A&E 🚨 Flashcards
What are the broad classifications of blood product transfusion complications?
Immunological, infective, transfusion-related acute lung injury (TRALI), transfusion-associated circulatory overload (TACO), other complications (e.g., hyperkalaemia, iron overload, clotting).
What is a non-haemolytic febrile reaction caused by?
Antibodies reacting with white cell fragments and cytokines that have leaked from blood cells during storage.
What are the features of a non-haemolytic febrile reaction?
- Fever
- Chills
How should a non-haemolytic febrile reaction be managed?
Slow or stop the transfusion, administer paracetamol, and monitor the patient.
What causes a minor allergic reaction during a blood transfusion?
Foreign plasma proteins.
What are the symptoms of a minor allergic reaction?
Pruritus, urticaria.
What is the management for a minor allergic reaction?
Temporarily stop the transfusion, administer antihistamine, and monitor.
What can cause anaphylaxis during blood transfusion?
IgA deficiency in patients with anti-IgA antibodies.
What are the symptoms of anaphylaxis during a blood transfusion?
- Hypotension
- Dyspnoea
- Wheezing
- Angioedema
How should anaphylaxis during a transfusion be managed?
Stop the transfusion, administer IM adrenaline, provide ABC support, oxygen, and fluids.
What is an acute haemolytic reaction caused by?
ABO-incompatible blood due to human error.
What are the symptoms of an acute haemolytic reaction?
- Fever
- Abdominal pain
- Hypotension
What is the management for an acute haemolytic reaction?
Stop transfusion, confirm diagnosis, check patient identity, send blood for direct Coombs test, supportive care.
What causes transfusion-associated circulatory overload (TACO)?
Excessive rate of transfusion, pre-existing heart failure.
What are the symptoms of TACO?
- Pulmonary oedema
- Hypertension
How should TACO be managed?
Slow or stop transfusion, consider IV loop diuretic (e.g., furosemide) and oxygen.
What characterizes transfusion-related acute lung injury (TRALI)?
Non-cardiogenic pulmonary oedema due to increased vascular permeability.
What are the features of TRALI?
- Hypoxia
- Pulmonary infiltrates on chest x-ray
- Fever
- Hypotension
What is the management for TRALI?
Stop the transfusion and provide oxygen and supportive care.
What pathogens are RBCs primarily at risk for transmitting?
- HIV
- HBV
- HCV
What is the clinical impact of viral infections from RBC transfusions?
Chronic disease states such as chronic hepatitis or AIDS.
What is the risk associated with platelet transfusions?
Bacterial contamination due to storage at room temperature.
What are common bacterial contaminants of platelet transfusions?
- Staphylococcus epidermidis
- Bacillus cereus
What is the risk of infectious complications from blood products based on?
Storage conditions, components involved, and duration of storage.
What is a chronic subdural haematoma?
A collection of blood within the subdural space present for weeks to months.
What are the typical symptoms of a subdural haematoma?
- Headache
- Confusion
- Lethargy
- Altered mental status
What imaging technique is first-line for diagnosing acute subdural haematoma?
CT imaging.
What characterizes an acute subdural haematoma?
Collection of fresh blood within the subdural space due to high-impact trauma.
What is the management for a chronic subdural haematoma without neurological deficits?
Conservative management.
What are the two main types of strokes?
- Ischaemic
- Haemorrhagic
What is a transient ischaemic attack (TIA)?
Sudden onset of focal neurologic symptoms lasting typically less than an hour.
What is the significance of a stroke being referred to as a ‘brain attack’?
It emphasizes the need for emergency assessment and treatment.
What is the clinical feature of lacunar strokes?
Isolated hemiparesis, hemisensory loss, or hemiparesis with limb ataxia.
What is the peak incidence time for seizures during alcohol withdrawal?
36 hours.
What is the first-line treatment for alcohol withdrawal?
Long-acting benzodiazepines (e.g., chlordiazepoxide, diazepam).
What is the characteristic feature of acute subdural haematomas on CT imaging?
Crescentic collection, hyperdense compared to the brain.
What are the associated effects of anterior cerebral artery lesions?
- Contralateral hemiparesis and sensory loss, lower extremity > upper
What are common symptoms of chronic subdural haematomas?
- Confusion
- Reduced consciousness
- Neurological deficit
What is the essential problem in ischaemic strokes?
‘Blockage’ in the blood vessel stops blood flow
What is the essential problem in haemorrhagic strokes?
Blood vessel ‘bursts’ leading to reduction in blood flow
What percentage of strokes are ischaemic?
85%
What percentage of strokes are haemorrhagic?
15%
Name a subtype of ischaemic stroke.
Transient ischaemic attack (TIA)
What is a TIA?
Sudden onset of a focal neurologic symptom lasting typically less than an hour
What are the general risk factors for cardiovascular disease?
- Age
- Hypertension
- Smoking
- Hyperlipidaemia
- Diabetes mellitus
What is a common risk factor for cardioembolism?
Atrial fibrillation
List some symptoms of stroke.
- Motor weakness
- Speech problems (dysphasia)
- Swallowing problems
- Visual field defects (homonymous hemianopia)
- Balance problems
What is the definition of stroke?
