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Amorning inA&E 7.6.25 Dr Milena Nossen, Dr Yi Sim, Dr Deepshikha KumarLearningOutcomes To revise the main presentations in A&E including: ● Chest Pain (ACS, PE, Aortic Dissection) ● Breathlessness (Asthma, COPD, Pneumonia, Pulmonary Embolism) ● Collapse & Altered Consciousness (Seizures, Stroke, Syncope, DKA, Hypoglycemia) ● Major Trauma (ATLS Principles, Head Injury, Spinal Cord Injury) ● Sepsis & Shock (Recognition, Sepsis 6, Fluid Resuscitation) ● Psychiatric emergencies (MHA, self harm, suicide, psychosis)Question 1 A 24-year-old man presents to A&E with shortness of breath, wheeze, and chest tightness. He has a history of asthma and reports using his salbutamol inhaler more frequently over the past two days. On examination, he is speaking in full sentences, respiratory rate is 22 breaths/min, heart rate is 98 bpm, oxygen saturation is 95% on room air, and there is widespread expiratory wheeze on auscultation. What is the most appropriate initial management? A) Administer nebulised salbutamol and ipratropium bromide, give oral prednisolone B) Start IV hydrocortisone and aminophylline infusion C) Provide high-flow oxygen and prepare for intubation D) Administer salbutamol via a spacer and give oral prednisolone E) Discharge with reassurance and GP follow-upQuestion 1 A 24-year-old man presents to A&E with shortness of breath, wheeze, and chest tightness. He has a history of asthma and reports using his salbutamol inhaler more frequently over the past two days. On examination, he is speaking in full sentences, respiratory rate is 22 breaths/min, heart rate is 98 bpm, oxygen saturation is 95% on room air, and there is widespread expiratory wheeze on auscultation. What is the most appropriate initial management? A) Administer nebulised salbutamol and ipratropium bromide, give oral prednisolone B) Start IV hydrocortisone and aminophylline infusion C) Provide high-flow oxygen and prepare for intubation D) Administer salbutamol via a spacer and give oral prednisolone E) Discharge with reassurance and GP follow-upAcute asthma-assessment 1. History a. Number and severity of previous exacerbations c. Medication compliancens d. Other risk factors (learning disability, social isolation etc) 2. Observations - HR, RR, sats 3. Examination 4. Peak flow 5. ABG if sats <92% or life-threatening 6. Viral swabs / culture if suggested infective causeAcute asthma-classificationAcute asthma-management 1. Oxygen (if required) + Salbutamol (via spacer initially) + prednisolone a. Nebuliser if no improvement 2. Oxygen + nebulised salbutamol +/- ipratropium + prednisolone/hydrocortisone 3. Oxygen + nebulised salbutamol + ipratropium + prednisolone/hydrocortisone a. Consider magnesium sulfate / b. ITU discussion / intubationQuestion 2 A 72-year-old woman with severe COPD presents to A&E with worsening dyspnoea and productive cough over the last 4 days. On arrival, she is drowsy and using accessory muscles to breathe. Oxygen saturation is 88% on room air. After initial treatment with controlled oxygen via a Venturi mask, nebulised salbutamol and ipratropium, and oral prednisolone, she remains breathless. Arterial blood gas shows: pH: 7.28 pCO₂: 8.4 kPa pO₂: 7.1 kPa HCO₃: 28 mmol/L What is the most appropriate next step in management? A) Continue current treatment and monitor for 1 more hour B) Increase oxygen concentration to 60% C) Start non-invasive ventilation (NIV) D) Intubate and commence invasive ventilation E) Discharge with antibiotics and oral steroidsQuestion 2 A 72-year-old woman with severe COPD presents to A&E with worsening dyspnoea and productive cough over the last 4 days. On arrival, she is drowsy and using accessory muscles to breathe. Oxygen saturation is 88% on room air. After initial treatment with controlled oxygen via a Venturi mask, nebulised salbutamol and ipratropium, and oral prednisolone, she remains breathless. Arterial blood gas shows: pH: 7.28 pCO₂: 8.4 kPa pO₂: 7.1 kPa HCO₃: 28 mmol/L What is the most appropriate next step in management? A) Continue current treatment and monitor for 1 more hour B) Increase oxygen concentration to 60% C) Start non-invasive ventilation (NIV) D) Intubate and commence invasive ventilation E) Discharge with antibiotics and oral steroidsCOPD-assessment 1. History a. Features: breathlessness, cough, fever, wheeze, URTI symptoms b. Baseline 2. Observations - HR, RR, sats, temp, BP 3. Examination 4. ABG a. T2RF with acidosis +/- raised HCO3 5. CXR 6. Sputum culture/ viral swabsCOPD-management 1. Salbutamol a. Nebulised via air (spacer if mild) 2. Ipratropium bromide a. Via nebulisers if salbutamol has no effect b. Stop long-acting antimuscarinics 3. Oxygen (scale 1 vs scale 2) a. Via Venturi 24%-28% 4. Prednisolone 5. Consider antibiotics if: a. Increased sputum volume/ purulence or dyspnoea 6. Consider NIV if: a. pH <7.35 and pCO2 >6.5 despite optimal medical treatment 7. Consider intubation if above fails / pH <7.25Question 3 A 25-year-old tall, slim man presents to A&E with sudden-onset left-sided pleuritic chest pain and shortness of breath. He is otherwise fit and well, with no history of trauma. His observations are: RR 20, HR 92 bpm, SpO₂98% on room air On examination, he has reduced breath sounds and hyperresonance on percussion on the left side. His trachea is central A chest X-ray confirms a left-sided pneumothorax with a 2.5 cm rim of air between the lung margin and chest wall at the level of the hilum. What is the most appropriate next step in management? A) Immediate needle decompression B) Discharge with safety netting and outpatient follow-up C) Insert a chest drain D) Attempt needle aspiration E) Administer high-flow oxygen and observe in hospitalQuestion 3 A 25-year-old tall, slim man presents to A&E with sudden-onset left-sided pleuritic chest pain and shortness of breath. He is otherwise fit and well, with no history of trauma. His observations are: RR 20, HR 92 bpm, SpO₂98% on room air On examination, he has reduced breath sounds and hyperresonance on percussion on the left side. His trachea is central A chest X-ray confirms a left-sided pneumothorax with a 2.5 cm rim of air between the lung margin and chest wall at the level of the hilum. What is the most appropriate next step in management? A) Immediate needle decompression B) Discharge with safety netting and outpatient follow-up C) Insert a chest drain D) Attempt needle aspiration E) Administer high-flow oxygen and observe in hospitalPneumothorax-assessment 1. ABCDE 2. Imagina. urgent chest x-rayPneumothorax-management 1. Conservative management 2. Needle aspiration a. 2nd intercostal space OR b. Safety triangle 3. Chest drain a. Safety triangle 4. Repeat imagingTension pneumothorax-management Immediate needle decompression + chest drain!!Question 4 A 74-year-old man presents to A&E with a 3-day history of productive cough, fever, and increasing shortness of breath. On examination, his temperature is 38.5°C, respiratory rate is 28 breaths/min, blood pressure is 92/58 mmHg, heart rate is 104 bpm, and SpO₂ is 90% on room air. Auscultation reveals bronchial breath sounds and coarse crackles in the right lower zone. His chest x-ray is shown on the right. Bloods show WCC 14.2 ×10⁹/L and CRP 136 mg/L. What is the most appropriate next step in management? A) Admit and start oral amoxicillin B) Discharge with oral doxycycline and safety-netting C) Calculate CURB-65 score and manage based on risk stratification D) Give IV furosemide and arrange urgent echocardiogram E) Start oseltamivir and isolate for suspected influenzaQuestion 4 A 74-year-old man presents to A&E with a 3-day history of productive cough, fever, and increasing shortness of breath. On examination, his temperature is 38.5°C, respiratory rate is 28 breaths/min, blood pressure is 92/58 mmHg, heart rate is 104 bpm, and SpO₂ is 90% on room air. Auscultation reveals bronchial breath sounds and coarse crackles in the right lower zone. His chest x-ray is shown on the right. Bloods show WCC 14.2 ×10⁹/L and CRP 136 mg/L. What is the most appropriate next step in management? A) Admit and start oral amoxicillin B) Discharge with oral doxycycline and safety-netting C) Calculate CURB-65 score and manage based on risk stratification D) Give IV furosemide and arrange urgent echocardiogram E) Start oseltamivir and isolate for suspected influenzaPneumonia-assessment 1. History 2. Examination 3. Observations a. HR, BP, RR, sats, temp, 4. Investigations a. Bloods - FBC, U&Es, LFTs, CRP b. Imaging - CXR c. Cultures - sputum, blood if septic, atypical pneumonia screen (pneumococcal, legionella, mycoplasma) d. Viral swabsPneumonia-management 1. ABCDE - fluids, oxygen 2. CURB-65 score - admission vs discharge 3. Antibiotics 4. Analgesia 5. F/u - repeat xray in 4-6 weeksQuestion 5 A 68-year-old man presents to A&E with progressive breathlessness and a non-productive cough over two weeks. He has a history of congestive heart failure and is a current smoker. On examination, there is decreased chest expansion on the right, stony dullness to percussion, and reduced breath sounds in the lower right lung zone. His chest X-ray is shown on the right What is the most appropriate initial investigation to determine the underlying cause of the effusion? A) High-resolution CT of the chest B) Diagnostic pleural aspiration C) Bronchoscopy D) Serum BNP and repeat chest X-ray in 1 week E) PET-CT scanQuestion 5 A 68-year-old man presents to A&E with progressive breathlessness and a non-productive cough over two weeks. He has a history of congestive heart failure and is a current smoker. On examination, there is decreased chest expansion on the right, stony dullness to percussion, and reduced breath sounds in the lower right lung zone. His chest X-ray is shown on the right What is the most appropriate initial investigation to determine the underlying cause of the effusion? A) High-resolution CT of the chest B) Diagnostic pleural aspiration C) Bronchoscopy D) Serum BNP and repeat chest X-ray in 1 week E) PET-CT scanPleural effusionPleural effusion Transudate Exudate <30g/L >30g/LPleural effusion-management 1. Imaging 2. Aspiration +/- chest drain 3. Pleural fluid tap - to ascertain cause 4. Treatment based on suspected/ confirmed cause a. E.g. diuresis, abx, CTQuestion 6 A 38-year-old woman presents to A&E with sudden-onset pleuritic chest pain and shortness of breath. She is a known asthmatic, however her symptoms have not resolved when using her reliever inhaler. On examination, her heart rate is 108 bpm, respiratory rate is 24, blood pressure is 116/74 mmHg, and oxygen saturation is 94% on room air. ECG shows sinus tachycardia. Examination of her chest is unremarkable. What is the most appropriate next step in management? A) Request an urgent chest x-ray B) Request an urgent CTPA C) Commence nebulisers D) Consider thrombolysis E) Start an therapeutic anticoagulationQuestion 6 A 38-year-old woman presents to A&E with sudden-onset pleuritic chest pain and shortness of breath. She is a known asthmatic, however her symptoms have not resolved when using her reliever inhaler. On examination, her heart rate is 108 bpm, respiratory rate is 24, blood pressure is 116/74 mmHg, and oxygen saturation is 94% on room air. ECG shows sinus tachycardia. Examination of her chest is unremarkable. What is the most appropriate next step in management? A) Request an urgent chest x-ray B) Request an urgent CTPA C) Commence nebulisers D) Consider thrombolysis E) Start an therapeutic anticoagulationPulmonaryEmbolism 1. Haemodynamically unstable? a. Consider thrombolysis 2. Well’s score a. More than 4 - PE likely i. Urgent CTPA ii. V/Q scan 2nd line iii. If delays, interim anticoagulation b. 4 or less - PE unlikely, i. D-Dimer - if results >4 hours offer interim anticoagulation ii. Positive - CTPA iii. Negative - consider alternative diagnosis 3. Anticoagulation choices a. apixaban/ rivaroxaban (treatment dose) b. LMWH -> dabigatran/ edoxaban 4. Further investigations b. Clottingvidence of right heart strain c. Malignancy screenPulmonaryEmbolism 1. Haemodynamically unstable? a. Consider thrombolysis 2. Well’s score a. More than 4 - PE likely i. Urgent CTPA ii. V/Q scan 2nd line iii. If delays, interim anticoagulation b. 4 or less - PE unlikely, i. D-Dimer - if results >4 hours offer interim anticoagulation ii. Positive - CTPA iii. Negative - consider alternative diagnosis 3. Anticoagulation choices a. apixaban/ rivaroxaban (treatment dose) b. LMWH -> dabigatran/ edoxaban 4. Further investigations b. Clottingvidence of right heart strain c. Malignancy screenBreathlessness-causes 1. Respiratory a. asthma b. COPD c. pneumonia d. pulmonary embolism e. pneumothorax f. pleural effusion 2. Cardiac a. pulmonary oedema b. ACS c. pericardial tamponade d. arrhythmias 3. Other a. anaemia b. DKA c. sepsis d. anxietyQuestion 7 A 68-year-old woman presents to the Emergency Department with a 2-hour history of central chest tightness radiating to her jaw, associated with nausea and sweating. Her past medical history includes hypertension and chronic kidney disease (eGFR 42). She takes ramipril and amlodipine. On examination: HR 98 bpm, BP 134/78 mmHg, RR 18, SpO₂: 96% on air An ECG is shown on the right. High-sensitivity troponin T is 58 ng/L GRACE score is calculated as 128. What is the most appropriate next step in management? A) Arrange immediate PCI B) Administer thrombolysis and start a GTN infusion C) Discharge with aspirin and cardiology follow-up in 1 week D) Start aspirin and fondaparinux, arrange inpatient coronary angiography within 24–72 hours E) Start dual antiplatelet therapy and refer for outpatient CT coronary angiographyQuestion 7 A 68-year-old woman presents to the Emergency Department with a 2-hour history of central chest tightness radiating to her jaw, associated with nausea and sweating. Her past medical history includes hypertension and chronic kidney disease (eGFR 42). She takes ramipril and amlodipine. On examination: HR 98 bpm, BP 134/78 mmHg, RR 18, SpO₂: 96% on air An ECG is shown on the right. High-sensitivity troponin T is 58 ng/L GRACE score is calculated as 128. What is the most appropriate next step in management? A) Arrange immediate PCI B) Administer thrombolysis and start a GTN infusion C) Discharge with aspirin and cardiology follow-up in 1 week D) Start aspirin and fondaparinux, arrange inpatient coronary angiography within 24–72 hours E) Start dual antiplatelet therapy and refer for outpatient CT coronary angiographyAcuteCoronarySyndrome-NSTEMI 1. Aspirin - 300mg loading dose + lifelong 75mg 2. Fondaparinux (unless PCI) 3. GRACE score a. Intermediate - high: i. offer angiography +/- PCI (immediate if unstable, else within 72h) ii. Anticoagulation: prasugrel/ ticagrelor or clopidogrel b. Low risk: i. Ticagrelor (or clopidogrel if high bleeding risk) 4. Assess systolic function 5. Cardiac rehab, secondary preventionAcuteCoronarySyndrome-STEMI 1. Aspirin - 300mg loading dose + lifelong 75mg 2. <12 hours of symptoms a. PCI within 120 minutes i. PCI ii. prasugrel (if not on anticoagulation) or clopidogrel b. outside of PCI window i. fibrinolysis ii. Antithrombin iii.ticagrelor (or clopidogrel if high bleeding risk) 3. >12 hours a. ticagrelor (or clopidogrel if high bleeding risk) 4. Assess systolic function 5. Cardiac rehab 6. Secondary preventionQuestion 8 A 64-year-old man presents to A&E with sudden-onset, severe tearing chest pain radiating to his back. He has a history of poorly controlled hypertension. On examination, he is anxious and diaphoretic. His right arm systolic blood pressure is 190 mmHg, and his left arm systolic BP is 160 mmHg. Heart sounds are normal. ECG shows non-specific ST-segment changes. A chest X-ray reveals a widened mediastinum. Which is the most appropriate next diagnostic investigation to confirm the diagnosis? A. Transthoracic echocardiogram (TTE) B. CT angiography of the thorax C. Coronary angiography D. Chest MRI E. D-dimerQuestion 8 A 64-year-old man presents to A&E with sudden-onset, severe tearing chest pain radiating to his back. He has a history of poorly controlled hypertension. On examination, he is anxious and diaphoretic. His right arm systolic blood pressure is 190 mmHg, and his left arm systolic BP is 160 mmHg. Heart sounds are normal. ECG shows non-specific ST-segment changes. A chest X-ray reveals a widened mediastinum. Which is the most appropriate next diagnostic investigation to confirm the diagnosis? A. Transthoracic echocardiogram (TTE) B. CT angiography of the thorax C. Coronary angiography D. Chest MRI E. D-dimer Aorticdissection-assessment 1. History a. severe chest pain - may radiate to back b. Risk factors (hypertension, Marfans) 2. Examination a. left/right side pulse difference b. diastolic murmur 3. Investigations a. ECG - rule out STEMI b. imaging (CT CAP, TTE or CXR) c. bloods (troponin, FBC, U&Es, LFTs, G&S, blood gas)Aorticdissection-managementQuestion 9 A 28-year-old man presents to the A&E with