Acute Care and Trauma (1) Flashcards

Question

What is the criteria for ARDS (American-European Consensus Conference)?

Answer 1

1. Acute onset (within 1 week of a known risk factor) 2. Pulmonary oedema: bilateral infiltrates on chest x-ray ('not fully explained by effusions, lobar/lung collapse or nodules) 3. Non-cardiogenic (pulmonary artery wedge pressure needed if doubt) 4. pO2/FiO2 < 40kPa (300 mmHg)

Answer 2

Due to the severity of the condition patients are generally managed in ITU Oxygenation/ventilation to treat the hypoxaemia General organ support e.g. vasopressors as needed Treatment of the underlying cause e.g. antibiotics for sepsis Certain strategies such as prone positioning and muscle relaxation have been shown to improve outcome in ARDS

Answer 3

Deficiency of adrenal cortical hormones (mineralocorticoids, glucocorticoids and androgens)

Answer 4

Primary (Addisons disease): Autoimmune (>70%) Secondary: Pituitary or hypothalamic disease. Surgical: After bilateral adrenalectomy. Medical: (iatrogenic) sudden cessation of long-term steroid therapy

Answer 5

4Is: 1. Infections: Tuberculosis, meningococcal septicaemia (Waterhouse–Friderichsen syndrome), Cytomegalovirus (HIV patients) 2. Infiltration: Metastasis (lung, breast, melanoma), lymphomas, amyloidosis 3. Infarction: Secondary to thrombophilia 4. Inherited: Adrenoleukodystrophy 1, ACTH receptor mutation

Answer 6

Most common cause is iatrogenic- sudden cessation in long term steroid therapy Primary causes are rare

Answer 7

(Addisonian crisis) Acute adrenal insufficiency with major haemody- namic collapse often precipitated by stress (e.g. infection or surgery)

Answer 8

Non-specific vague symptoms such as dizziness, anorexia, weight loss, diarrhoea, vomiting, abdominal pain, lethargy, weakness, depression

Answer 9

Postural hypotension Increased pigmentation: more noticeable on buccal mucosa, scars, skin creases, nails, pressure points (resulting from melanocytes being stimulated by increased ACTH levels) Loss of body hair in women (androgen deficiency) Associated autoimmune conditions: e.g. vitiligo

Answer 10

Hypotensive shock Tachycardia Pale Cold and clammy Oliguria

Answer 11

Definite investigation is ACTH stimulation (synACTHen) test 9am serum cortisol may also be helpful

Answer 12

> 500 nmol/l makes Addison's very unlikely < 100 nmol/l is definitely abnormal 100-500 nmol/l should prompt a ACTH stimulation test to be performed ACTH stimulation test should show an increase in plasma cortisol levels 30 minutes after giving Synacthen 250ug IM

Answer 13

Bloods- Haematology (FBC for neutrophilic, CRP and ESR for infection) Biochemistry (U&Es for hyperkalaemia, hyponatraemia, hypoglycaemia and metabolic acidosis) Microbiology (blood cultures) Urine- MCS

Answer 14

Sepsis or surgery causing an acute exacerbation of chronic insufficiency (Addison's, Hypopituitarism) Adrenal haemorrhage eg Waterhouse-Friderichsen syndrome (fulminant meningococcemia) Steroid withdrawal

Answer 15

Hydrocortisone 100 mg im or iv 1 litre normal saline infused over 30-60 mins or with dextrose if hypoglycaemic Continue hydrocortisone 6 hourly until the patient is stable (no fludrocortisone is required because high cortisol exerts weak mineralocorticoid action) Oral replacement may begin after 24 hours and be reduced to maintenance over 3-4 days Treat the underlying cause e.g. Abx for sepsis

Answer 16

Replacement therapy of glucocorticoid and mineralocorticoid Combination of: Hydrocortisone (usually given in 2 or 3 divided doses, 20-30 mg per day, with the majority given in the first half of the day) and fludrocortisone Patient education: importance of not missing doses, MedicAlert bracelets, hydrocortisone injection for crisis Management of intercurrent illness: glucocorticoid dose should be doubled with fludrocortisone staying the same

