improve breathing in a trauma patient

Back 115

◾ Dressings: 3-sided valve

◾ Thoracocentesis (pleural tap)

◾ Chest drain

Front 116

How do you assess circulation in ALTS (ABCDE)?

Back 116

◾ Patient's appearance (color, etc.)

◾ HR

◾ BP

◾ Feel peripheral T°C

◾ Cap refill

◾ Insert two large-bore cannulae in antecubital fossa

◾ From first cannula, draw blood for: group and save, FBC, LFT, U&E, amylase and clotting

◾ Run a bag of warm saline in each cannula to maintain patency

◾ Evidence of external bleeding, check abdomen and limbs

◾ Pelvic X-ray

Front 117

What 3 actions can be taken to improve circulation in a patient with trauma?

Back 117

◾ Warm fluids - 2x1L (in each cannula) of warm Hartmann's

◾ Stop bleeding: dressing, tourniquet, splintage, pelvic binder

◾ Pericardiocentesis (if cardiac tamponade)

Front 118

Who can help if there are problems restoring circulation in a trauma patient?

Back 118

Surgeon

FAST scan and Diagnostic peritoneal lavage (DPL) to assess internal bleeding

Front 119

How are disabilities assessed in ATLS (ABCDE)?

Back 119

◾ Responsive: "Can you wiggle your toes and fingers for me, please? Do you have any numbness or pins and needles anywhere?"

◾ Non-responsive: supra-orbital pressure to see for response to pain

◾ AVPU

◾ Capillary blood glucose (nurse)

◾ Pupils with a pen torche (size and reactivity)

◾ Plantar reflexes

Front 120

What three actions can be taken if there are worries about disability in ATLS patients?

Back 120

◾ Analgesia

◾ Glucose

◾ CT head

Front 121

Who can help make decisions about disabilities in trauma patients?

Back 121

Neuro-surgeon

Front 122

How is exposure assessed in ATLS (ABCDE)?

Back 122

◾ Expose patient fully to check for any signs of injury

◾ T°C (nurse)

◾ Cover patient with blanket to maintain T°C

Front 123

Who can help if there are any worries raised during the exposure stage of ATLS?

Back 123

ITU

Front 124

What action can you take for a hypothermic patient in ATLS?

Back 124

Bair Hugger Warming Blankets

Front 125

How is the primary survey closed in ATLS (5)?

Back 125

ECG

ABG

Urinary catheter

Gastric catheter

Log roll and secondary survey

Front 126

What 3 actions are taken before starting the primary survey in ATLS?

Back 126

1) Ask for help

2) Personal protective equipment of gown, glasses and gloves

3) "Is it safe to approach?"

Front 127

If a patient appears not to be breathing in a trauma scenario, what is your next step?

Back 127

◾ Jaw trust (even if there is risk of C-spine injury)

◾ Insert a Guedel and check that patient tolerates it

◾ Give Oxygen 15L via a non-rebreatheable mask

◾ Only then apply C-colar

Front 128

What is the indication for a definitive airway in ATLS? Who should put it?

Back 128

In any patient that has required an adjunct (adjunct is only temporary).

Call the anaesthetist

Front 129

Where should pelvic binder be positioned?

Back 129

Over the greater trochanters, not over the iliac crests

Front 130

How are nasopharyngeal tube calibrated?

Back 130

Diameter = Diameter of the little finger

Front 131

Chocking algorithm

Back 131

1) If pt coughing, encourage to cough more

2) Tap on back between scapulae up to 5x

3) Heimlich’s manoeuvre

Front 132

Classifications of haemorrhage and what fluid you use in each

Back 132

Front 133

Significance of laryngeal crepitus

Back 133

Its absence suggests laryngeal injury

Front 134

Significance of abdo guarding, tenderness, peritonism in ATLS?

Back 134

Suggests possibility of internal bleeding

Front 135

What are the 5 areas to look for signs of haemorrhage in ATLS?

Back 135

Chest (done in B)

External

Abdo

Pelvis

Long bones

Front 136

How is pelvic injury assessed in ATLS?

Back 136

Look for asymmetry

Feel pubic symphysis and iliac crest (without pressure !)

Front 137

In ATLS, what should be done about a suspected fractured femur? fracture of humerus?

Back 137

Femur: Traction splint

Humerus: Box splint or vacuum splint

Front 138

How is the result of BM interpreted in ATLS?

Back 138

Expected to be high die to acute response

Low is worrying

Front 139

Main differential for SOB

Back 139

Respiratory

Pneumonia

Effusion

PE

Pneumothorax

Asthma

COPD

Cardiovascular

Anaemia

ACS

Pulmonary oedema (LVF)

Arrhythmia

Metabolic

Acidosis

Renal failure

DKA

Neuro

Neuromuscular diseases

Stroke with hypothalamic lesions

Miscellaneous

Anxiety

Pregnancy

Trauma

Front 140

What is diaphoresis?