A clinical syndrome consisting of rapidly developing clinical signs of focal disturbance of cerebral function caused by a vascular problem
What characterizes cerebral hemisphere infarcts?
- Contralateral hemiplegia
- Contralateral sensory loss
- Homonymous hemianopia
- Dysphasia
What are lacunar infarcts?
Small infarcts around the basal ganglia, internal capsule, thalamus, and pons
What is the Oxford Stroke Classification used for?
To classify strokes based on the initial symptoms
What criteria should be assessed in the Oxford Stroke Classification?
- Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- Homonymous hemianopia
- Higher cognitive dysfunction e.g. dysphasia
What are the four types of strokes classified by the Oxford Stroke Classification?
- Total anterior circulation infarcts (TACI)
- Partial anterior circulation infarcts (PACI)
- Lacunar infarcts (LACI)
- Posterior circulation infarcts (POCI)
What is a common symptom more likely in haemorrhagic strokes?
Decrease in the level of consciousness
What does the FAST mnemonic stand for?
- Face
- Arms
- Speech
- Time
What is the first-line imaging technique for suspected stroke?
Non-contrast CT head scan
What is the recommended immediate treatment for ischaemic strokes?
Thrombolysis if certain criteria are met
What is the ABCD2 prognostic score used for?
To risk stratify patients who present with a suspected TIA
What is the recommended immediate antithrombotic therapy for TIAs?
Aspirin 300 mg immediately, unless contraindicated
What should be done if imaging confirms a haemorrhagic stroke?
Consider neurosurgical consultation for further management
What should be done with anticoagulants in the event of a haemorrhagic stroke?
Stop anticoagulants to minimize further bleeding
What is thrombolysis used for?
To treat acute ischaemic stroke
What are the absolute contraindications to thrombolysis?
- Previous intracranial haemorrhage
- Seizure at onset of stroke
- Intracranial neoplasm
- Suspected subarachnoid haemorrhage
- Stroke or traumatic brain injury in preceding 3 months
What is mechanical thrombectomy?
A treatment option for patients with acute ischaemic stroke
What is the recommended secondary prevention for ischaemic stroke?
Clopidogrel is recommended ahead of combination use of aspirin plus modified-release dipyridamole
Fill in the blank: The FAST campaign uses the mnemonic _______.
[Face, Arms, Speech, Time]
True or False: Symptoms alone can differentiate between haemorrhagic and ischaemic strokes.
False
What does the ROSIER score assess?
It assesses the likelihood of stroke based on specific criteria
What is the significance of the hyperdense artery sign in acute ischaemic stroke?
It corresponds with the responsible arterial clot and tends to be visible immediately
What should be maintained within normal limits in acute stroke management?
- Blood glucose
- Hydration
- Oxygen saturation
- Temperature
What is the recommended time frame for administering thrombolysis in acute ischaemic stroke?
Within 4.5 hours of onset of stroke symptoms
What is the recommended action for patients with suspected TIA in the last 7 days?
Arrange urgent assessment (within 24 hours) by a specialist stroke physician
What imaging is necessary to confirm thrombolysis eligibility?
Imaging must definitively exclude haemorrhage
What are the three criteria assessed in the Bamford Classification for strokes?
- Unilateral hemiparesis and/or hemisensory loss of the face, arm & leg
- Homonymous hemianopia
- Higher cognitive dysfunction (e.g. dysphasia)
What characterizes Total Anterior Circulation Infarcts (TACI)?
Involves middle and anterior cerebral arteries with all three criteria present.
What defines Partial Anterior Circulation Infarcts (PACI)?
Involves smaller arteries of anterior circulation with 2 of the 3 criteria present.
What are the characteristics of Lacunar Infarcts (LACI)?
Involves perforating arteries with presentations including:
* Unilateral weakness (and/or sensory deficit)
* Pure sensory stroke
* Ataxic hemiparesis
What symptoms are associated with Posterior Circulation Infarcts (POCI)? (3)
Presents with:
* Cerebellar or brainstem syndromes
* Loss of consciousness
* Isolated homonymous hemianopia
What is Lateral Medullary Syndrome also known as?
Wallenberg’s syndrome
What are the symptoms of Lateral Medullary Syndrome?
- Ipsilateral ataxia
- Nystagmus
- Dysphagia
- Facial numbness
- Cranial nerve palsy (e.g. Horner’s)
- Contralateral limb sensory loss
What is Staphylococcal toxic shock syndrome?
A severe systemic reaction to staphylococcal exotoxins, particularly TSST-1.
What are the CDC diagnostic criteria for Staphylococcal toxic shock syndrome?
- Fever: temperature > 38.9ºC
- Hypotension: systolic blood pressure < 90 mmHg
- Diffuse erythematous rash
- Desquamation of rash, especially of palms and soles
- Involvement of three or more organ systems
What management is recommended for Staphylococcal toxic shock syndrome?
- Removal of infection focus
- IV fluids
- IV antibiotics
Define osteoporosis.
A condition where bones gradually decrease in bone mineral density, increasing the likelihood of fragility fractures.
What is the male-to-female ratio for osteoporosis?
1:6
What are common sites for osteoporotic fractures?