sharp, central chest pain that worsens when lying flat and improves when sitting forward. He recently recovered from a viral upper respiratory tract infection. On auscultation, a high-pitched scratching sound is heard. His ECG is shown below. Given the most likely diagnosis, what is the most appropriate first-line management? A. High-dose corticosteroids B. Intravenous antibiotics C. Colchicine and NSAIDs D. Urgent pericardiocentesis E. Loading dose aspirinQuestion 9 A 28-year-old man presents to the A&E with sharp, central chest pain that worsens when lying flat and improves when sitting forward. He recently recovered from a viral upper respiratory tract infection. On auscultation, a high-pitched scratching sound is heard. His ECG is shown below. Given the most likely diagnosis, what is the most appropriate first-line management? A. High-dose corticosteroids B. Intravenous antibiotics C. Colchicine and NSAIDs D. Urgent pericardiocentesis E. Loading dose aspirinPericarditis-assessment 1. History a. risk factors (cardiac surgery, recent illness) 2. Examination a. pericardial rub 3. Investigations a. ECG, troponin, CXR, echoPericarditis-ECG Reciprocal ST depression / PR elevation 1. Insert text here Widespread, concave ST elevation / Sinus tachycardia PR depressionPericarditis-management 1. NSAIDS + colchicine (unless TB suspected/ confirmed) + PPI 2. Consider steroids 3. Exercise restriction 4. Treat underlying cause a. TB, bacterial/fungal/parasitic infections b. cardiac surgery/ PCI c. autoimmune disorders d. secondary immune processes (rheumatic fever, post MI) e. drugs f. neoplasms 5. Purulent pericarditis: a. Broad spectrum antibiotics + specialist inputQuestion 10 A 72-year-old man presents to A&E with palpitations, shortness of breath, and dizziness. His heart rate is 140 bpm and irregularly irregular. ECG confirms new-onset atrial fibrillation. He is haemodynamically stable, with no chest pain or signs of heart failure. The onset of symptoms was 8 hours ago. What is the most appropriate immediate management? A. Immediate DC cardioversion B. Rate control with beta-blocker or calcium channel blocker C. Start anticoagulation and discharge with cardiology follow-up D. Intravenous amiodarone E. Emergency coronary angiographyQuestion 10 A 72-year-old man presents to A&E with palpitations, shortness of breath, and dizziness. His heart rate is 140 bpm and irregularly irregular. ECG confirms new-onset atrial fibrillation. He is haemodynamically stable, with no chest pain or signs of heart failure. The onset of symptoms was 8 hours ago. What is the most appropriate immediate management? A. Immediate DC cardioversion B. Rate control with beta-blocker or calcium channel blocker C. Start anticoagulation and discharge with cardiology follow-up D. Intravenous amiodarone E. Emergency coronary angiographyAtrial fibrillation-assessment 1. History a. Palpitations 2. Examination a. Irregular pulse 3. Investigations a. ECG - no P waves, irregular irregular rhythm b. Bloods (FBC, U&E, TFTs, clotting) c. CXR d. echocardiogramAtrial fibrillation-managementChest pain-causes 1. Cardiac a. Acute Coronary Syndrome (ACS) b. Pericarditis c. Myocarditis e. Cardiac tamponade 2. Respiratoa. Pulmonary Embolism b. Pneumothorax / Tension pneumothorax c. Pneumonia d. Pleuritis e. Lung malignancy 3. Gastrointestinal a. Gastro-oesophageal reflux disease b. Oesophageal spasm / rupture (Boerhaave) c. Peptic ulcer disease d. Biliary colic / Cholecystitis 4. Musculoskeletal b. Muscle strain / traumaze’s syndrome c. Rib fractureBreaktime!Question 11 A 25-year-old male sustains a gunshot wound to the abdomen and is taken straight to theatre from the emergency department due to haemodynamic instability and a positive FAST scan. Intraoperatively, a large laceration to the right hepatic lobe involving the inferior vena cava is found, resulting in massive bleeding. What is the most appropriate initial strategy for managing his blood product replacement? A. Use Factor VIII concentrates early B. Avoid use of 'o' negative blood C. Transfuse packed cells, FFP and platelets in fixed ratios of 1:1:1 D. Transfuse packed cells and FFP in a fixed ratio of 4:1 E. Perform goal directed transfusion based on the Hb, PT and TEG studiesQuestion 11 A 25-year-old male sustains a gunshot wound to the abdomen and is taken straight to theatre from the emergency department due to haemodynamic instability and a positive FAST scan. Intraoperatively, a large laceration to the right hepatic lobe involving the inferior vena cava is found, resulting in massive bleeding. What is the most appropriate initial strategy for managing his blood product replacement? A. Use Factor VIII concentrates early B. Avoid use of 'o' negative blood C. Transfuse packed cells, FFP and platelets in fixed ratios of 1:1:1 D. Transfuse packed cells and FFP in a fixed ratio of 4:1 E. Perform goal directed transfusion based on the Hb, PT and TEG studiesTransfusions in MajorTrauma Uncontrolled haemorrhage is a major cause of trauma-related death, accounting for up to 39% of cases. In the UK, around 2% of trauma patients will require a massive transfusion. 🔄 What is Massive Transfusion? Massive transfusion is defined as: ● Replacement of the patient's entire blood volume within 24 hours, or ● More than half of the estimated blood volume transfused in one hour 🕒 Early Interventions ● In bleeding trauma patients, tranexamic acid (TXA) should be given early — supported by the CRASH-2 study, which showed a reduction in mortality when administered within 3 hours of injury. 🩸 Haemostatic Resuscitation This is the practice of transfusing blood components in fixed ratios to prevent coagulopathy during massive bleeding. A commonly used ratio is: ● Packed red cells : Fresh frozen plasma : Platelets = 1:1:1 This strategy helps to reduce mortality by addressing blood loss and maintaining clotting function. Transfusions in MajorTrauma Parameter Target 🎯 Target Parameters During Haemoglobin (Hb) 8–10 g/dL Resuscitation Platelets > 100 x10⁹/L Aim to correct physiological derangements using the following targets: INR / APTT < 1.5 Fibrinogen > 1.0 g/L Calcium (Ca²⁺) > 1.0 mmol/L pH 7.35–7.45 Reference Weymouth W et al. Whole Blood in Base Excess (BE) ± 2 Trauma: A Review for Emergency Clinicians. J Emerg Med. 2019 Core Temperature (ToC) > 36°C May;56(5):491-498.Question 12 A 24-year-old man presents to the emergency department after being punched in the face during an altercation. He is alert but in pain, with noticeable facial swelling and bruising around both eyes. On examination, there is midface mobility, bilateral periorbital ecchymosis, and numbness over the maxilla. His nasal bridge appears flattened. Which of the following clinical findings is least likely to be associated with this type of facial fracture? A: Excessive mobility of the palate B: Paraesthesia in the region supplied by the inferior alveolar nerve C: Malocclusion of the teeth D: Enophthalmos E: Paresthesia in the region supplied by the infraorbital nerveQuestion 12 A 24-year-old man presents to the emergency department after being punched in the face during an altercation. He is alert but in pain, with noticeable facial swelling and bruising around both eyes. On examination, there is midface mobility, bilateral periorbital ecchymosis, and numbness over the maxilla. His nasal bridge appears flattened. Which of the following clinical findings is least likely to be associated with this type of facial fracture? A: Excessive mobility of the palate B: Paraesthesia in the region supplied by the inferior alveolar nerve C: Malocclusion of the teeth D: Enophthalmos E: Paresthesia in the region supplied by the infraorbital nerve Craniomaxillofacial injuries Injuries in the UK are due to: ● Interpersonal violence (52%) ● Motor vehicle accidents (16%) ● Sporting injuries (19%) ● Falls (11%) Le Fort 1 Le Fort II Le Fort III ● Pyramidal-shaped fracture Extends posteriorly along the medial orbital wall, passing ● Extends from the nasal septum to the ● Extends from the nasal bridge at or below the through: lateral pyriform rims nasofrontal suture ● Ethmoid bonesgroove ● Travels horizontally above the teeth ● Passes through the frontal process of the maxillaTypically does not involve the optic canal due to the thick ● Travels inferolaterally through: sphenoid bone apices ● Lacrimal bones Inst●ad, Along the orbital floor ● Crosses below the ● Inferior orbital floor and rim (near or through the ● Through the inferior orbital fissure