Back 140

Abnormally abundant sweating

Front 141

Normal inspiration on CXR

Back 141

5 to 7 anterior ribs intersecting the diaphragm in the mid-clavicular line

Front 142

What ventilation device may you consider in a patient with an acute exacerbation of COPD?

Back 142

Non-invasive positive pressure ventilation

Front 143

Compare the presentation of pneumococcal and atypical pneumonia

Back 143

Pneumococcal

Sudden onset fever, rigors, productive cough, SOB

Atypical

Low grade fever, coryza, dry cough

Front 144

What tool can help determine what patients with pneumonia to admit to hospital.

Back 144

CURB-65 score

Confusion (AMT ≤ 8)

Urea > 7

RR ≥ 30

SBP < 90 or DBP ≤ 60

Age ≥ 65

0-1: Outpatient

2-3: Consider short stay

4-5: Admit, consider ITU

Front 145

ABx of choice in pneumonia in allergic to penicillin and not and based on severity.

Back 145

CURB 0-1

Amoxicillin

Allergic: Doxycycline

CURB 2-5

Amoxicillin IV + Clarithromycin PO

Allergic: Ceftriaxone IV + Clarithromycin PO

Front 146

ABx of choice in septic shock

Back 146

Co-amoxiclav + Gentamicin (one dose)

Allergic: Ceftriaxone + Gentamicin (one dose)

Front 147

Signs of CHF on CXR

Back 147

ABCDE

Alveolar oedema (in a ‘bat’s wing’s distribution)

Kerley B lines

Cardiomegaly

Upper Lobe Diversion

Pleural Effusion

Front 148

Investigation of congestive heart failure

Back 148

CXR (ABCDE)

Bloods: FBC, Electrolytes, trop

ECG

Search for cause of decompensation

Front 149

One marker that correlates with CHF severity

Back 149

BNP

Front 150

T/F: BNP is used in GP but not in ED

Back 150

T

Front 151

Pattern recognition

Pink frothy sputum

Back 151

Heart failure/Pulmonary oedema

Front 152

Acute management of heart failure

Back 152

Arrhythmias – ECG monitoring and treatment

Diuretics – Furosemide 40-80mg IV slowly
Oxygen – 100% if not COPD
Nitrates – GTN 2 puffs SL (avoid if SBP < 90)
Opioids – Diamorphine 1.25-5mg IV

Front 153

What do you do if a patient with CHF keeps deteriorating despite ADONO?

Back 153

Diuretics – Add a dose of furosemide 40-80mg IV

Oxygen – Consider CPAP (get help!)

Nitrates – Increase if SBP remains > 100

Front 154

3 top causes of traumatic brain injury in the UK

Back 154

Assaults (40%)

Falls (30%)

Road traffic collisions (25%)

Front 155

What explains that raised ICP (as caused by a mass) decreases the volume of venous blood and CSF

Back 155

Monro-Kellie doctrine

Front 156

Define the cerebral perfusion pressure

Back 156

CPP = Mean arterial pressure - ICP

Front 157

Normal value of CPP. Why is that relevant?

Back 157

>70 mmHg

Maintaining the CPP above 70mmHg is one of the key target of treatment to reduce mortality in TBI

Front 158

What is the primary and secondary brain injury

Back 158

Primary

At time of injury causing neuronal death/damage

Secondary

Occurs later and can be prevented by resuscitation and treatment

Front 159

What causes secondary brain injury?

Back 159

Hypoxia

Hypovolaemia

Hypoglycaemia

Raising ICP (haematoma, oedema, hypercapnia)

Epilepsy

Infection

Front 160

Name key elements of PMH (2), DH (2) in TBI

Back 160

PMH

Neurosurgery, clotting disorders

DH

Anticoagulants, tetanus state

Front 161

T/F: Skull X-ray should always be acquired in a patient with TBI in which skull fracture is suspected

Back 161

False: diagnosis is clinical and with CT

SXR has been shown to be not sensitive enough and NICE recommends against it

Front 162

Patient with TBI has low GCS and smell of ETOH. What do you do?

Back 162

Admit the patient for later investigation. Do never attribute low GCS to ETOH!

Front 163

When should minor head injury be admitted?

Back 163

All very intuitive

Low GCS

Neurological deficit

Seizure

Skull #

Severe headache, vomiting

Inability to assess (eg ETOH)

No one at home to look after patient

Front 164

How is major head injury managed

Back 164

Similarly to ATLS

Obvious scalp lacerations, haematoma... are acknowledged in secondary survey

Front 165

Four signs of basal skull fracture

Back 165

Panda eyes

Battle's sign

Otorrhoea/Rhinorrhoea

Haemotympanum

Front 166

What does RSI refer to in airway management?