- Spine (vertebra)
- Hip
- Wrist
List risk factors for osteoporotic fractures.
- Advancing age
- Previous history of fragility fracture
- Frequent or prolonged use of glucocorticoids
- History of falls
- Family history of hip fracture
- Low BMI (< 18.5)
- Tobacco smoking
- High alcohol intake
What signs may indicate osteoporotic vertebral fractures?
- Loss of height
- Kyphosis
- Localized tenderness on palpation
What is the first investigation ordered for suspected osteoporotic fractures?
X-ray of the spine
What tools can estimate the 10-year risk of a fracture?
- FRAX tool
- QFracture tool
What defines neutropenic sepsis?
Neutrophil count of < 0.5 * 10^9 with temperature > 38ºC or other signs of sepsis.
What is the most common cause of neutropenic sepsis?
Coagulase-negative, Gram-positive bacteria, particularly Staphylococcus epidermidis.
What is the initial management for neutropenic sepsis?
Start antibiotics immediately without waiting for WBC results.
What are the updated definitions of sepsis according to the Surviving Sepsis Guidelines?
- Sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection
- Septic shock: a more severe form of sepsis with greater risk of mortality
What is the qSOFA score used for?
To identify adult patients outside of ICU at heightened risk of mortality with suspected infection.
List the red flag criteria for sepsis.
- Responds only to voice or pain/unresponsive
- Acute confusional state
- Systolic B.P <= 90 mmHg
- Heart rate > 130 per minute
- Respiratory rate >= 25 per minute
- Needs oxygen to keep SpO2 >= 92%
- Non-blanching rash, mottled/ashen/cyanotic
- Not passed urine in last 18 h/UO < 0.5 ml/kg/hr
- Lactate >= 2 mmol/l
What are the components of the ‘sepsis six’ management?
- Administer oxygen
- Take blood cultures
- Give broad-spectrum antibiotics
- Give intravenous fluid challenges
- Measure serum lactate
- Measure accurate hourly urine output
What is the mortality risk associated with a SOFA score of 2 or more?
Approximately 10% in a general hospital population with suspected infection.
What are common factors associated with an increased risk of suicide?
- Male sex
- History of deliberate self-harm
- Alcohol or drug misuse
- History of mental illness
- Depression
- Schizophrenia
- History of chronic disease
- Advancing age
- Unemployment or social isolation
- Being unmarried, divorced, or widowed
What factors reduce the risk of a patient committing suicide?
- Family support
- Having children at home
- Religious belief
What is the presentation of a ruptured abdominal aortic aneurysm?
- Severe, central abdominal pain radiating to the back
- Pulsatile, expansile mass in the abdomen
- Patients may be shocked or may have collapsed
What is the management for a suspected ruptured AAA?
Immediate vascular review with a view to emergency surgical repair.
What are the two main types of respiratory failure?
- Type 1: ↓ pO2 with normal or ↓ pCO2
- Type 2: ↑ pCO2 with normal or ↓ pO2
List causes of type 1 respiratory failure. (5)
- Pneumonia
- Pulmonary embolism
- Asthma
- Pulmonary oedema
- Acute respiratory distress syndrome
List causes of type 2 respiratory failure.
- Chronic obstructive pulmonary disease
- Decompensation in other respiratory conditions
- Neuromuscular disease
- Obesity hypoventilation syndrome
- Sedative drugs
What is the condition characterized by ↑ pCO2 with a normal or ↓ pO2?
Type 2 respiratory failure
Hypercapnia leads to ↓ pH and respiratory acidosis.
List the causes of type 1 respiratory failure. (5)
- pneumonia
- pulmonary embolism
- asthma
- pulmonary oedema
- acute respiratory distress syndrome
What are common causes of type 2 respiratory failure?
- chronic obstructive pulmonary disease
- decompensation in other respiratory conditions
- neuromuscular disease
- obesity hypoventilation syndrome
- sedative drugs
What guidelines did the British Thoracic Society publish in 2002?
Guidelines on the use of non-invasive ventilation in acute respiratory failure
Followed by the Royal College of Physicians guidelines in 2008.
What are key indications for non-invasive ventilation? (4)
- COPD with respiratory acidosis (pH 7.25-7.35)
- Type II respiratory failure secondary to chest wall deformity
- Cardiogenic pulmonary oedema unresponsive to CPAP
- Weaning from tracheal intubation
What are the recommended initial settings for bi-level pressure support in COPD?
- EPAP: 4-5 cm H2O
- IPAP: 10-15 cm H2O
- Back up rate: 15 breaths/min
- Inspiration:expiration ratio: 1:3
What is the purpose of head tilt and chin lift in airway management?
To open the airway
Jaw thrust is preferred if there is concern about cervical spine injury.
What is an extradural (epidural) haematoma?
A collection of blood between the skull and the dura, typically caused by trauma
What is the classical presentation of an extradural haematoma?
Loss of consciousness, brief regain, and then loss again after a low-impact head injury
This brief regain is termed the ‘lucid interval’.
What imaging appearance does an extradural haematoma have?
Biconvex (lentiform), hyperdense collection around the surface of the brain
Limited by the suture lines of the skull.
