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A+E Flashcards

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1
Q

what are the 3 types of Acute coronary syndrome (ACS)?

A

Unstable Angina
ST-Elevation Myocardial infarction (STEMI)
Non-ST-elevation MI (NSTEMI)

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2
Q

where do the coronary arteries branch from?

A

the root of the aorta

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3
Q

what areas of the heart does the right coronary artery supply?

A

R Atrium
R ventricle
Inferior aspect of L ventricle
Posterior Septal area

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4
Q

what 2 vessels does the Left coronary artery split into?

A

circumflex artery
Left anterior descending (LAD)

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5
Q

what areas of the heart does the circumflex artery supply?

A

L atrium
Posterior aspect of L ventricle

curves around top, left and back of heart

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6
Q

what areas of the heart does the LAD supply?

A

anterior aspect of left ventricle
Anterior aspect of septum

travels down middle of heart

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7
Q

what are 6 presentations of ACS?

A

Central crushing chest pain radiating to jaw or arm
Nausea and vom
Sweaty and clammy
SOB
Palpitations
feeling of impending doom

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8
Q

How long do symptoms of ACS have to occur to be considered ACS?

A

> 15 mins at rest

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9
Q

who is at risk of silent MIs?

A

people with diabetes

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10
Q

what are 2 ECG changes seen in STEMIs?

A

ST segment elevation
New Left bundle branch block

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11
Q

what are 2 ECG changes seen in NSTEMIs?

A

ST segment depression
T wave inversion

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12
Q

what are pathological Q waves on ECG and when do they typically appear?

A

Indicate deep full thickness infarction of heart (transmural)
typically appear >6 hours post symptoms

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13
Q

An infarct in the LCA would cause disruption in which leads?

A

Anterior and Lateral region =>

I
aVL
V3-6

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14
Q

An infarct in the LAD would cause disruption in which leads?

A

Septal/Anterior region =>

Leads V1-4

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15
Q

An infarct in the circumflex artery would cause disruption in which leads?

A

Lateral region

I
aVL
V5-6

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16
Q

An infarct in the RCA would cause disruption in which leads?

A

Inferior region =>

II
III
aVF

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17
Q

what are 5 conditions other than MI that can cause raised troponin?

A

CKD
Sepsis
Myocarditis
Aortic dissection
Pulmonary embolism

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18
Q

what are 6 investigations for ACS?

A

ECG
Troponin
Bloods - FBC, U+E, LFT, Lipids, Glucose
CXR - for other cause of CP
Echo - to assess damage
coronary angiogram

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19
Q

what causes a diagnosis of unstable angina?

A

symptoms of ACS with normal troponin and either a normal ECG or ST depression and T-wave inversion

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20
Q

What is the initial management of ACS?

A

MONA

Morphine - IV
O2 if low sats
Nitrates - GTN
Aspirin - 300mg

Also perform ECG

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21
Q

what is the management of STEMI?

A

Percutaneous coronary intervention if available <2 hours since presentation

Thrombolysis - if PCI unavailable - with alteplase, streptokinase or tenecteplase

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22
Q

what is the medical management of NSTEMI?

A

BATMAN

Base decision for angiography/PCI on GRACE score
Aspirin 300mg stat
Ticagrelor - 180mg stat (clopi if bleed risk, prasugrel if angiography)
Morphine
Antithrombin therapy - fondaparinux
Nitrates - GTN

Oxygen if low sats

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23
Q

what scoring system can be used to asses risk of 6 month mortality in acs?

A

GRACE score

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24
Q

patients over what GRACE score are considered for angiography with PCI within 72 hours?

A

3% - medium to high risk

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25
Q

what is the secondary prevention for ACS?

A

6As

Aspirin 75mg daily for life
Another Anti-platelet - ticagrelor/clopi for 12 months
Atorvostatin 80mg OD
ACEi
Atenolol - or another beta blocker
Aldosterone - for those with clinical heart failure - eplerenone titrated to 50mg OD

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26
Q

what are 5 complications of MI?

A

DREAD

Death - most commonly due to cardiac arrest
Rupture of heart septum or papillary muscles
Oedema - heart failure
Arythmia and Aneurysm
Dressler’s syndrome and acute pericarditis

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27
Q

what is Dressler’s syndrome?

A

usually 2-3 weeks after MI
caused by localised immune response that results in inflammation of pericardium causing pericarditis symptoms

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28
Q

How is dresslers syndrome diagnosed?

A

ECG - ST elevation, T wave inversion
ECHO - pericardial effusion
raised inflammatory markers

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29
Q

what is the management of dresslers syndrome?

A

NSAIDs
Steroids - if severe
pericardiocentisis may be required with significant pericardia effusion

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30
Q

what are the different types of MI?

A

ACDC

Type 1: A- ACS type MI
Type 2: C - Cant cope MI - ischaemia secondary to to increased demand or reduced supply of O2
Type 3: D - Dead by MI
Type 4: Caused by us MI - iatrogenic

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31
Q

What is the 3vcriteria for AKI?

A

Rise in creatinine >25 micromol/L in 48 hours
Rise in creatinine >50% in 7 days
Urine output <0.5ml/Kg/hour in 6 hours

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32
Q

what are 9 risk factors for AKI?