zygomaticomaxillary junction inferior orbital foramen) ● Superolaterally through the lateral orbital wall ● Continues inferiorly through the anterior wall of the● Across the zygomaticofrontal junction and zygomatic ● Passes through the pterygomaxillary maxillary sinus Intranasally, a branch of the fracture travels: junction ● Through the base of the perpendicular plate of the ● Crosses the pterygomaxillary fissure ethmoid ● Interrupts the pterygoid plates ● Passes through the pterygoid plates ● Through the pterygoid plate interface to the sphenoid base This fracture pattern increases the risk of CSF rhinorrhoea more than other types Craniomaxillofacial injuries Ocular injuries Nasal Injuries Retrobulbar haemorrhage Superior orbital fissure syndrome: Severe ● Common injury Rare but important ocular emergency. Presents force to the lateral wall of the orbit ● Ensure new and not old deformity with: Complete ophthalmoplegia and ptosis, RAPD, ● Pain (usually sharp and within the pupil dilation, loss corneal and accommodation, ● Control epistaxis ● CSF rhinorrhoea implies that the globe) Altered sensation from forehead to vertex cribriform plate has been breached and ● Proptosis (frontal branch of trigeminal nerve). ● Pupil reactions are lost antibiotics will be required. Orbital blow out fracture ● Usually best to allow bruising and ● Paralysis (eye movements lost) swelling to settle and then review ● Visual acuity is lost (colour vision is lost patient clinically. Major persistent first) Orbital floor/ sinus roof displaced into sinus deformity requires fracture Periorbital fat herniation down manipulation, best performed within 10 May be the result of Le Fort type facial days of injury. fractures. fat/ muscle entrapment of inferior rectus Diplopia on upward and outward gaze Rx with orbital floor reconstruction/ ORIFQuestion 13 A 31-year-old pregnant woman at 32 weeks gestation is hit by a car. Upon arrival at the emergency department, her systolic blood pressure is 105 mmHg and her heart rate is 126 bpm. On abdominal examination, there is generalised tenderness and bruising on the left flank. A FAST scan shows no abnormalities. What is the most appropriate next step in her management? A: Arrange a departmental abdominal USS scan B: Arrange an urgent abdominal MRI scan C: Perform a laparotomy D: Perform diagnostic peritoneal lavage E: Arrange an urgent abdominal CT scanQuestion 13 A 31-year-old pregnant woman at 32 weeks gestation is hit by a car. Upon arrival at the emergency department, her systolic blood pressure is 105 mmHg and her heart rate is 126 bpm. On abdominal examination, there is generalised tenderness and bruising on the left flank. A FAST scan shows no abnormalities. What is the most appropriate next step in her management? A: Arrange a departmental abdominal USS scan B: Arrange an urgent abdominal MRI scan C: Perform a laparotomy D: Perform diagnostic peritoneal lavage E: Arrange an urgent abdominal CT scan Imaging in the pregnant trauma patient Modality Usefulness Sensitivity Radiation Risk Key Notes Sonography / Established in - 90% in 1st None Sensitivity ↓ in later pregnancy FAST pregnancy; avoids trimester - 60–80% due to enlarged uterus ionising radiation overall CT Scan First-line in major traumaMost sensitive for Pelvic CT < 5 Still used despite risks; crucial for with suspected visceral visceral injuries and mSv (safe limit) injury placental abruption diagnosis in major trauma Radiation - Max safe dose in - Early exposure: risk of anomalies/foetal Considerations pregnancy: 5 mSv loss - Late exposure: 2× risk of childhood cancerQuestion 14 A 30-year-old man is brought to the emergency department after a motorbike collision. He is alert and complains of severe neck pain and weakness in all four limbs. On examination, he has reduced power (3/5) in both upper and lower limbs, diminished pinprick sensation below the neck, and urinary retention. His vitals are stable. A cervical spine CT reveals a fracture at C5. Which of the following is the most appropriate initial management step in this patient? A. Immediate surgical decompression B. High-dose intravenous corticosteroids C. Immobilisation with a cervical collar and urgent spinal MRI D. Foley catheter insertion followed by discharge with neurology follow-up E. CT head to rule out associated traumatic brain injuryQuestion 14 A 30-year-old man is brought to the emergency department after a motorbike collision. He is alert and complains of severe neck pain and weakness in all four limbs. On examination, he has reduced power (3/5) in both upper and lower limbs, diminished pinprick sensation below the neck, and urinary retention. His vitals are stable. A cervical spine CT reveals a fracture at C5. Which of the following is the most appropriate initial management step in this patient? A. Immediate surgical decompression B. High-dose intravenous corticosteroids C. Immobilisation with a cervical collar and urgent spinal MRI D. Foley catheter insertion followed by discharge with neurology follow-up E. CT head to rule out associated traumatic brain injuryQuestion 14 A 30-year-old man is brought to the emergency department after a motorbike collision. He is alert and complains of severe neck pain and weakness in all four limbs. On examination, he has reduced power (3/5) in both upper and lower limbs, diminished pinprick sensation below the neck, and urinary retention. His vitals are stable. A cervical spine CT reveals a fracture at C5. Which of the following is the most appropriate initial management step in this patient? C. Immobilisation with a cervical collar and urgent spinal MRI Signs of a cervical spinal cord injury following trauma — quadriparesis, sensory level, and urinary retention are classic. Although the CT confirms a bony fracture at C5, MRI is needed to assess spinal cord compression, oedema, ligamentous injury, or disc herniation, which guide definitive management. Early and appropriate immobilisation is essential to prevent secondary spinal cord injury.NeurogenicShockvs Spinal injuries Neurogenic Shock ● A type of distributive shock due to disruption of sympathetic pathways, often following spinal cord injury above T6. This is a cardiorespiratory manifestation of spinal cord injury. ● This is different to Spinal Shock! ● Key features: ○ Hypotension (due to vasodilation) ○ Bradycardia (unopposed vagal tone) ○ Warm, dry skin (vs. cool/clammy in hypovolaemic shock) ● Management: ○ Supportive: fluid resuscitation ○ Vasopressors (e.g. norepinephrine) for persistent hypotension ○ Atropine for bradycardia ○ Maintain spinal precautions and airway protection NeurogenicShockvs Spinal injuries Anterior Cord Syndrome Brown-Séquard Syndrome ● Often due to infarction or flexion injury ○ Hemisection of the spinal cord, e.g. penetrating ● Loss of motor function and pain/temperature injury below lesion ○ Ipsilateral motor loss and proprioception ● Preserved proprioception and vibration ○ Contralateral pain and temperature loss Central Cord Syndrome Posterior Cord Syndrome ● Typically due to hyperextension injury in ○ Rare; loss of vibration and proprioception elderly with cervical spondylosis ○ Motor and pain/temperature usually intact ● Greater weakness in arms than legs ● Variable sensory loss; often bladder dysfunction Conus Medullaris vs Cauda Equina ○ Conus: mixed UMN + LMN signs, early bladder/bowel involvement ○ Cauda: LMN signs, radicular leg pain, saddle anaesthesia, a-reflexic bladderQuestion 15 A 68-year-old woman with type 2 diabetes and stage 3 chronic kidney disease presents with a 2-day history of malaise, dysuria, and confusion. She is febrile (38.6°C), hypotensive (BP 92/58 mmHg), and tachypnoeic (RR 24). Her pulse is 98 bpm, and oxygen saturation is 96% on air. Capillary blood glucose is 11.3 mmol/L. On examination, she appears drowsy and has suprapubic tenderness. Initial blood tests show: ● WCC: 14.9 x10⁹/L ● CRP: 212 mg/L ● Creatinine: 185 µmol/L (baseline 120 µmol/L) ● Lactate: 3.4 mmol/L Which of the following best supports a diagnosis of sepsis in this patient according to current definitions? A. Presence of fever, hypotension, and raised WCC B. Lactate > 2 mmol/L and hypotension in a diabetic patient C. Acute confusion and raised inflammatory markers D. Evidence of infection with acute organ dysfunction E. SIRS criteria ≥ 2 in the context of suspected infectionQuestion 15 A 68-year-old woman with type 2 diabetes and stage 3 chronic kidney disease presents with a 2-day history of