Back 166

Rapid sequence intubation

The protocol followed to intubate a patient

Front 167

Roughly speaking, which adults with TBI require a CT head scan?

Back 167

Those with worrying features

Low GCS

Suspected (basal) skull fracture

Seizure

Focal neurological deficit

Several vomiting

Those on warfarin

Those with LOC or amnesia and some RF for intracranial bleed

Front 168

Roughly speaking, which children with TBI require a CT head scan?

Back 168

Similar to adults but also all children with suspected NAI

Front 169

Most common aetiology of extradural, subdural, and subarachnoid haematoma.

Back 169

Extradural – Trauma

Subdural – Trauma, aging, alcohol (tearing of veins)

Subarachnoid – Ruptured Berry aneurysm (80%), arteriovenous malformation (15%)

Front 170

Which blood vessels are most commonly affected in extradural, subdural, and subarachnoid haematoma?

Back 170

Extradural – Artery (middle meningeal artery)

Subdural – Small bridging veins (+ if acute, possibly venous sinus)

Subarachnoid – Bifurcations in arterial network

Front 171

Immediate LOC followed by lucid interval followed by progressive decline in GCS is the presentation of what type of intracranial haemorrhage? How long does the lucid interval last and in what fraction of patients does it occur?

Back 171

Extradural (lucid interval in 20–50% of patients for couple of hours)

Front 172

Sudden onset of severe thunderclap headache is the presentation of what type intracranial haemorrhage?

Back 172

Subarachnoid

Front 173

Personality change and memory loss is the presentation of what type of intracranial haemorrhage?

Back 173

Chronic subdural

Front 174

Sudden severe headache (“worst headache in my life”, it's like I got hit by a hammer") is the presentation of what type of intracranial haemorrhage?

Back 174

Subarachnoid

Front 175

Which of the following intracranial haemorrhages may cause midline shift?

◾ EDH

◾ Acute SDH

◾ Chronic SDH

◾ SAH

Back 175

EDH and acute SDH

Front 176

Management of extradural, subdural and subarachnoid haemorrhages

Back 176

EDH: Emergency evacuation

Acute SDH: Emergency invasive evacuation (blood is clotted)

Chronic SDH: Burr hole evacuation (blood is liquid)

SAH: Calcium channel blocker + Endovascular coiling (better than clipping when possible)

Front 177

What should be done regarding BP in patients with subarachnoid haemorrhage?

Back 177

Maintain a higher–than–normal SBP to maintain adequate perfusion (even if it increases bleeding)

Front 178

Main complication of extradural, subdural and subarachnoid haemorrhages

Back 178

Extradural – Herniation

Subdural – Progressive stroke

Subarachnoid – Rebleeding, hydrocephalus, vasospasm

Front 179

Evolving stroke is the presentation of what intracranial haemorrhage?

Back 179

Subdural (due to progressively increasing ICP)

Front 180

What intracranial haemorrhage is particularly more likely in elderly? Why?

Back 180

Subdural because the brain shrinks and therefore tense the bridging veins.

Front 181

Back 181

Subdural haemorrhage

Compression of the brain but no infiltration in sucli and fissures and banana–shaped

Front 182

Back 182

Subdural haemorrhage

Compression of the brain but no infiltration in sucli and fissures and banana shaped

Front 183

Back 183

Subdural and extradural haemorrhage

Compression of the brain but no infiltration in sucli and fissures and banana shaped (right) and lemon shaped (left)

Front 184

Back 184

Extradural haemorrhage

Compression of the brain but no infiltration in sulci and fissures and lemon shaped

Front 185

Back 185

Subarachnoid haemorrhage

No compression of the brain but infiltration of blood in sulci, fissures and brainstem

Front 186

Back 186

Intracranial haematoma

Focal area of haemorrhagic contusion in right frontal lobe with surrounding hypointensity due to infarction or oedema

Front 187

Name a likely mechanism for this intracranial haematoma

Back 187

Contre-coup

Front 188

Back 188

Subarachnoid haemorrhage

No compression of the brain but infiltration of blood in sulci, fissures and brainstem

Front 189

Back 189

Depressed skull fracture of the left parietal bone

Front 190

Management in ED if abnormal CT is found

Back 190

Discuss with neurosurgeons

In the meantime: aim to prevent secondary brain damage

Front 191

Zones of a burn

Back 191

Coagulation

Cells have been destroyed, avascular

Stasis

Cells injured but should survive

Hyperaemia

Minimal thermal damage but marked inflammatory response

Front 192

Scald in French

Back 192

Ebouillanter

Front 193

6 mechanisms of burn

Back 193

Wet heat (scald)

Dry heat (flame)

Explosions

Chemical

Electrical

Ionising radiation

Front 194

Classes of burns based on anatomy

Back 194

Superficial (1°)

Superficial partial thickness (2°)

Deep partial thickness (2°)

Full thickness (3°)

Front 195

Appearance of superficial burn

Back 195

Also called simple erythema

Front 196

Appearance of a superficial partial thickness burn

Back 196

Front 197

Appearance of a deep partial thickness burn

Back 197

Front 198

Appearance of a full thickness burn

Back 198

Front 199

How can the 1% rule be used to assess body surface area of a burn?