A

Age >65 years
Sepsis
Chronic kidney disease
Diabetes
Heart failure
Liver disease
Cognitive impairment - reduced fluid intake
Medications - NSAIDs, Gentamicin, diuretics, ACEi
Radiology contrasts - iodine based

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33
Q

what are 3 pre-renal causes of AKI?

A

Dehydration
Shock
Heart failure

Due to insufficient blood supply - hypoperfusion

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34
Q

what are 5 renal causes of AKI?

A

Acute tubular necrosis
Glomerulonephritis
Acute interstitial nephritis
Haemolytic uraemic syndrome
Rhabdomyolysis

Due to intrinsic disease of kidney

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35
Q

what are 5 post-renal causes of AKI?

A

Kidney stones
Tumours
strictures
BPH
neurogenic bladder

Due to obstructed outflow leading to back-flow

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36
Q

what is acute tubular necrosis?

A

damage and death of epithelial cells of the renal tubules due to ischaemia or nephrotoxins

renal epithelial cells can regenerate - recovery usually takes 1-3 weeks

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37
Q

what is the most common renal cause of AKI?

A

acute tubular necrosis

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38
Q

what is seen on urinalysis in acute tubular necrosis?

A

muddy brown casts

renal tubular epithelial cell may also be seen

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39
Q

what is the management of aki?

A

IV fluids
withhold medications that may worsen aki
withhold/adjust medications that are renally excreted
relieve the obstruction
Dialysis

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40
Q

what are 3 ways to avoid aki?

A

avoid nephrotoxic medications
ensure adequate fluid intake
additional fluids before and after radiocontrast

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41
Q

what are 4 complications of AKI?

A

Fluid overload, heart failure, pulmonary oedema
hyperkalaemia
metabolic acidosis
uraemia - can lead to encephalopathy an pericarditis

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42
Q

when should people with AKI be referred to urology? (4)

A

pyonephrosis
obstructed solitary kidney
bilateral upper urinary tract obstruction
complications of AKI caused by urological obstruction

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43
Q

When should people with AKI be referred for dialysis?

A

Any not responding to medical management:

Hyperkalaemia
metabolic acidosis
symptoms or complications of uraemia
fluid overload pulmonary oedema

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44
Q

what classification system is used in AKI?

A

KDIGO

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45
Q

What is stage one aki?

A

creatinine rise >26 micromol in 48 hours

creatinine rise 50-99% from baseline within 7 days

urine output
<0.5ml/Kg/hour over 6 hours

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46
Q

what is stage 2 AKI?

A

100-199% creatinine rise from baseline within 7 days

Urine output
<0.5ml/kg/hour over 12 hours

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47
Q

what is stage 3 AKI?

A

> 200% or more creatinine rise in 7 days

creatinine rise to 354 micromol/L or more with acute rise of 26 micromol/L or more within 48 hours or 50% or more rise within 7 days

Urine output <0.3 ml/Kg/hour for 24 hours or anuria for <12 hours

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48
Q

what are 3 unmodifiable risk factors for ACS?

A

Increasing age - peak incidence 60-70
Male
Fhx

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49
Q

What are 5 modifiable risk factors for acs?

A

smoking
diabeted mellitus
hypertension
hypercholesterolaemia
obesity

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50
Q

What is the criteria for STEMI?

A

symptoms >20 mins
>2.5 small squares ST elevation in V2-3 if <40 years or >2 if >40 years MALE
>1.5 small squares in V2-3 in WOMEN
1 small square elevation in any other leads
new LBBB

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51
Q

What is the criteria for PCI in STEMI?

A

presentation <12 hours since onset of symptoms and PCI available within 120 mins

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52
Q

what is the criteria for thrombolysis in STEMI?

A

within 12 hours of symptom onset if PCI cannot be given within 120 mins of presentation

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53
Q

what antiplatelets are used prior to PCI?

A

ASPIRIN +

Parasugrel if patient not on anticoagulant

Clopidogrel if patient is on anticoagulant

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54
Q

what are 5 investigations that can be done for AKI?

A

Dipstick
Urine MSC
Protein:creatinine if glomerulonephritis suspected
Bloods - U+Es, FBC, CRP, Bone profile, creatinine kinase
USS

Strange bloods - ANA, ANCA, anti-GBM, complement levels, immunoglobulin levels, antistreptolysin O titre, HIV

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55
Q

what 5 medications should be stopped in AKI due to worsening renal function?

A

NSAIDs
Aminoglycosides
ACEi
ARBs
Diuretics

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56
Q

what 3 medications may need to be stopped in AKI due to increased risk of toxicity?

A

Metformin
Lithium
Digoxin

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57
Q

what are the 2 shockable rhythms in cardiac arrest?

A

ventricular tachycardia
Ventricular fibrillation

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58
Q

what are the 2 non-shockable rhythms in cardiac arrest

A

pulseless electrical activity
Asystole

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59
Q

what is a narrow QRS complex?

A

<0.12s (or 0.10) - 3 little squares

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60
Q

what are 4 causes of narrow complex tachycardias?