What is idiopathic intracranial hypertension?
A condition seen in young, overweight females, also known as pseudotumour cerebri
List the risk factors for idiopathic intracranial hypertension.
- obesity
- female sex
- pregnancy
- drugs (e.g. combined oral contraceptive pill, steroids)
- tetracyclines
- retinoids
- lithium
What are the common features of idiopathic intracranial hypertension?
- headache
- blurred vision
- papilloedema
- enlarged blind spot
- sixth nerve palsy
What is the management for idiopathic intracranial hypertension?
- weight loss
- carbonic anhydrase inhibitors (e.g. acetazolamide)
- topiramate
- repeated lumbar puncture (temporary)
- surgery (optic nerve sheath decompression)
What does papilloedema describe?
Optic disc swelling caused by increased intracranial pressure
It is almost always bilateral.
List the features observed during fundoscopy of papilloedema.
- venous engorgement
- loss of venous pulsation
- blurring of the optic disc margin
- elevation of optic disc
- loss of the optic cup
- Paton’s lines
What are common causes of papilloedema? (5)
- space-occupying lesion
- malignant hypertension
- idiopathic intracranial hypertension
- hydrocephalus
- hypercapnia
What is the normal intracranial pressure (ICP) in adults?
7-15 mmHg in the supine position
What is cerebral perfusion pressure (CPP)?
The net pressure gradient causing cerebral blood flow to the brain
CPP = mean arterial pressure - ICP.
What are the features of increased intracranial pressure?
- headache
- vomiting
- reduced levels of consciousness
- papilloedema
- Cushing’s triad
What is a subarachnoid haemorrhage (SAH)?
An intracranial haemorrhage defined as the presence of blood within the subarachnoid space
What is the most common cause of spontaneous SAH?
Intracranial aneurysm (saccular ‘berry’ aneurysms)
What are classical presenting features of spontaneous SAH?
- sudden-onset headache
- severe headache
- nausea and vomiting
- meningism
- coma
- seizures
What is the first-line investigation for SAH?
Non-contrast CT head
What should be done if CT head is normal within 6 hours of symptom onset?
Consider an alternative diagnosis
New guidelines suggest not doing a lumbar puncture.
What is the aim of investigation after confirming spontaneous SAH?
Identify a causative pathology that needs urgent treatment
What are the common complications of aneurysmal SAH? (5)
- re-bleeding
- hydrocephalus
- vasospasm
- hyponatraemia
- seizures
What is a subdural haematoma?
A collection of blood deep to the dural layer of the meninges
List the classifications of subdural haematomas based on age.
- Acute
- Subacute
- Chronic
What are the typical clinical features of a subdural haematoma?
- altered mental status
- focal neurological deficits
- headache
- seizures
What is an acute subdural haematoma?
A collection of blood within the subdural space that presents variably, from incidental findings to severe coma.
What imaging technique is used as the first-line investigation for acute subdural haematomas?
CT imaging.
What does CT imaging show in cases of acute subdural haematomas?
A crescentic collection, hyperdense compared to the brain.
What is the typical management for small or incidental acute subdural haematomas?
Observation and conservative management.
What are the surgical options for large acute subdural haematomas?
Monitoring of intracranial pressure and decompressive craniectomy.
What defines a chronic subdural haematoma?
A collection of blood within the subdural space present for weeks to months.
What is the typical presentation of a chronic subdural haematoma?
Progressive confusion, reduced consciousness, or neurological deficit.
What imaging findings are associated with chronic subdural haematomas?
Hypodense crescentic shapes that compress the brain.
What is the management for small chronic subdural haematomas without neurological deficits?
Conservative management.
What are the potential features of pulmonary embolism?
- Chest pain
- Dyspnoea
- Haemoptysis
- Tachycardia
- Tachypnoea.
What percentage of patients present with the textbook triad of pleuritic chest pain, dyspnoea, and haemoptysis in pulmonary embolism?
Around 10%.
What is the PIOPED study?
A study that examined the frequency of symptoms and signs in patients diagnosed with pulmonary embolism.
What is the significance of tachypnea in the context of pulmonary embolism?
It occurs in 96% of patients with pulmonary embolism.
What is the pulmonary embolism rule-out criteria (PERC)?
Criteria used to rule out PE when the pre-test probability is low (< 15%).
What should be done if the suspicion of pulmonary embolism is greater than low probability?
Move straight to the 2-level PE Wells score.
What is the 2-level PE Wells score used for?
To assess the likelihood of pulmonary embolism based on clinical features.
What is the management recommendation for patients with a likely PE (> 4 points)?
Arrange an immediate computed tomography pulmonary angiogram (CTPA).
What is the recommended initial lung-imaging modality for non-massive PE?
CTPA.
What is the sensitivity and specificity of V/Q scans?
Sensitivity of around 75% and specificity of 97%.
What are the key changes in NICE guidelines regarding the management of VTE in 2020?
- Use of direct oral anticoagulants (DOACs) as first-line treatment
- Outpatient treatment for low-risk PE patients.
What is the cornerstone of VTE management?
Anticoagulant therapy.
What should be the duration of anticoagulation for all patients with VTE?
At least 3 months.