malaise, dysuria, and confusion. She is febrile (38.6°C), hypotensive (BP 92/58 mmHg), and tachypnoeic (RR 24). Her pulse is 98 bpm, and oxygen saturation is 96% on air. Capillary blood glucose is 11.3 mmol/L. On examination, she appears drowsy and has suprapubic tenderness. Initial blood tests show: ● WCC: 14.9 x10⁹/L ● CRP: 212 mg/L ● Creatinine: 185 µmol/L (baseline 120 µmol/L) ● Lactate: 3.4 mmol/L Which of the following best supports a diagnosis of sepsis in this patient according to current definitions? A. Presence of fever, hypotension, and raised WCC B. Lactate > 2 mmol/L and hypotension in a diabetic patient C. Acute confusion and raised inflammatory markers D. Evidence of infection with acute organ dysfunction E. SIRS criteria ≥ 2 in the context of suspected infectionQuestion 15 ● According to the Sepsis-3 definition, sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection. A. Presence of fever, hypotension, and raised WCC ● Organ dysfunction is defined as an increase in SOFA score ≥2 points from baseline. B. Lactate > 2 mmol/L and hypotension in a ● This patient has: diabetic patient ○ Suspected infection (UTI) C. Acute confusion and raised inflammatory markers ○ Organ dysfunction: AKI (↑ creatinine), altered mental state, raised lactate D. Evidence of infection with acute organ dysfunction Why others are incorrect: E. SIRS criteria ≥ 2 in the context of suspected ● A. These are part of SIRS criteria, which are outdated and not sufficient for sepsis infection diagnosis alone. ● B. Raised lactate and hypotension suggest poor perfusion but are not in themselves diagnostic of sepsis. ● C. Confusion and raised CRP/WCC are supportive, but again not sufficient to meet sepsis criteria. ● E. The SIRS-based definition has been replaced by SOFA/qSOFA in current guidelines.SEPSIS: Recognition and assessment What’s the goal: ● Early identification of patients developing (or with) a clinical picture of sepsis. ● Two criteria both required for a diagnosis of sepsis: -Presence of a known or suspected infection - Clinical features of organ dysfunction ● Calculating a ‘SOFA score’ is a means by which clinicians can quantify the level of organ dysfunction ● SOFA score: > 2= sepsis ● SOFA score can also be used to monitor and quantify a patient’s clinical course and response to treatment for sepsisSEPSIS: qSOFAscore Shortened version of the full SOFA criteria. Developed to allow for the rapid assessment of potential sepsis, based purely on clinical signs. Permits diagnosis of potential sepsis to be made prior to any investigations and can be completed by any healthcare professional. Any patient with a known or suspected infection and a qSOFA score ≥2 should be investigated and managed for sepsis as necessary. The qSOFA criteria are: Respiratory Rate ≥ 22/min (1 point) Altered Mental State (1 point) Systolic Blood Pressure ≤100mmHg (1 point)Question 16 A 62-year-old man is brought to A&E with confusion, fever, and hypotension after collapsing at home. He has a history of diabetes and recent urinary catheterisation. On arrival, his observations are: ● Temp: 39.2°C ● HR: 124 bpm ● BP: 84/52 mmHg ● RR: 30 ● SpO₂: 96% on room air ● GCS: 14 (confused) Capillary refill is prolonged, and his skin is mottled. A bedside bladder scan reveals 650 mL of retained urine. You suspect septic shock. According to ATLS principles, what is the most appropriate immediate next step in his management? A. Administer IV piperacillin-tazobactam and obtain blood cultures B. Insert urinary catheter and start maintenance fluids C. Start high-dose vasopressors to improve perfusion D. Administer a 30 mL/kg crystalloid fluid bolus E. Request urgent CT abdomen and pelvis to identify the sourceQuestion 16 A 62-year-old man is brought to A&E with confusion, fever, and hypotension after collapsing at home. He has a history of diabetes and recent urinary catheterisation. On arrival, his observations are: ● Temp: 39.2°C ● HR: 124 bpm ● BP: 84/52 mmHg ● RR: 30 ● SpO₂: 96% on room air ● GCS: 14 (confused) Capillary refill is prolonged, and his skin is mottled. A bedside bladder scan reveals 650 mL of retained urine. You suspect septic shock. According to ATLS principles, what is the most appropriate immediate next step in his management? A. Administer IV piperacillin-tazobactam and obtain blood cultures B. Insert urinary catheter and start maintenance fluids C. Start high-dose vasopressors to improve perfusion D. Administer a 30 mL/kg crystalloid fluid bolus E. Request urgent CT abdomen and pelvis to identify the sourceATLS + SEPSIS Airway, Breathing, Circulation (ABC) remains the initial framework, even in sepsis In circulatory shock, fluid resuscitation comes before vasopressors unless pulmonary oedema is evident In septic shock, start with: ● 30 mL/kg of crystalloid fluids within the first hour ● Then reassess for response and signs of fluid overload Vasopressors (e.g., noradrenaline) are only started after fluids if hypotension persists Antibiotics and cultures are critical but come after stabilising ABCs Source control (e.g., imaging, drainage) is important but not the first priorityQuestion 17 A 22-year-old man sustains a circumferential full-thickness burn to his leg following entrapment in a car fire. There are no associated fractures. Two hours post-injury, he reports tingling sensations, and the leg appears dusky in colour. What is the most appropriate next step in management? A: Fasciotomy B: Escharotomy C: Angioplasty D: Pain control E: AnticoagulationQuestion 17 A 22-year-old man sustains a circumferential full-thickness burn to his leg following entrapment in a car fire. There are no associated fractures. Two hours post-injury, he reports tingling sensations, and the leg appears dusky in colour. What is the most appropriate next step in management? A: Fasciotomy B: Escharotomy C: Angioplasty D: Pain control E: AnticoagulationBurns Type Skin Layers Affected Appearance Blanchi Management ng Epidermal / Epidermis Red, moist Yes Conservative Superficial Superficial Epidermis + partial Pale, dry Yes Heals Partial dermis spontaneously Deep Partial Epidermis + full dermis Mottled No May need Thickness red, dry surgery Full Thickness Full skin + Dry, No Burns centre subcutaneous tissue leathery referral Burns Burn Depth Assessment: Initial Resuscitation Sensation Other Management Principles ● Adults: >15% TBSA → IV fluids ● Stop the burn (cooling/irrigation) Blanching ● Children: >10% TBSA → IV fluids ● No routine prophylactic Bleeding on prick antibiotics Visual inspection ● Parkland Formula: TBSA% x weight (kg) x 2–4 mL ● Topical antibiotics not routinely required % Burn Estimation: (Ringer’s lactate) Lund-Browder chart (most accurate, esp. in children) ○ Give half in first 8 hours ● Complex burns → surgical excision & grafting Wallace Rule of 9s ● Insert urinary catheter, give analgesia Palmar method: 1 palm ≈ 0.8% TBSA Burns: SystemicEffects,Escalation &AdvancedCare ⚠ Systemic Response to 🔄 Indications for Burns Centre ✂ Escharotomy Indications Major Burns Referral ● Circumferential ● Fluid loss → ● Resuscitation needed full-thickness burns to: hypovolaemia (burn shock) ○ Limbs (→ relieve ● Third-spacing → ● Burns to face, hands, oedema genitals, perineum compartment syndrome) ● Immunosuppression ● Deep partial or full ○ Torso (→ thickness improve ● Catabolism ventilation) ● Chemical/electrical burns ● ↑ Risk of sepsis (esp. ● Involves surgical division with large burns) ● >10% TBSA in adults / >5% of stiff eschar in childrenQuestion 18 A 68-year-old man is involved in a low-impact road traffic collision and suffers a minor head injury, including a small scalp laceration. His medical history includes atrial fibrillation, for which he takes bisoprolol and dabigatran. On assessment, he is drowsy with a Glasgow Coma Score (GCS) of 12, but no focal neurological deficits are observed. What is the most appropriate next step in his management? A: Arrange a skull X-ray B: Arrange an MRI scan of the brain C: Admit for observation with GCS measurements every 30 minutes D: Admit for observation with GCS measurements every 60 minutes E: Arrange a CT scan of the headQuestion 18 A 68-year-old man is involved in a low-impact road traffic collision and suffers a minor head injury, including a small scalp laceration. His medical history includes atrial fibrillation, for which he takes bisoprolol and dabigatran. On assessment, he is drowsy with a Glasgow Coma Score (GCS) of 12, but no focal neurological deficits are observed. What