A

sinus tachycardia
supra ventricular tachycardia
atrial fibrillation
atrial flutter

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61
Q

what are 4 differentials for broad complex tachycardias?

A

ventricular tachycardia
polymorphic ventricular tachycardia - torsades de pointes
atrial fibrillation with bundle branch block
supra ventricular tachycardia with bundle branch block

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62
Q

what is a broad QRS complex?

A

> 0.12s - 3 small squares

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63
Q

what classes as sustained VT?

A

> 30 seconds or requiring intervention due to haemodynamic compromise

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64
Q

what are 3 causes of VT?

A

Re-entry - due to two conduction pathways usually due to myocardia scaring after MI

Triggered activities - early or late after-depolarisations - torsades de pointes or digoxin toxicity

Abnormal automaticity

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65
Q

what is brugada’s sign?

A

In ventricular tachycardia

distance from onset QRS to nadir (base) of S-wave >0.1s

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66
Q

What is usually seen in ventricular tachycardia (VT) on ECG? (6)

A

Broad QRS complexes - >0.12 (usually >0.2s)
Usually uniform (monomorphic)
Brugada’s sign - distance from onset QRS to nadir of S-wave >0.1s
Josephson’s sign - notching near nadir of S wave
RSR’ Complexes - complexes with taller LEFT rabbit ears
Extreme axis deviation - northwest axis
capture or fusion beats

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67
Q

what is josephson’s sign?

A

In ventricular tachycardia

notching near nadir of S wave

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68
Q

what is the management of ventricular tachycardia?

A

Unstable - DC cardioversion, then IV amiodarone hydrochloride

Stable - 1 - amiodarone hydrochloride 200mg TDS BO, 5mg/kg over 20-120 mins with ECG monitoring. Max 1.2g/day

flecainide acetate, propafenone hydrochloride. Catheter ablation can be used if indicated and non-urgent

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69
Q

what is torsade de pointes?

A

ventricular tachycardia with QRS complexes which vary in amplitude axis and duration along with long QT

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70
Q

what should the QT interval be?

A

Men - QTc should be <440ms
Women - QTc should be <460ms

QTc should not be <350ms

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71
Q

QTc over what increases risk of torsades de pointes?

A

> 500ms

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72
Q

what is the management of torsades de pointes and polymorphic VT?

A

IV magnesium sulfate
2g over 10-15 mins

correct underlying cause
defibrillation if VT occurs

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73
Q

what is the dose of amiodarone in VT, SVT, AF, Vfib, WPW?

A

amiodarone hydrochloride 200mg TDS orally

OR

5mg/kg IV over 20-120 mins with ECG monitoring. Max 1.2g/day

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74
Q

what are 3 electrolyte imbalances that can lead to long QT?

A

hypokalaemia
hypomagnesaemia
hypocalcaemia

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75
Q

what are 6 medications that can cause long QT?

A

antipsychotics
citalopram
flecainide
sotalol
amiodarone
macrolide Abx

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76
Q

what is the appearance of Atrial flutter on ECG?

A

sawtooth - due to repeated P waves between QRS complexes
Narrow complex tachycardia

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77
Q

what is the management of atrial flutter?

A

anticoagulation - CHADSVASc
Radiofrequency ablation of accessory pathways

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78
Q

what is seen on ECG with supraventricular tachycardia (SVT)?

A

narrow complex tachycardia
p waves often buried in QRS complexes so not visible

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79
Q

what is the management of SVT?

A

1 - Vasovagal manoeuvres
2 - adenosine 6mg IV - give centrally if pos, then 12mg, then 18mg
3 - verapamil or beta blocker
4 - syncronised DC cardioversion

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80
Q

what are 7 causes of ventricular fibrilation?

A

electric shock
ischaemia/hypoxia
electrolyte abnormality - low K+/Mg2+
altered autonomic and vagal inputs
mechanical stimuli
congenital susceptability
acquired disorders - ischaemia, hypertrophy, myocarditis

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81
Q

what is the management of V fib?

A

defibrillation - non-synchronised
correction of cause
CPR

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82
Q

what are 5 features of hypokalaemia on ECG?

A

U waves (after T wave)
Small/absent/biphasic T waves
prolonged PR interval
ST depression
Long QT

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83
Q

what are 4 features of digoxin toxicity on ECG?

A

down sloping ST depression - reverse tick
Flattened/inverted T waves
short QT (<360ms)
Arrythmias

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84
Q

what are 5 ECG findings in hyperkalaemia?

A

Peaked/tall tented T waves (>2.5 squares in limb leads or >1.4 in chest)
Loss of P waves
Broad QRS complexes (>100ms)
Sinusoidal wave pattern
V-fib

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85
Q

what is 1st degree heart block?

A

where they is delay in AV node conduction
Every P wave followed by QRS

PR interval >0.2 seconds

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86
Q

what is 2nd degree heart block Type 1?

A

Atrial impulses take progressively longer to get through AV node leading to increasing PR interval until P wave not followed by QRS, then returns to normal and repeats

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87
Q

what is 2nd degree heart block Mobitz type 2?

A

intermittent failure of conduction through AV node usually in a set ration of P waves to QRS complexes

at risk of asystole

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88
Q

what is 3rd degree heart block?