What is primary postpartum haemorrhage defined as?
Blood loss of > 500 ml after a vaginal delivery occurring within 24 hours.
What are the causes of primary postpartum haemorrhage?
- Tone (uterine atony)
- Trauma (e.g., perineal tear)
- Tissue (retained placenta)
- Thrombin (clotting/bleeding disorder).
What is the management approach for primary postpartum haemorrhage?
Involves the ABC approach, blood transfusion, and medications like IV oxytocin.
What is the classification of pneumothoraces?
- Spontaneous pneumothorax
- Primary spontaneous pneumothorax (PSP).
What is secondary postpartum hemorrhage?
Occurs between 24 hours - 12 weeks, typically due to retained placental tissue or endometritis.
What is pneumothorax?
A condition characterized by the accumulation of air in the pleural space, resulting in the partial or complete collapse of the affected lung.
What are the classifications of pneumothorax?
- Spontaneous pneumothorax
- Traumatic pneumothorax
- Iatrogenic pneumothorax
What is primary spontaneous pneumothorax (PSP)?
Occurs without underlying lung disease, often in tall, thin, young individuals, associated with the rupture of subpleural blebs or bullae.
What is secondary spontaneous pneumothorax (SSP)?
Occurs in patients with pre-existing lung disease, such as COPD, asthma, cystic fibrosis, lung cancer, or Pneumocystis pneumonia.
What is a tension pneumothorax?
A severe pneumothorax resulting in the displacement of mediastinal structures, potentially leading to severe respiratory distress and hemodynamic collapse.
What are the clinical features of pneumothorax?
- Dyspnoea
- Chest pain (often pleuritic)
- Hyper-resonant lung percussion
- Reduced breath sounds
- Reduced lung expansion
- Tachypnoea
- Tachycardia
What are the symptoms of tension pneumothorax?
- Respiratory distress
- Tracheal deviation away from the side of the pneumothorax
- Hypotension
What are the minimal symptoms defined by the British Thoracic Society for pneumothorax?
No significant pain or breathlessness and no physiological compromise.
What is the first step in managing a symptomatic pneumothorax?
Assess for high-risk characteristics.
What are high-risk characteristics for pneumothorax?
- Haemodynamic compromise
- Significant hypoxia
- Bilateral pneumothorax
- Underlying lung disease
- Age ≥ 50 with significant smoking history
- Haemothorax
What management options are available for pneumothorax?
- Conservative care
- Ambulatory device
- Needle aspiration
- Chest drain
What is the role of a chest drain in pneumothorax management?
Inserted if needle aspiration is unsuccessful to allow continuous drainage of air.
What is the recommended follow-up for patients managed conservatively for primary spontaneous pneumothorax?
Reviewed every 2-4 days as an outpatient.
What is Legionnaire’s disease caused by?
The intracellular bacterium Legionella pneumophilia.
What are common features of Legionnaire’s disease?
- Flu-like symptoms
- Dry cough
- Relative bradycardia
- Confusion
- Lymphopaenia
- Hyponatraemia
- Deranged liver function tests
- Pleural effusion
What is the diagnostic test of choice for Legionnaire’s disease?
Urinary antigen.
What distinguishes Mycoplasma pneumoniae from other pneumonias?
It often affects younger patients and lacks a peptidoglycan cell wall, leading to resistance to penicillins and cephalosporins.
What are some complications of Mycoplasma pneumoniae? (7)
- Cold agglutination
- Erythema multiforme
- Meningoencephalitis
- Bullous myringitis
- Pericarditis/myocarditis
- Gastrointestinal issues
- Renal problems
What is the classical x-ray finding in pneumonia?
Consolidation.
What are typical symptoms of pneumonia?
- Cough
- Sputum
- Dyspnoea
- Chest pain
- Fever
What is the CURB-65 scoring system used for?
Risk stratification in patients with community-acquired pneumonia.
What does the ‘C’ in CURB-65 stand for?
Confusion (abbreviated mental test score <= 8/10).
What is the recommended treatment for patients with a CURB-65 score of 0?
Home-based care.
What antibiotic is generally used first-line for pneumonia?
Oral amoxicillin.
What should be avoided for patients with pneumothorax regarding travel?
Flying for 2 weeks after successful drainage if there is no residual air.
What is the risk of developing a pneumothorax in healthy smoking men?
Around 10%.
What is the management for persistent or recurrent pneumothorax?
Consider video-assisted thoracoscopic surgery (VATS) for mechanical/chemical pleurodesis +/- bullectomy.
What does the ‘C’ in the CRB65 criteria stand for?
Confusion (abbreviated mental test score <= 8/10)
What does the ‘R’ in the CRB65 criteria indicate?
Respiration rate >= 30/min
What does the ‘B’ in the CRB65 criteria refer to?
Blood pressure: systolic <= 90 mmHg and/or diastolic <= 60 mmHg
What age group does the ‘65’ in CRB65 refer to?
Aged >= 65 years
How is patient risk stratified based on CRB65 scores?
0: low risk (less than 1% mortality risk)
1 or 2: intermediate risk (1-10% mortality risk)
3 or 4: high risk (more than 10% mortality risk)
What is the recommendation for patients with a CRB65 score of 0?