is the most appropriate next step in his management? A: Arrange a skull X-ray B: Arrange an MRI scan of the brain C: Admit for observation with GCS measurements every 30 minutes D: Admit for observation with GCS measurements every 60 minutes E: Arrange a CT scan of the head Head injury with anticoagulants= CT head Head InjuryManagement Category Key Actions / Criteria Initial - Assess within 15 minutes of arrival- Document all 3 components of GCS- Airway stabilisation if GCS ≤ 8 Assessment C-spine Immobilisation Immobilise spine until assessment if:• GCS < 15• Neck pain/tenderness• Paraesthesia in limbs• Focal neurological deficit• Suspected cervical spine injury Imaging – C-Spine 3-view X-ray if C-spine injury suspected CT C-spine preferred if:• Intubated• GCS < 13• Persistent suspicion despite normal X-ray• Focal neurology• Abnormal plain films• CT head already indicated CT Head (within 1 Indications:• GCS < 12 on arrival• GCS < 15 two hours post-admission• Suspected open/depressed hr) skull fracture• Suspected base of skull fracture (e.g. Battle’s sign, CSF leak)• Focal neurological deficit• >1 episode of vomiting• Post-traumatic seizure Contact When:• Persistent GCS ≤ 8• Unexplained confusion > 4 hrs• Falling GCS post-admission• Progressive Neurosurgery neurology• Incomplete recovery post-seizure• Penetrating head injury• CSF leak Observations - GCS every 30 minutes until GCS = 15 Anticoagulated Consider CT scan (no longer strictly mandatory in all cases) PatientsQuestion 19 A 10-year-old boy is injured when a firework explodes, causing a full-thickness burn to his left arm. Which of the following statements does not typically apply to this type of injury? A: Leathery Appearance B: Area is painful until skin grafted C: Always heals with scarring D: Does not blanch under pressure E: Few blisters of absence of blistersQuestion 19 A 10-year-old boy is injured when a firework explodes, causing a full-thickness burn to his left arm. Which of the following statements does not typically apply to this type of injury? Full-thickness burns damage the entire dermis and underlying skin structures. A: Leathery Appearance The skin appears leathery and often white B: Area is painful until skin grafted in colour. C: Always heals with scarring Initially, these burns are painless D: Does not blanch under pressure (insensate). E: Few blisters of absence of blisters Pain may develop later during healing, particularly after skin grafting. They do not blanch when pressure is applied.Question 20 A 24-year-old man arrives at the emergency department with a crush injury to his forearm. Examination reveals tenderness, redness, and swelling of the arm. He has signs of an ulnar fracture and is unable to move his fingers. What is the best next step in management? A: External fixator B: Closed reduction C: Fasciotomy D: Discharge and Review in Fracture Clinic E: DebridementQuestion 20 A 24-year-old man arrives at the emergency department with a crush injury to his forearm. Examination reveals tenderness, redness, and swelling of the arm. He has signs of an ulnar fracture and is unable to move his fingers. What is the best next step in management? A: External fixator B: Closed reduction C: Fasciotomy D: Discharge and Review in Fracture Clinic E: Debridement Compartment syndrome Aspect Details Definition Raised pressure within a closed anatomical compartment after fractures or ischaemia-reperfusion injury, leading to compromised tissue blood flow and necrosis.Manometer or slit catheter is used to measure pressures. Common Supracondylar fractures and tibial shaft fractures are the most common associated injuries. Causes Symptoms - Severe pain, worsened by movement (even passive) & Signs - Paraesthesia (tingling/numbness) - Pallor may be present - Arterial pulses often still palpable - Paralysis of affected muscles can develop Diagnosis Intracompartmental pressure measurement: - >20 mmHg is abnormal - >40 mmHg confirms diagnosis Treatment - Urgent, extensive fasciotomy to relieve pressure - Lower limb decompression requires thorough technique to avoid missing deep muscles - Risk of myoglobinuria causing renal failure; requires aggressive IV fluids - Necrotic muscle must be debrided; amputation may be necessary - Muscle death can occur within 4-6 hoursBreakTimeA 22 year old female was rushed into A&E by paramedics after her family noted her body shaking and stiffening up. Paramedics stated she has been have recurrent episodes of 1 minute tonic clonic seizures from finding her on the street and throughout the ambulance ride. Her mother provided a collateral history that she is known to the Neurology team for Tonic Clonic Epilepsy where she is taking Levetiracetam (Keppra) for prophylaxis with no order PMHx or Dx. She has NKDA and is normally fit and well. The A&E team are suspecting that she has the potential to develop Status Epilepticus What is the definition of Status Epilepticus? A) An episode of seizures lasting more than 10 minutes without full recovery of consciousness B) An episode of seizures lasting more than 5 minutes without full recovery of consciousness C) Recurrent episodes of back to back seizures of 1 minute with a minimum pause of at least 1 minute in between each episode D) Two or more seizures regardless of duration that occur over the last 24 hours E) An episode of seizures lasting more than 2 minutes with a progressive decline of consciousnessStatus Epilepticus A 22 year old female was rushed into A&E by paramedics after her family noted her body shaking and stiffening up. Paramedics stated she has been have recurrent episodes of 1 minute tonic clonic seizures from finding her on the street and throughout the ambulance ride. Her mother provided a collateral history that she is known to the Neurology team for Tonic Clonic Epilepsy where she is taking Levetiracetam (Keppra) for prophylaxis with no order PMHx or Dx. She has NKDA and is normally fit and well. The A&E team are suspecting that she has the potential to develop Status Epilepticus What is the definition of Status Epilepticus? A) An episode of seizures lasting more than 10 minutes without full recovery of consciousness B) An episode of seizures lasting more than 5 minutes without full recovery of consciousness C) Recurrent episodes of back to back seizures of 1 minute with a minimum pause of at least 1 minute in between each episode D) Two or more seizures regardless of duration that occur over the last 24 hours E) An episode of seizures lasting more than 2 minutes with a progressive decline of consciousnessA 50 year old lady presented to A&E with a history of sudden onset weakness on the left arm and left leg. Her husband that came along with her in the ambulance also noted a left sided facial droop that developed over the last 30 minutes. Her memory remains intact, there was no sensation loss or paraesthesia. No neglect or dysdiadokinesia was noted. There was mild dysphasia throughout the conversation. She was able to follow commands otherwise with a GCS 15/15. In a panic you think this is a stroke. What scoring system would be best used to quickly screen for a potential stroke? A) Rockall Score B) CHADVaSC Score C) NIHSS D) Garden Classification E) Alberta Scoring SystemA 50 year old lady presented to A&E with a history of sudden onset weakness on the left arm and left leg. Her husband that came along with her in the ambulance also noted a left sided facial droop that developed over the last 30 minutes. Her memory remains intact, there was no sensation loss or paraesthesia. No neglect or dysdiadokinesia was noted. There was mild dysphasia throughout the conversation. She was able to follow commands otherwise with a GCS 15/15. In a panic you think this is a stroke. What scoring system would be best used to quickly screen for a potential stroke? A) Rockall Score B) CHADVaSC Score C) NIHSS D) Garden Classification E) Alberta Scoring SystemRegardless of NIHSS do a CT Head If NIHSS >6, consider doing a CT Intracranial Angiogram (but must discuss with Stroke SpR/Consultant first!)A 50 year old lady presented to A&E with a history of sudden onset weakness on the left arm and left leg. Her husband that came along with her in the ambulance also noted a left sided facial droop that developed over the last 30 minutes. Her memory remains intact, there was no sensation loss or paraesthesia. No neglect or dysdiadokinesia was noted. There was no dysphasia throughout the conversation. She was able to follow commands otherwise