A

complete heart block
no relationship between P waves and QRS complexes

significant risk of asystole

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89
Q

what is sick sinus syndrome?

A

dysfunction of SA node causing sinus bradycardia, sinus arrhythmias and prolonged pauses

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90
Q

what are 4 side effects of atropine?

A

pupil dilation
dry mouth
urinary retention
constipation

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91
Q

what are 6 contraindications to adenosine?

A

Asthma
COPD
heart failure
heart block
severe hypotension
potential atrial arrhythmias with pre-excitation (WPW)

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92
Q

what is seen on ECG in left bundle branch block?

A

WiLLiaM

W in V1
M in V6

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93
Q

what are 5 causes of LBBB?

A

MI
Hypertension
aortic stenosis
cardiomyopathy
rare - idiopathic fibrosis, digoxin toxicity, hyperkalaemia

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94
Q

what is sen on ECG in Right bundle branch block?

A

MaRRoW

M in V1
W in V6

AKA Bunny ears in V1 with larger Right ear

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95
Q

what are 7 causes of RBBB?

A

normal variation
right ventricular hypertrophy
cor pulmonale/chronic increased right ventricular pressure
pulmonary embolism
MI
ASD
Cardiomyopathy/myocarditis

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96
Q

what are 5 ECG changes in hypothermia?

A

bradycardia
J wave - small hump at end of QRS
1st degree heart block
long QT
atrial and ventricular arrythmias

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97
Q

what are the 8 reversible causes of cardiac arrest?

A

4Hs and 4Ts

Hypoxia
hypo/hyperkalaemia
Hypothermia/hyperthermia
Hypovolaemia

Tension pneumothorax
Tamponade
Thrombosis
Toxins

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98
Q

what is wolff-parkinsons-white syndrome?

A

presence of congenital accessory cardiac pathways leading to episodes of tachyarrythmia

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99
Q

what are 5 ECG signs in WPW syndrome?

A

Increased PR interval < 120ms
Delta wave: slurring slow rise of initial portion of the QRS
Wide QRS > 110ms

Discordant ST-segment and T-wave changes (i.e. in the opposite direction to the major component of the QRS complex)
Pseudo-infarction patterns

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100
Q

what is the risk of WPW syndrome?

A

if concurrent AF, chaotic electrical activity may pass into ventricles leading to v-fib and posible cardiac arrest

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101
Q

what medications are contraindicated in WPW syndrome?

A

anti-arrhythmic medications (e.g., beta blockers, calcium channel blockers, digoxin and adenosine)

increase this risk of v-fib by reducing conduction through the AV node and promoting conduction through the accessory pathway

102
Q

what are 4 features of AF?

A

irregularly irregular heart rate
Tachycardia
heart failure - due to impaired filling of ventricles during diastole
increased stroke risk

103
Q

what are 5 causes of AF?

A

SMITH

Sepsis
Mitral valve pathology - stenosis or regurg
Ischaemic heart disease
Thyrotoxicosis
Hypertension

104
Q

what are 2 lifestyle causes of AF?

A

Alcohol
Caffeine

105
Q

what is the risk of stroke in AF?

A

5x that of a normal person
Around 5% risk per year

106
Q

what are 5 symptoms of AF?

A

Palpitations
SOB
Dizziness/syncope
Symptoms of associated conditions - stroke, sepsis, thyrotoxicosis
Chest discomfort

107
Q

How are ventricular ectopics rate dependant?

A

Usually disappear with higher heart rate during exercise

108
Q

what are 3 ecg findings in AF?

A

Absent p waves
narrow QRS complex tachycardia (<100ms)
irregularly irregular ventricular rhythm

109
Q

how long can paroxysmal AF last?

A

anywhere from 30s to 7 days usually stops within 48 hours

110
Q

what are 3 respiratory risk factors of AF?

A

pneumonia
smoking
obstructive sleep apnoea

111
Q

what are 5 signs of haemodynamic compromise in AF?

A

HR >150
BP <90 mmHg
Syncope/severe dizziness
SOB
Chest pain

112
Q

what is the 1st/2nd/3rd line management of AF?

A

RATE CONTROL

1 - Beta blocker - atenolol or bisoprolol

2 - Ca Channel blocker - diltaliazem or verapamil

3 - Digoxin

113
Q

when is rhythm control used in AF?

A

reversible cause for AF
New onset AF - within 48h
Heart failure caused by AF
Symptoms despite rate control

114
Q

when is cardioversion used in AF?

A

AF present <48 hours
Life-threatening haemodynamic instability

115
Q

what medications are used for pharmacological cardioversion in AF?

A

Flecainide
Amiodarone - 1st if structural heart disease

116
Q

what 3 medications are used for long term rhythm control?

A

1 - Beta blockers

2 - Dronedarone

3 - Amiodarone - in HF

117
Q

what scoring system is used to determine is risk of stroke/TIA in AF?

A

CHA2DS2-VASc

118
Q

what medication is used for anticoagulation in AF?

A

1 - DOAC - apixaban, riveroxaban, edoxaban, dabigatran

2 - warfarin

119
Q

what is the MOA of DOACs?