Home-based care should be considered
What CRP level indicates that antibiotic therapy should not be routinely offered?
CRP < 20 mg/L
What is the recommendation for patients with a CRP level between 20 - 100 mg/L?
Consider a delayed antibiotic prescription
What should be offered to patients with CRP > 100 mg/L?
Offer antibiotic therapy
What additional criterion does CURB65 include compared to CRB65?
Urea > 7 mmol/L
What is the recommendation for patients with a CURB65 score of 0 or 1?
Consider home-based care (low risk, < 3% mortality risk)
What is the recommendation for patients with a CURB65 score of 2 or more?
Consider hospital-based care (intermediate risk, 3-15% mortality risk)
What is the recommendation for patients with a CURB65 score of 3 or more?
Consider intensive care assessment (high risk, > 15% mortality risk)
What is the first-line treatment for low-severity community-acquired pneumonia?
Amoxicillin
What alternative should be used if a patient is penicillin allergic?
Macrolide or tetracycline
What is the recommended duration of antibiotic treatment for low-severity community-acquired pneumonia?
5 days
What is the recommended treatment for moderate and high-severity community-acquired pneumonia?
Dual antibiotic therapy with amoxicillin and a macrolide
What duration of antibiotic treatment is recommended for moderate and high-severity pneumonia?
7-10 days
What should be monitored for admitted patients to determine response to treatment?
CRP levels
What are the discharge criteria for patients with pneumonia?
Not routinely discharged if they have 2 or more of the following:
* Temperature > 37.5°C
* Respiratory rate >= 24 breaths per minute
* Heart rate > 100 beats per minute
* Systolic blood pressure <= 90 mmHg
* Oxygen saturation < 90% on room air
* Abnormal mental status
* Inability to eat without assistance
What is the recommended follow-up for all cases of pneumonia after clinical resolution?
Repeat chest X-ray at 6 weeks
What is the most common cause of community-acquired pneumonia?
Streptococcus pneumoniae
What are characteristic features of pneumococcal pneumonia?
Rapid onset, high fever, pleuritic chest pain, herpes labialis
What are common symptoms of pneumonia?
- Cough with purulent sputum
- Dyspnoea
- Chest pain
- Fever
- Malaise
What signs may indicate systemic infection in pneumonia patients?
- High temperature
- Tachycardia
- Hypotension
- Confusion
- Tachypnoea
- Low oxygen saturation
What is the pathophysiology of pneumonia?
Inflammatory cascade begins after pathogen entry, leading to neutrophil migration and fluid accumulation in alveoli
What are some common risk factors for pneumonia?
- Aged under 5 or over 65 years
- Smoking
- Recent viral respiratory tract infection
- Chronic respiratory diseases
- Immunosuppression
- Aspiration risk
- IV drug use
- Other non-respiratory comorbidities
What is the initial treatment for paracetamol overdose if ingested less than 1 hour ago?
Activated charcoal
Activated charcoal is used to reduce absorption of the toxin.
What is the main antidote for paracetamol overdose?
N-acetylcysteine (NAC)
NAC is used to replenish glutathione and prevent liver damage.
What is the treatment for salicylate overdose?
Urinary alkalinization with IV bicarbonate
This increases the excretion of salicylates.
What medication is used to reverse opioid overdose?
Naloxone
Naloxone is an opioid antagonist that quickly reverses the effects of opioids.
What is the primary treatment for benzodiazepine overdose?
Flumazenil
Flumazenil can reverse benzodiazepine effects but is used cautiously due to seizure risk.
True or False: The majority of overdoses are managed with supportive care only.
True
Supportive care is often sufficient, particularly in non-severe cases.
What is the role of IV bicarbonate in tricyclic antidepressant overdose?
May reduce the risk of seizures and arrhythmias in severe toxicity
It helps to correct acidosis and stabilize cardiac function.
Which class of antiarrhythmics should be avoided in tricyclic antidepressant overdose?
Class 1a and class Ic antiarrhythmics
These classes can prolong depolarization and worsen arrhythmias.
What is the first-line management for tricyclic induced arrhythmias?
Correction of acidosis
Addressing acidosis is crucial before other interventions.
In lithium toxicity, what may help in mild to moderate cases?
Volume resuscitation with normal saline
This aids in hydration and may improve kidney function.
What is the management for severe lithium toxicity?
Haemodialysis
Haemodialysis helps to remove excess lithium from the body.
What is the antidote for warfarin overdose?
Vitamin K and prothrombin complex
These agents help to restore clotting factors.
What is the treatment for heparin overdose?
Protamine sulphate
Protamine sulphate neutralizes the effects of heparin.
What is the treatment for bradycardia due to beta-blocker overdose?
Atropine
Atropine increases heart rate by blocking vagal effects.
What are the first-line treatments for ethylene glycol poisoning?
Fomepizole or ethanol
Both agents inhibit alcohol dehydrogenase to prevent toxic metabolite formation.
What is the role of haemodialysis in ethylene glycol poisoning?
Used in refractory cases
It helps to remove ethylene glycol and its metabolites.
What is the primary management for methanol poisoning?