with a GCS 15/15. In a panic you think this is a stroke. Using the Bamford classification, what type of stroke is most likely occuring at this point? A) Right Lacunar Stroke B) Right Total Anterior Circulation Stroke C) Left Lacunar Stroke D) Left Total Anterior Circulation Stroke E) Left Partial Anterior Circulation StrokeA 50 year old lady presented to A&E with a history of sudden onset weakness on the left arm and left leg. Her husband that came along with her in the ambulance also noted a left sided facial droop that developed over the last 30 minutes. Her memory remains intact, there was no sensation loss or paraesthesia. No neglect or dysdiadokinesia was noted. There was no dysphasia throughout the conversation. She was able to follow commands otherwise with a GCS 15/15. In a panic you think this is a stroke. Using the Bamford classification, what type of stroke is most likely occuring at this point? A) Right Lacunar Stroke B) Right Total Anterior Circulation Stroke C) Left Lacunar Stroke D) Left Total Anterior Circulation Stroke E) Left Partial Anterior Circulation Stroke Always do a CT Head to Rule out Bleeds!! Ischaemic Haemorrhagic 4.5 hour from onset Window!! ● Neurosurgical Referral for ● If within: Alteplase/Tenecteplase ● If not: 300 mg Aspirin Loading + 75 mg Aspirin haematoma evacuation!! maintenance 2 weeks ● Supportive management to ● Clopidogrel 300 mg Loading will be added as well + Lifelong Clopidogrel 75 mg prepare for theatre + prevent If Angiogram spots Large vessel occlusion in Proximal or deterioration (e.g seizures) middle part of a Cerebral artery = Mechanical Thrombectomy (within 24 hours from onset) ● Long term Prevention: Clopidogrel 75 mg OD + Atorvastatin 80 mg ODA 64 year old gentleman was found drowsy and laid down on the side of the street by a bystander who phoned the Paramedics. On presentation to the A&E department he wasn’t able to identify where he was, who the hospital staff were, and thinks he is in jail. The HCAs and A&E nurses describe him as “always on edge”. On examination you noted he was not able to keep his balance when walking around the side room. You note an abducted left eye in the neutral gaze position. 4AT score = 8. As he is agitated and aggressive you are not able to safely do any examination. Based on the most likely diagnosis, what would be the next best management step? A) Lactulose 15 ml BD B) IV Thiamine and then IV 5% Dextrose C) IV Dexamethasone, IV Metronidazole and IV Aciclovir D) IV Immunoglobulins E) CT Head and then AlteplaseWernicke’s Encephalopathy A 64 year old gentleman was found drowsy and laid down on the side of the street by a bystander who phoned the Paramedics. On presentation to the A&E department he wasn’t able to identify where he was, who the hospital staff were, and thinks he is in jail. The HCAs and A&E nurses describe him as “always on edge”. On examination you noted he was not able to keep his balance when walking around the side room. You note an abducted left eye in the neutral gaze position. 4AT score = 8. As he is agitated and aggressive you are not able to safely do any examination. Based on the most likely diagnosis, what would be the next best management step? A) Lactulose 15 ml BD B) IV Thiamine and then IV 5% Dextrose C) IV Dexamethasone, IV Metronidazole and IV Aciclovir D) IV Immunoglobulins E) CT Head and then AlteplaseGlucose metabolism is heavily dependent on thiamine, and if a thiamine-deficient individual receives a large glucose load, the limited thiamine stores can be rapidly depleted!! We give glucose as alcoholics could be deficient in caloric intake from food sources due to alcohol dependenceA 72-year-old woman presents to her GP after a recent episode of fainting while getting out of bed in the morning. She reports feeling lightheaded, sweaty, and nauseated just before losing consciousness for a few seconds. She recovered spontaneously and felt tired but otherwise well. Her past medical history includes hypertension, type 2 diabetes mellitus, and osteoarthritis. Her medications include amlodipine, metformin, and paracetamol. On examination, her supine blood pressure is 138/82 mmHg and drops to 102/68 mmHg after standing for 3 minutes, with associated dizziness. Which of the following best explains the mechanism of her syncope? A. Cardiac arrhythmia causing reduced cerebral perfusion B. Carotid sinus hypersensitivity leading to vagal overstimulation C. Autonomic dysfunction causing impaired baroreceptor reflex D. Reflex bradycardia secondary to standing-induced venous pooling E. Postictal cerebral hypoperfusion following a seizureVasovagal Syncope A 72-year-old woman presents to her GP after a recent episode of fainting while getting out of bed in the morning. She reports feeling lightheaded, sweaty, and nauseated just before losing consciousness for a few seconds. She recovered spontaneously and felt tired but otherwise well. Her past medical history includes hypertension, type 2 diabetes mellitus, and osteoarthritis. Her medications include amlodipine, metformin, and paracetamol. On examination, her supine blood pressure is 138/82 mmHg and drops to 102/68 mmHg after standing for 3 minutes, with associated dizziness. Which of the following best explains the mechanism of her syncope? A. Cardiac arrhythmia causing reduced cerebral perfusion B. Carotid sinus hypersensitivity leading to vagal overstimulation C. Autonomic dysfunction causing impaired baroreceptor reflex D. Reflex bradycardia secondary to standing-induced venous pooling E. Postictal cerebral hypoperfusion following a seizureVasovagal attacks are triggered from sudden reflex bradycardia due to underlying unopposed parasympathetic inhibition. ● Brief LOC ● Lightheadness +/- visual disturbance ● Nausea Key: Lying Standing BP +/- Tilt ● +/- sweating Table ● PROMPT RECOVERY ● ABLE TO REMEMBER EVENTS BP Difference: 20 systolic, 10 Causes: diastolic ● Prolonged Standing ● Fear (e.g sight of needles) Tx: ● Pain 1) Manage underlying cause ● N+V 2) If none: Orthostatic ● Dehydration ● Cervical Shock: IUD/IUS Insertion Hypotension ● Excessive Straining on toilet ● Fludrocortisone ● Micturition ● Excessive Coughing ● Midodrine ● Medications e.g B-blockers, Digoxin, Amiodarone, VerapamilA 75 year old man was admitted via GP referral from the Urgent Treatment Centre before loss consciousness suddenly while in the waiting area, leading to transfer to A&E. He had been feeling increasingly fatigued and lightheaded over the past two days, and earlier today he briefly lost consciousness while walking to the kitchen. He mentions he doesn’t remember the events that occur from walking to the floor. His wife reports she heard him fall before rushing to the kitchen finding him on his side. His medical history includes hypertension, atrial fibrillation, and chronic kidney disease. Medications include Bisoprolol 5 mg OD, Ramipril 2.5 mg OD, and apixaban 5 mg OD. He is says he is getting more forgetful over time, he decided to get a dosette box to help organise his tablets, but may have gotten confused on which tablet is which when organising them in the boxes. On examination: GCS 15/15, HR: 38 bpm, regular, BP: Lying 90/60 mmHg (unable to safely stand or sit up due to “feeling of blacking out”) Blood glucose: 5.6 mmol/L Based on the above what is the best first line management step? A) Titrate Bisoprolol down to 2.5 mg OD B) Admit urgently under Cardiology for Transcutaneous Pacing C) Atropine 500 mg IV D) Atropine 500 mcg IV E) 10% Dextrose 200 ml STATCardiacSyncope:Atropine A 75 year old man was admitted via GP referral from the Urgent Treatment Centre before loss consciousness suddenly while in the waiting area, leading to transfer to A&E. He had been feeling increasingly fatigued and lightheaded over the past two days, and earlier today he briefly lost consciousness while walking to the kitchen. He mentions he doesn’t remember the events that occur from walking to the floor. His wife reports she heard him fall before rushing to the kitchen finding him on his side. His medical history includes hypertension, atrial fibrillation, and chronic kidney disease. Medications include Bisoprolol 5 mg OD, Ramipril 2.5 mg OD, and apixaban 5 mg OD. He is says he is getting more forgetful over time, he decided to get a dosette box to help organise his tablets, but may have gotten confused on which tablet is which when organising them in the boxes. On examination: GCS 15/15, HR: 38 bpm, regular, BP: Lying 90/60 mmHg (unable to safely