A

Apixaban, riveroxaban, edoxaban - Direct inhibitors of factor Xa

Dabigatran - direct thrombin inhibitor

120
Q

what is the antidote for apixaban and rivaroxaban?

A

Andexanet alfa

121
Q

what is the antidote for dabigatran?

A

idarucizumab

122
Q

what are 3 indications for DOACs?

A

stroke prevention in AF
Tx of DVT and PE
Prophylaxis of VTE after hip/knee replacement

123
Q

what is the MOA of Warfarin?

A

vitamin K antagonist

causes increased prothrombin time

124
Q

what is the INR target for patients with AF on warfarin?

A

between 2-3

125
Q

what is the antidote for warfarin?

A

Vitamin K

126
Q

what foods can affect warfarin?

A

Leafy green veg
cranberry juice
alcohol

127
Q

what CHA2DS2-VASc score needs anticoagulation?

A

> 1 in Men
2 in Women

128
Q

what does CHA2DS2-VASc stand for?

A

Congestive heart failure
Hypertension
Age >75 (2)
Diabetes
Stroke or TIA (2)

Vascular disease
Age 65-74
Sex (female)

129
Q

what score is used to assess bleeding risk in AF patients on anticoagulation?

A

ORBIT

130
Q

what does ORBIT stand for?

A

Older age >75
Renal impairement (GFR<60)
Bleeding previously
Iron - low haemoglobin or haematocrit
Taking antiplatelets

131
Q

what orbit score is high risk of bleeds?

A

> 4

132
Q

what orbit score is medium risk of bleeds?

A

3

133
Q

what is the normal blood pH?

A

7.35-7.45

134
Q

what is normal paO2 on ABG?

A

10.7-13.3 kPa

135
Q

what is normal PaCO2 on ABG?

A

4.7-6 kPa

136
Q

what is normal HCO3 on ABG?

A

22-26 mmol/L

137
Q

which is normal base excess on ABG?

A

-2 to +2

138
Q

what is normal lactate on ABG?

A

0.5-1 mmol/L

139
Q

How do you calculate anion gap?

A

(Na + K) - (Cl + HCO3)

140
Q

what is the normal anion gap?

A

10-18 mmol/L

141
Q

what does a raised bicarbonate on ABG indicate in respiratory acidosis?

A

chronic retainer of CO2 - bicarb is being produced as a buffer

142
Q

when does respiratory alkalosis occur?

A

when a patient cannot get rid of enough CO2

143
Q

when does respiratory alkalosis occur?

A

when patient has raises resp rate and removes too much CO2. High pH and Low PaCO2.

due to hyperventilation syndromes and pulmonary embolisms . In PE PaO2 will be low too!

144
Q

what is the ABG picture in metabolic acidosis?

A

Low pH
Low bicarb

145
Q

what are 4 causes of metabolic acidosis?

A

raised lactate
raised ketones - DKA
Increaed hydrogen ions - renal failure, type 1 renal tubular acidosis, rhabdo
reduced bicarb - diarrhoea, renal failure, type 2 renal tubular acidosis

146
Q

what is the ABG picture in metabolic alkalosis?

A

raised pH
Raised Bicarb

147
Q

what are 3 mechanisms for metabolic alkalosis?

A

H+ loss through GI tract - vomiting
H+ loss due to increased activity of aldosterone > increased H+ excretion (Conn syndrome)
Renal loss of H+ ions - loop/thiazide diuretics, heart failure, nephrotic syndrome, cirrhosis

148
Q

what are 5 causes of increased activity of aldosterone?

A

conn syndrome
liver cirrhosis
heart failure
loop diuretics
thiazide diuretics

149
Q

what are 6 causes of respiratory alkalosis?

A

anxiety hyperventilation
PE
slicylate poisoning
CNS disorders
altitude
pregnancy

150
Q

what are 5 causes of respiratory acidosis?

A

COPd
decompensation of asthma/pulmonary oedema
neuomuscular disease
obesity hypoventilation syndrome
sedatives - benzos, opioid overdose

151
Q

what PaO2 is hypoxaemic?

A

<10kPa

<8kPa is severely hypoxaemic

152
Q

wha are 4 causes of a high anion gap metabolic acidosis?

A

diabetic ketoacidosis
lactic acidosis
aspirin overdose
renal failure

153
Q

what are 3 causes of a normal anion gap metabolic acidosis?

A

gastrointestinal losses of HCO3-
renal tubular disease
Addisons disease

154
Q

what is the ratio of chest compressions to ventilations in adult ALS?

A

30 compressions to 2 ventilations

155
Q

what is the 1st line delivery of drugs in cardiac arrest via?

A

IV

156
Q

what is the 2nd line method of drug delivery in cardiac arrest?

A

Intraosseous (IO)

157
Q

what medication should be given for non-shockable rhythms?

A

1mg Adrenaline ASAP

158
Q

when is adrenaline given for shockable rhythms?

A

after 3rd shock once chest compressions have started

159
Q

when should adrenaline be repeated in ALS?

A

1mg every 3-5 minutes

160
Q

what should be given in shockable rhythms after the 3rd shock?

A

amiodarone 300mg

Further 150mg after 5 shocks

161
Q

what medication can be used as an alternative to amiodarone in cardiac arrest?