Back 199

One hand flat with fingers together ≈ 1% of total body area

Front 200

How can the Wallace rule of 9s rule be used to assess body surface area of a burn?

Back 200

Front 201

How can the Lund and Browder chart be used to assess body surface area of a burn?

Back 201

Like the Wallace rule of 9s but more accurate

Front 202

Name 4 body areas that lead to worse prognosis if burnt. How does the management differ in those cases?

Back 202

Require specialist assessment

Face

Hands and feet

Ears

Perineum and genitalia

Front 203

Criteria to refer to burns unit (6)

Back 203

Critical burns (% of body surface area)

◾ Superficial burn 75%

◾ Partial thickness 15% (adult), 10% (child), 5% (elderly)

◾ Full thickness 5%

◾ Inhalation injury

◾ Significant chemical burns

◾ Burns complicated with fracture or soft tissue injury

Front 204

Type and quantity of fluid required for replacement in burns

Back 204

Parkland's formula – 24h

Volume in mL=%BSA (2°) x Weight x 4

of combined Hartman's (half given over 8h and the rest over 16h)

Front 205

How much fluid would you give to a patient of 75kg with a 70% burn of 1° and a 5% burn of 2°?

Back 205

Volume in mL=%BSA (2°) x Weight x 4 = 5x75x4 = 1500mL

of Hartman's (half given over 8h and the rest over 16h)

750mL given over 8h

750mL given over the next 16h

Front 206

Name 4 injuries associated with burns

Back 206

Inhalation injury

Blast injury

CO poisoning

Cyanide poisoning

Front 207

Pathogenesis of inhalation injuries

Back 207

◾ Heat injures the upper airway causing oedema of pharynx & larynx – may lead to acute obstruction

◾ Smoke inhaled into bronchial tree causing smoke inhalation injury – may lead to adult respiratory distress syndrome (ARDS)

Front 208

T/F: If a patient is not in respiratory distress after a burn, he won't have ARDS later

Back 208

False: ARDS can be of late onset

Front 209

4 clinical signs and symptoms of inhalation injury

Back 209

Altered LOC

Mouth burn

Soot in nostrils

Respiratory distress

Front 210

5 investigations to carry out in a suspected inhalation injury

Back 210

PEF

CXR

ECG

ABG

COHb

Front 211

Management of inhalation injury (3)

Back 211

Early intubation

Highest possible concentration of O2 (possibly hyperbaric if suspected CO poisoning too)

Salbutamol if bronchospasms

Front 212

What causes primary, secondary, tertiary, and quaternary blast injuries

Back 212

Primary – Blast wave, barotrauma

Secondary – Projectile

Tertiary – Blast wind, crush injuries, amputations

Quaternary – Burns, inhalation injuries

Front 213

Pathogenesis of CO poisoning

Back 213

CO has higher affinity to Hb than O2 and knocks off O2 and CO2

Front 214

Presentation of mild exposure to CO

Back 214

Slight headache

N&V

Fatigue

Flu-like

Front 215

Presentation of moderate exposure to CO

Back 215

Severe headache

Drowsiness

Confusion

Tachycardia

Front 216

Presentation of severe exposure to CO

Back 216

LOC

Convulsions

Heart/Respiratory failure

Death

Front 217

Maximum indoor air quality level of CO

Back 217

9 ppm

Front 218

Management of CO poisoning

Back 218

Secure airway

100% oxygen 15L/min

Seek specialist advice ASAP

May require hyperbaric O2

Front 219

Patient presents to A&E with a burn over his face and neck. He was found unconscious in his apartment that was on fire. You suspect he might have had CO poisoning and do a pulse oximetry which is normal. What do you do?

Back 219

Keep investigating

Pulse oximetry is useless in CO poisoning as it is not altered.

Front 220

What causes cyanide poisoning in burns?

Back 220

Burning of certain polymers

Front 221

Management of cyanide poisoning

Back 221

Specialist help ASAP (an antidote exists)

Front 222

Management of smaller burns

Back 222

A lot of cold water

Analgesia

Tetanus status

Sterile non-adherent dressing