stand or sit up due to “feeling of blacking out”) Blood glucose: 5.6 mmol/L Based on the above what is the best first line management step? A) Titrate Bisoprolol down to 2.5 mg OD B) Admit urgently under Cardiology for Transcutaneous Pacing C) Atropine 500 mg IV D) Atropine 500 mcg IV E) 10% Dextrose 200 ml STATCardiac Syncope Ix: ● AF ● ECG ● HF ● Continuous monitoring ● MI ● 24/48 hour Holter Monitor ● Transthoracic ● HB Echocardiogram ● Arrhythmias e.g Long QT syndrome ● Pulmonary Embolism ● Exercise Stress Test ● Medication review ● Valvulopathies ● Cardiomyopathies e.g HOCMA 16-year-old boy is brought to the emergency department with a 2-day history of feeling generally unwell after his school called an ambulance. He complains of mild, vague abdominal discomfort, nausea, and vomiting. He also mentions excessive thirst and frequent urination over the past week. On examination, he is lethargic with dry mucous membranes. His respiratory rate is 26/min with deep, labored breathing. Heart rate is 110 bpm, and blood pressure is 100/60 mmHg. Capillary blood glucose is 28 mmol/L. What is the most likely diagnosis? A) Acute appendicitis B) Diabetic ketoacidosis (DKA) C) Viral gastroenteritis D) Urinary Tract Infection (UTI) E) Hyperosmolar hyperglycaemic state (HHS)DKA A 16-year-old boy is brought to the emergency department with a 2-day history of feeling generally unwell after his school called an ambulance. He complains of mild, vague abdominal discomfort, nausea, and vomiting. He also mentions excessive thirst and frequent urination over the past week. On examination, he is lethargic with dry mucous membranes. His respiratory rate is 26/min with deep, labored breathing. Heart rate is 110 bpm, and blood pressure is 100/60 mmHg. Capillary blood glucose is 28 mmol/L. What is the most likely diagnosis? A) Acute appendicitis B) Diabetic ketoacidosis (DKA) C) Viral gastroenteritis D) Urinary Tract Infection (UTI) E) Hyperosmolar hyperglycaemic state (HHS)The boy was then admitted to a paediatric acute medical unit next to A&E. During reading past medical notes this boy actually has been managing with insulin for T1DM. This case was further reviewed with a Registrar for medical on call. However when talking about this further the boy admits that he has been intentionally withdrawing his insulin doses during the past 2 days. He admits that he has googled what will happen if he doesn’t take insulin last week, and has been planning to do this last week as well. He notes that “life isn’t worth living anymore” and that he is a “worthless shadow”. He confirms he hasn’t done anything else as his household is strict, and he cannot find opportunities to do anything else at school. Despite being aware of the risks and asking if he wants help, he confirms that “I would rather die than have anyone waste their time on me”. The Registrar is thinking of implementing the Mental Health Act of 1983. Which section of the Mental Health Act 1983 is most appropriate for this situation? A) Section 5(2) B) Section 5(4) C) Section 2 D) Section 3 E) Section 136The boy was then admitted to a paediatric acute medical unit next to A&E. During reading past medical notes this boy actually has been managing with insulin for T1DM. This case was further reviewed with a Registrar for medical on call. However when talking about this further the boy admits that he has been intentionally withdrawing his insulin doses during the past 2 days. He admits that he has googled what will happen if he doesn’t take insulin last week, and has been planning to do this last week as well. He notes that “life isn’t worth living anymore” and that he is a “worthless shadow”. He confirms he hasn’t done anything else as his household is strict, and he cannot find opportunities to do anything else at school. Despite being aware of the risks and asking if he wants help, he confirms that “I would rather die than have anyone waste their time on me”. The Registrar is thinking of implementing the Mental Health Act of 1983. Which section of the Mental Health Act 1983 is most appropriate for this situation? A) Section 5(2) B) Section 5(4) C) Section 2 D) Section 3 E) Section 136Section 2 allows detention for assessment (and treatment if necessary) for up to 28 days when a patient is at risk of harm to self or others and refuses or lacks capacity to consent to admission (Lack of insight). This must be done by 2 health professionals who are section 12(2) approved - Doctors (FY2 or above) - 1 AMHP ● Section 3 is for longer-term treatment (up to 6 months), usually after assessment under Section 2. ● Section 5(4): Registered Medical Nurses can detain an individual up to 6 hours prior to either upgrade to Section 5(2) or prior to Section 2 assessment ● Section 5(2): Doctors can detain an individual up to 72 hours prior to Section 2 assessment ● Section 136: When an individual in a public place is a danger to themselves and others, grants police temporary holding powers for up to 72 hours for a doctor and AMHP to do a MHA. All of the above cannot be done in Emergency Department as it is not technically an admission to hospital (AKA classed as a public place as people can freely leave)A 24-year-old man with a history of schizophrenia was started on Aripriprazole one week ago. He now presents with a 2-day history of high fever, muscle stiffness, confusion, and sweating. On examination, his temperature is 39.2°C, heart rate is 115 bpm, blood pressure 160/95 mmHg, and he has generalized “lead-pipe” rigidity. Laboratory tests show elevated creatine kinase and leukocytosis. What is the most likely diagnosis? A) Serotonin syndrome B) Neuroleptic malignant syndrome C) Malignant hyperthermia D) Encephalitis E) Neutropenic SepsisNeurolepticMalignant Syndrome A 24-year-old man with a history of schizophrenia was started on Aripriprazole one week ago. He now presents with a 2-day history of high fever, muscle stiffness, confusion, and sweating. On examination, his temperature is 39.2°C, heart rate is 115 bpm, blood pressure 160/95 mmHg, and he has generalized “lead-pipe” rigidity. Laboratory tests show elevated creatine kinase and leukocytosis. What is the most likely diagnosis? A) Serotonin syndrome B) Neuroleptic malignant syndrome C) Malignant hyperthermia D) Encephalitis E) Neutropenic SepsisRare, life threatening reaction to Antipsychotics ● Fever, Muscle rigidity, sweating, Autonomic instability ● Death from Renal Failure (Dehydration + Rhabdomyolysis), Seizures, Hyperthermia Risks: Young men, High doses, Typical AntipsychoticsA 45-year-old man with bipolar disorder on lithium therapy presents to the emergency department with nausea, vomiting, diarrhea, and increasing confusion over the past 24 hours. On examination, he is tremulous with ataxic gait and shows coarse hand tremors. His serum lithium level is 2.1 mmol/L (therapeutic range 0.6–1.2 mmol/L). His ECG shows a prolonged QT interval. What is the most appropriate next step in management? A) Increase lithium dose and start intravenous fluids B) Discontinue lithium and provide supportive care with hydration C) Start hemodialysis immediately D) Administer activated charcoal E) Begin intravenous sodium bicarbonateLithiumT oxicity A 45-year-old man with bipolar disorder on lithium therapy presents to the emergency department with nausea, vomiting, diarrhea, and increasing confusion over the past 24 hours. On examination, mmol/L (therapeutic range 0.6–1.2 mmol/L). His ECG shows a prolonged QT interval. level is 2.1 What is the most appropriate next step in management? A) Increase lithium dose and start intravenous fluids B) Discontinue lithium and provide supportive care with hydration C) Start hemodialysis immediately D) Administer activated charcoal E) Begin intravenous sodium bicarbonateLithium is a mood stabiliser for Mania and Bipolar Disorder. ● Measure levels 12h post first dose, and 4-7d after ● Also monitor U+Es, TFTs, BMI, HbA1c and Bone profile Toxicity Early signs: Tremor, Agitation, thirst, polyuria, N+V Late signs: Spasms, Coma, Arrhythmias, AKI Tx: 1) STOP LITHIUM 2) FLUIDS!!! 3) Daily level bloods including lithium levels 4) Supportive monitoring 5) Psychiatry reviewOther Psych emergencies to note ● Serotonin Syndrome ● SSRI Discontinuation Syndrome ● Hypertensive Crisis; MOAIs and Tyramine reactions (from tyramine containing foods) ● Agranulocytosis and Sepsis ● Acute Dystonia SEEYOUNEXT https://linktr.ee/medtic.teaching THURSDAY! 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