A

lidocaine

162
Q

what is the skin sensitisation theory of allergy?

A

there is a break in the infants skin that allergens from the environment cross and react with the immune system as foreign
the child doesn’t have exposure to the allergen through the GI tract so it is not recognised as safe
When the child encounters the allergen again a full immune response is launched due to being viewed as foreign

163
Q

What classification system is used for hypersensitivity reactions?

A

Coombs and Gell

164
Q

what is a type 1 hypersensitivity reaction and what antibody is involved?

A

IgE

trigger mast cell and basophil degranulation to release histamines and other cytokines. Causes immediate reaction - typical food allergy reaction

165
Q

what is a type 2 hypersensitivity reaction?

A

IgG and IgM mediated

complement system dependant, leads to direct damage of local cells

Haemolytic disease of the newborn and transfusion reactions

take hours

166
Q

what is a type 3 hypersensitivity reaction?

A

immune complexes accumulate and cause damage to local tissues

autoimmune conditions - SLE, RhA, Coeliac, HSP

takes days

167
Q

what is a type 4 hypersensitivity reaction?

A

T lymphocytes are inappropriately activated causing inflammation and damage to local tissues

organ transplant rejection and contact dermatitis

takes days - 12-72 hours

168
Q

what are 3 ways to test for allergies?

A

skin prick test
RAST testing - blood test for total and specific IgE
Food challenge

169
Q

what is the gold standard for diagnosing allergy?

A

food challenge

170
Q

what are 4 allergic symptoms?

A

urticaria
itching
angio-oedema - swelling around lips and eyes
Abdo pain

171
Q

what are 6 symptoms indicating anaphylaxis in allergy?

A

SOB
wheeze
swelling of larynx and stridor
Tachycardia
Lightheadedness
Collapse - hypotension

172
Q

What is the management of anaphylaxis?

A

ABCDE

Secure airway
provide O2 if required, salbutamol can help with wheeze
provide IV bolus
Lie patient flat for improved cerebral perfusion
look for flushing, angioedema, urticaria

IM Adrenaline 500micrograms (1:1000) in adults - repeat after 5 minutes
Antihistamines - chlorphenamine (4mg) or cetirizine (10mg)

173
Q

what investigation can be used to confirm anaphylaxis?

A

serum mast cell tryptase within 6 hours

174
Q

what are 5 risk factors which may require people with non-aphylactic allergies to have epipens?

A

asthma requiring ICS
poor access to medical treatment - rural
Adolescents who are high risk
Nut or insect sting allergies
significant co-morbidities like CVD

175
Q

How are epipens administered?

A

Remove safety cap on non-needle end (blue on epipen)
Grip device in fist with needle pointing downwards (orange in epipen)
Administer injection to outer portion of mid thigh until device clicks - can be through clothes - hold in place for 3-10 seconds
remove device and massage area for 10 seconds
Phone ambulance

176
Q

what is the management for anaphylaxis after 2 doses of IM adrenaline?

A

IV adrenaline

177
Q

what dose of adrenaline is given to babies <6 months in anaphylaxis?

A

100-150 micrograms

0.1-0.15 ml 1 in 1000

178
Q

what dose of adrenaline is given to 6 month - 6 years in anaphylaxis?

A

150 micrograms
0.15ml 1 in 1000

179
Q

what dose of adrenaline is given to 6-12 year olds in anaphylaxis?

A

300 micrograms

0.3 ml 1 in 1000

180
Q

what dose of adrenaline is given to adults and children >12 years in anaphylaxis?

A

500 micrograms

0.5ml 1 in 1000

181
Q

what are 9 non diabetic causes of hypoglycaemia?

A

EXPLAINS H

Exogenous Drugs - diabetic drugs, alcohol, quinine, BetaB paracetamol and valporate overdose

Pituitary insufficiency/Post prandial hypoglycaemia

Liver disease

Addisons

Insulinoma/Immune hypoglycaemia/Infection

Non-pancreatic neoplasms / non-insulinoma pancreatogenous hypoglycaemia

Starvation and Malnutrition

Hypothyroidism - myxoedema coma

182
Q

what is shock?

A

failure to perfuse and therefore adequately oxygenate vital organs

183
Q

what are 6 signs of shock?

A

Hypotension
Tachycardia/brady with haemorrhage
Altered conscious level
Poor peripheral perfusion - >cap refill, cool peripheries, clammy, pale
Oliguria - due to decreased renal perfusion
Tachypnoea

184
Q

what are the 4 types of shock?

A

Hypovolaemic
Cardiogenic
Obstructive
Distributive

185
Q

what is hypovolaemic shock?

A

most common type caused by insufficient circulating volume

caused by blood loss, vomiting/dehydration, burns, DKA

186
Q

what is class I haemorrhagic shock?

A

Blood loss <750ml

Normotensive, no symptoms, HR<100

187
Q

what is class II haemorrhagic shock?

A

750-1500ml blood loss

HR>100, BP normal, raised RR, urine 20-30ml, anxious

Treat with IV fluids

188
Q

what is class III haemorrhagic shock?