Fomepizole or ethanol
Similar to ethylene glycol, these agents inhibit the formation of toxic metabolites.
What is the treatment for organophosphate insecticide poisoning?
Atropine
Atropine counteracts the effects of excessive acetylcholine.
What is used for digoxin overdose?
Digoxin-specific antibody fragments
These fragments bind to digoxin and neutralize its effects.
What is the chelating agent used for iron overdose?
Desferrioxamine
Desferrioxamine helps to remove excess iron from the body.
What is the treatment for lead poisoning?
Dimercaprol and calcium edetate
Both agents chelate lead to facilitate its excretion.
What is the management for carbon monoxide poisoning?
100% oxygen and hyperbaric oxygen
These treatments help to displace carbon monoxide from hemoglobin.
What is the antidote for cyanide poisoning?
Hydroxocobalamin
Hydroxocobalamin binds to cyanide and forms a non-toxic complex.
What are the central nervous system features of synthetic cannabinoid toxicity?
Agitation, tremor, anxiety, confusion, somnolence, syncope, hallucinations, changes in perception, acute psychosis, nystagmus, convulsions, coma
These symptoms can vary in severity and may require different management approaches.
What cardiac symptoms are associated with synthetic cannabinoid toxicity?
Tachycardia, hypertension, chest pain, palpitations, ECG changes
These symptoms indicate potential cardiovascular complications from synthetic cannabinoid use.
What renal complication is associated with synthetic cannabinoid toxicity?
Acute kidney injury
This can occur due to various factors, including dehydration and metabolic changes.
List the muscular features of synthetic cannabinoid toxicity.
Hypertonia, myoclonus, muscle jerking, myalgia
These muscular symptoms can lead to significant discomfort and may complicate management.
What are some other features of synthetic cannabinoid toxicity?
Cold extremities, dry mouth, dyspnoea, mydriasis, vomiting, hypokalaemia
Other symptoms may vary depending on the individual and the specific synthetic cannabinoid used.
What is cocaine derived from?
The coca plant
Cocaine is an alkaloid that has significant recreational use.
What mechanism of action does cocaine have?
Cocaine blocks the uptake of dopamine, noradrenaline, and serotonin
This action leads to its stimulant effects and potential for toxicity.
List the cardiovascular adverse effects of cocaine.
Coronary artery spasm, myocardial ischaemia/infarction, tachycardia, bradycardia, hypertension, QRS widening, QT prolongation, aortic dissection
These effects can lead to serious complications and require prompt management.
What are some neurological adverse effects of cocaine?
Seizures, mydriasis, hypertonia, hyperreflexia
Neurological effects can significantly impact patient management.
What is the first-line management for cocaine toxicity?
Benzodiazepines
Benzodiazepines help manage agitation, seizures, and other complications.
What is the role of glyceryl trinitrate in cocaine toxicity management?
Used for chest pain in combination with benzodiazepines
This combination can help alleviate myocardial ischemia.
What are the clinical features of MDMA (Ecstasy) use?
Agitation, anxiety, confusion, ataxia, tachycardia, hypertension, hyponatraemia, hyperthermia, rhabdomyolysis
These symptoms can be life-threatening and require immediate attention.
What is the management for hyperthermia due to MDMA?
Supportive care and dantrolene if simple measures fail
Dantrolene is particularly effective in cases of severe hyperthermia.
What are the psychoactive symptoms of LSD toxicity?
Variable subjective experiences, impaired judgement, amplification of current mood, agitation, drug-induced psychosis
These symptoms can lead to significant distress and require careful management.
What are the somatic symptoms of LSD toxicity?
Nausea, headache, palpitations, dry mouth, drowsiness, tremors
These symptoms can complicate the clinical picture of LSD intoxication.
What is the typical clinical presentation following massive overdoses of LSD?
Respiratory arrest, coma, hyperthermia, autonomic dysfunction, bleeding disorders
These complications can be life-threatening and require intensive management.
What is the mechanism of action of nitrous oxide?
Blocks NMDA receptors, impairing pain perception and inducing euphoria
This dissociative anaesthetic effect is why nitrous oxide is used in both medical and recreational settings.
What are long-term effects of nitrous oxide misuse?
Vitamin B12 deficiency, neurological impairments, psychological issues, physical harm
Chronic misuse can lead to significant health complications.
What are novel psychoactive substances (NPS)?
Chemically related to established recreational drugs, often referred to as ‘legal highs’
Their sale and distribution have been illegal in the UK since 2016.
What are the features of opioid misuse?
Rhinorrhoea, needle track marks, pinpoint pupils, drowsiness, watering eyes, yawning
These signs can help identify individuals who may be misusing opioids.
What complications can arise from opioid misuse?
Viral infections, bacterial infections, venous thromboembolism, overdose, psychological problems, social problems
These complications can significantly affect the health and well-being of individuals who misuse opioids.
What is the emergency management for opioid overdose?
IV or IM naloxone
Naloxone has a rapid onset and is critical for reversing opioid overdose.
What are the first-line treatments for opioid detoxification recommended by NICE?
Methadone or buprenorphine
These medications help alleviate withdrawal symptoms and cravings.
What is the difference between methadone and buprenorphine?