A

1500-2000ml blood loss

HR>120, BP decreased, RR 30-40, urine 5-15ml
confused

Fluids and packed red cells

189
Q

what is class IV haemorrhagic shock?

A

> 2000ml

HR>140, BP decreased, RR >35, urine <5ml, lethargic

Agressive IV fluids and Red cells

190
Q

what is cardiogenic shock?

A

failure of heart to pump effectively leading to inadequate organ perfusion

191
Q

what are 5 signs of cardiogenic shock?

A

distended jugular veins/increaed venous pressure
weak/absent pulse
Abnormal HR
pulsus paradoxus (often in tampenade)
reduced BP
SOB

192
Q

what are 6 causes of cardiogenic shock?

A

MI
Dysrhythmias
Cardiomyopathies/myocarditis
Congestive heart failure
Myocardiac contusion
Valvular heart disease

193
Q

what is obstructive shock?

A

shock due to physical obstruction of great vessels in systemic or pulmonary circulation

194
Q

what are 7 causes of obstructive shock?

A

cardiac tamponade
constrictive pericarditis
tension pneumothorax
PE
aortic stenosis
Abdominal compartment syndrome
Hypertrophic sub-aortic stenosis

195
Q

what is distributive shock?

A

inadequate end organ perfusion due to decreased BP de to dilation of blood vessels

196
Q

what are 3 types of distributive shock?

A

Anaphylactic
Septic shock
Neurogenic shock

197
Q

what is the mechanism for shock in sepsis and anaphylaxis?

A

widespread release of histamine in response to infection/allergen leading to widespread vasodilation, hypotension and increased capillary permeability

198
Q

what is the mechanism of neurogenic shock?

A

Usually due to high spinal cord injury, there is a disruption to sympathetic chain leading to loss of vascular tone causing vasodilation and absence of reflex tachycardia

199
Q

what are 4 endocrine causes of shock?

A

Hypothyroidism - can cause reduced cardiac out put and cardiogenic shock

thyrotoxicosis - may induce reversible cardiomyopathy

Acute adrenal insufficiency

Relative adrenal insuficiency - in critically ill patients where hormone levels are insufficient to meet higher demands of illness

200
Q

what marker can be used to measure severity of shock?

A

lactate - measures level of tissue hypoxia

201
Q

what is a normal lactate?

A

<2

severe if >4

202
Q

what are resuscitation fluids?

A

500ml 0.9% NaCl over <15 mins

203
Q

what is compartment syndrome?

A

A complication following fracture or re-perfusion injury characterised by raised pressure within a closed anatomical space (fascial compartment). The raised pressure eventually compromises tissue perfusion resulting in necrosis

204
Q

what are the two main fractures that cause compartment syndrome?

A

supracondylar fractures
tibial shaft injuries

205
Q

what is the management of compartment syndrome?

A

fasciotomies - repeated for debridement of necrotic tissue

206
Q

what are the features of compartment syndrome?

A

5 Ps
- Pain - excessive and especially on movement
- Paraesthesia
- Pallor
- Palaysis
- Pressure is high

NOT PULSELESS

207
Q

can you diagnose compartment syndrome on X-ray?

A

NO!

208
Q

what can be used to measure compartment pressure in suspected compartment syndrome?

A

Needle manometry - measures resistance to injecting saline through needle into compartment

209
Q

what is the initial management of compartment syndrome?

A

call ortho registrar or consultant
remove external dressings/bandage
Elevate leg to heart level
Maintaining good blood pressure

210
Q

what can be a complication of fasciotomy?

A

myoglobinuria

require aggressive IV fluids

211
Q

how quickly can muscle groups die in compartment syndrome?

A

within 4-6 hours

surgery should be within one hour of diagnosis

212
Q

what are the usual intracompartmental pressures of fascia?

A

Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic

213
Q

what is usually the cause of an extradural haematoma and what is the epidemiology?

A

Trauma - falls or fights

More common in males
Peak incidence - 20-30 years

214
Q

what artery is often affected in extradural haematoma?

A

Middle meningeal artery

215
Q

what is the thin portion of skull over the temporal region that often causes extradural haematomas called?

A

pterion

216
Q

what is the classic presentation of subdural haematoma?

A

patient who initially loses and briefly regains consciousness then loses it again - called lucid interval

as hematoma expands uncus of temporal lobe herniates around tentorium cerebelli and patient develops fixed dilated pupil de to compression of parasympathetic fibres of CN3

217
Q

what does extradural haematoma look like on CT?

A

biconvex hyperdense collection limited by suture lines of skull

218
Q

what is the definitive management of extradural haematoma?

A

craniotomy and evacuation of haematoma

219
Q

what patients are at risk for subdural haemorrhage?

A

elderly
alcoholics

due to brain atrophy and fragile bridging veins

220
Q

what is the appearance of subdural haemorrhage on CT?

A

sickle/crescent shaped collection not limited by suture lines

Hyperdense (light) if acute and Hypodense (dark) if chronic

Can have mass effect and cause midline shift or herniation

221
Q

what is the management of subdural haematoma?

A

Decompressive craniotomy

Surgical decompession with burr holes

222
Q

What is the epidemiology of subarchnoid haemorrhages?

A

F > M
peak 40-50 years

223
Q

what are 4 conditions associated with berry aneurysm?

A

hypertension
familial polycystic kidney disease
Ehlers-danlos syndrome
coarctation of the aorta

224
Q

what are 6 features of Subarachnoid haemorrhage?

A

Headache - thunderclap, worst of life, reaching peak intensity in <5 mins
N+V
Meningism - photophobia, neck stiffness
Altered consciousness
Focal neurology - CN palsy, hemiparesis or hemiplegia, speech disturbance
Seizure

225
Q

what are 4 examination findings in SAH?

A

subhyaloid haemorrhages on fundoscopy
Papilloedema - uncommon due to Raised ICP
+ve Kernig’s/Brudzinskis sign
Hypertension is common, hypotension is poor prognostic sign

226
Q

what investigations should be done for SAH?

A

non-contrast CT head

LP - if CT >6 hours of onset and normal

CT intracranial angiogram

227
Q

what can be seen on LP in SAH?

A

raised xanthochromia

228
Q

when should LP be performed for SAH?

A

at least 12 hours following onset of symptoms

229
Q

what medication can be used to PREVENT vasospasm in SAH?

A

oral nimodipine 60mg every 4 hours for 21 days

230
Q

what medication can be used to TREAT vasospasm in SAH?

A

IV 0.5mg/hour or 1 mg/hour (weight dependant) increased to 2mg/hour

231
Q

what is the management of SAH?

A

angiographical coiling by interventional radiologists
Craniotomy and surgical clip ligation

232
Q

what are 5 complications of SAH?

A

re-bleeding - 10%
Hydrocephalus
Vasospasm
Hyponatraemia - due to SIADH
Seizure

233
Q

what is the scoring for the glasgow coma scale?

A

MoVE

6, 5, 4

M6, V5, E4

234
Q

what is the motor scoring for the GCS?

A

6 - obeys comands
5 - localises to pain
4 - withdraws from pain
3 - abnormal flexion to pain
2 - extending to pain
1 - no response

235
Q

what is the verbal scoring for GCS?

A

5 - orientated
4 - confused
3 - inappropriate words
2 - sounds
1 - none

236
Q

what is the eye opening scoring for GCS?

A

4 - spontaneous
3 - to speech
2 - to pain
1 - none

237
Q

what are 10 risk factors for DVT?

A

Immobilisation
Inflammatory state - vasculitis, sepsis
Malignancy
Medication - Chemo, HRT, COCP
Obesity
Pregnancy
Previous VTE/FHx
Recent surgery/trauma
smoking
varicose veins
Polycythaemia

238
Q

what is virchows triad?

A

Alteration in flow
Hyper-coagulability
Vessel wall injury/endothelial damage

239
Q

what are 4 hereditary causes of hypercoagulability? (thrombophilias)

A

factor V leiden
Anti-thrombin 3 deficiency
protein S/C deficiency
Antiphospholipid syndrome

240
Q

what are 6 features of DVT?

A

Pain in lower leg - cramping or throbbing, exacerbated by exertion

Swelling - either calves or entire leg, pitting oedema

Skin changes - pallor, cyanosis or diffuse erythema, distended superficial veins

Increased temp

tender solid calf

Tenderness on palpation of deel veins of leg

difference in size of calves - >3cm

241
Q

what score can be used for DVT?

A

DVT Wells score

242
Q

what are 10 features of wells score?

A

active cancer (1)
Paralysis/immobilised (1)
Bed ridden >3 days or surgery in last 12 weeks (1)
Deep vein tenderness (1)
Entire leg swollen (1)
Calf swelling >3cm larger (1)
Unilateral Pitting oedema (1)
collateral superficial veins (1)
prev DVT (1)

Alternative diagnosis at least as likely (-2)

243
Q

what wells score signifies likely DVT?

A

> 2 inclusive

244
Q

what is the management of DVT?

A

if unlikely on Well’s do D-Dimer
- if raised, then for leg vein USS

If likely on Well’s - do leg vein USS <4 hours if not available then D-Dimer + anticoagulation until available

245
Q

what is the 1st line treatment of DVT or PE?

A

Apixaban 10mg OD for 10 days then 5mg BD

Rivaroxaban - 15mg BD for 21 days then 20mg OD

for 3 months then review

246
Q

what is the management of DVT/PE in renal impairment?

A

LMWH for 5 days

then edoxaban or dabigatran (if CrCl >30)

if Cr clearance <15 ml/min

247
Q

what is the management of DVT/PE in someone with antiphospholipid syndrome?

A

LMWH then Warfarin

248
Q

what is post thrombotic syndrome?

A

complication of DVT leading to painful heavy calves, pruritus, swelling, varicose veins and venous ulceration

treated with compression stockings

249
Q

what is the first line treatment for DVT in pregnancy?

A

LMWH

250
Q

what is budd-chiari syndrome?

A

obstruction to outflow of blood from liver caused by thrombosis in hepatic veins or inferior vena cava

triad of - abdo pain, hepatomegaly, ascites

diagnosis - dopper USS

Tx - LMWH + warfarin, thrombolysis or angioplasty, liver transplant

251
Q
A

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