Methadone is a full agonist; buprenorphine is a partial agonist and kappa-opioid antagonist
This difference impacts their effects and management of opioid dependence.
What is adhesive capsulitis commonly known as?
Frozen shoulder
In which population is adhesive capsulitis most common?
Middle-aged females
What is the aetiology of frozen shoulder?
Not fully understood
What percentage of diabetics may experience an episode of frozen shoulder?
Up to 20%
What shoulder movement is affected more in adhesive capsulitis?
External rotation
How are both active and passive movement affected in frozen shoulder?
Both are affected
What are the three typical phases of frozen shoulder?
Painful freezing phase, adhesive phase, recovery phase
What percentage of patients may have bilateral frozen shoulder?
Up to 20%
How long does an episode of frozen shoulder typically last?
Between 6 months and 2 years
What is the usual method of diagnosing adhesive capsulitis?
Clinical diagnosis
What may be required for atypical or persistent symptoms of frozen shoulder?
Imaging
What is the effectiveness of a single intervention in improving long-term outcomes for frozen shoulder?
No single intervention has been shown to improve outcome in the long-term
Name some treatment options for adhesive capsulitis.
- NSAIDs
- Physiotherapy
- Oral corticosteroids
- Intra-articular corticosteroids
What condition is characterized by notching of the inferior border of the ribs in adults and older children?
Coarctation of the aorta
This occurs due to the development of dilated intercostal collateral vessels to maintain blood flow to the descending aorta.
What causes the inferior margin of the ribs to erode in coarctation of the aorta?
Pressure from dilated intercostal collateral vessels
These vessels develop to compensate for the aortic obstruction.
Which conditions do NOT cause rib notching?
- Acromegaly
- Liver cirrhosis
- Renal artery stenosis
Rare cases of rib notching have been reported in Marfan’s syndrome, affecting the upper margin of the ribs.
What is coarctation of the aorta?
A congenital narrowing of the descending aorta
It is more common in males and has a notable association with Turner’s syndrome.
Name two associations with coarctation of the aorta.
- Turner’s syndrome
- Bicuspid aortic valve
Other associations include berry aneurysms and neurofibromatosis.
What are the infant features of coarctation of the aorta?
Heart failure
This is a common presentation in infants with coarctation.
What adult feature is commonly associated with coarctation of the aorta?
Hypertension
Refractory hypertension can also occur due to the condition.
What is a typical physical exam finding in adults with coarctation of the aorta?
Radio-femoral delay
This finding indicates a difference in blood pressure between the arms and legs.
What type of murmur is associated with coarctation of the aorta?
Mid systolic murmur, maximal over the back
An apical click from the aortic valve may also be heard.
Fill in the blank: Coarctation of the aorta is associated with _______.
Turner’s syndrome
This condition has a notable association with coarctation.
True or False: Notching of the inferior border of the ribs is seen in young children with coarctation of the aorta.
False
Notching is not seen in young children; it occurs in adults and older children.
What tests are needed prior to starting anti-TB medications?
Urea and Electrolytes, LFTs, vision testing, FBC
These tests are crucial to monitor for hepatotoxicity and other potential side effects.
Why must LFTs be taken before starting anti-TB medications?
All drugs in the regimen are hepatotoxic
This ensures that liver function is monitored before treatment initiation.
What is the medication regimen for treating active tuberculosis?
Rifampicin, Isoniazid, Pyrazinamide, Ethambutol
This combination is known as the RIPE regimen.
What is the duration of the initial phase of TB treatment?
First 2 months
This phase includes all four drugs in the regimen.
What is the duration of the continuation phase of TB treatment?
Next 4 months
This phase continues with Rifampicin and Isoniazid.
How long is treatment for latent tuberculosis?
3 months of isoniazid and rifampicin OR 6 months of isoniazid
Pyridoxine is recommended with isoniazid.
What is the treatment duration for meningeal tuberculosis?
At least 12 months with the addition of steroids
Meningeal TB requires prolonged treatment due to its severity.
What is directly observed therapy and when is it indicated?
A three times a week dosing regimen for certain groups
Indicated for homeless people, those likely to have poor concordance, and all prisoners.
What is immune reconstitution disease?
Occurs typically 3-6 weeks after starting treatment, often presents with enlarging lymph nodes
It is a complication of TB treatment.
What are the adverse effects of rifampicin?
- Potent liver enzyme inducer
- Hepatitis
- Orange secretions
- Flu-like symptoms
These side effects can significantly impact patients’ health.
What is the main adverse effect of isoniazid?
Peripheral neuropathy
It can be prevented with pyridoxine (Vitamin B6).
What are the adverse effects of pyrazinamide?
- Hyperuricaemia causing gout
- Arthralgia
- Myalgia
- Hepatitis
Monitoring for these effects is essential during treatment.
What is a significant adverse effect of ethambutol?
Optic neuritis
Visual acuity should be checked before and during treatment.
True or False: Rifampicin can cause urine and tears to turn orange-red.
True
This is a harmless side effect but does not affect urine tests.
Fill in the blank: The initial phase of TB treatment includes the drugs _______.
Rifampicin, Isoniazid, Pyrazinamide, Ethambutol
Known collectively as RIPE.