Answer 17

Give hydrocortisone before thyroxine to avoid precipitating an Addisonian crisis

Answer 18

Hyperkalaemia Death during an Addisonian crisis

Answer 19

Adrenal function rarely recovers, but normal life expectancy can be expected if treated

Answer 20

A patient who is alcohol dependent and has stopped or reduced their alcohol intake within hours or days of presentation

Answer 21

1. Chronic alcohol consumption enhances GABA mediated inhibition in the CNS (similar to benzodiazepines) and inhibits NMDA-type glutamate receptors 2. Alcohol withdrawal is thought to be lead to the opposite (decreased inhibitory GABA and increased NMDA glutamate transmission)

Answer 22

Characterized by three or more of: . Withdrawal on cessation of alcohol . Tolerance . Compulsion to drink, difficulty controlling termination or the levels of use . Persistent desire to cut down or control use . Time is spent obtaining, using, or recovering from alcohol . Neglect of other interests (social, occupational, or recreational) . Continued use despite physical and psychological problems

Answer 23

Symptoms start at 6-12 hours: tremor, sweating, tachycardia, anxiety Peak incidence of seizures at 36 hours Peak incidence of delirium tremens is at 48-72 hours: coarse tremor, confusion, delusions, auditory and visual hallucinations, fever, tachycardia

Answer 24

HAD A PINT Headache Anxiety/ agitation Depression Anorexia Palpitations Insomnia Nausea Tremor

Answer 25

Dupuytrens contracture Palmar erythema Bruising Spider naevi Telangiectasia- widened venules cause threadlike red lines or patterns on the skin Bilateral parotid enlargement Gynaecomastia Smell of alcohol

Answer 26

A to E approach VBG: respiratory alkalosis with delirium tremens Bloods: Increased MCV, thrombocytopenia, hypomagnesaemia, hypokalaemia, hypophosphataemia, elevated AST, ALT, and GGT Coagulation studies: prolonged INR and prothrombin time Drug screen: barbiturates, paracetamol

Answer 27

First-line: long-acting benzodiazepines e.g. chlordiazepoxide or diazepam (lorazepam may be preferable in patients with hepatic failure) with a reducing dose protocol B1 thiamine, pabrinex Carbamazepine also effective in treatment of alcohol withdrawal Patients with a history of complex withdrawals from alcohol (i.e. delirium tremens, seizures, blackouts) should be admitted to hospital for monitoring until withdrawals stabilised

Answer 28

Seizures (generalised tonic-clonic) - cause of fatality Delirium tremens

Answer 29

Cerebral atrophy and dementia Cerebellar degeneration Optic atrophy Peripheral neuropathy Myopathy Indirect effects include hepatic encephalopathy, thiamine deficiency, causing Wernickes encephalopathy or Korsakoffs psychosis

Answer 30

Depends on complications. Alcoholic fatty liver is reversible on abstinence from alcohol In general, 5-year survival rates in those with alcoholic cirrhosis who stop drinking are 60–75%, but < 40% in those who continue

Answer 31

A severe, life-threatening, generalised or systemic hypersensitivity reaction

Answer 32

There is sudden release of mast cell- and basophil-derived mediators into the circulation

Answer 33

Rapidly developing life-threatening airway and/or breathing and/or circulation problems Usually associated with skin and mucosal changes

Answer 34

Immunologic: IgE-mediated or immune complex/complement-mediated Non-immunologic: mast cell or basophil degranulation without the involvement of antibodies (e.g. reactions caused by vancomycin, codeine, ACE inhibitors)

Answer 35

Food (e.g. nuts) - the most common cause in children Drugs Venom (e.g. wasp sting)

Answer 36

The sudden onset and rapid progression of symptoms Airway and/or Breathing and/or Circulation problems

Answer 37

Airway: swelling of the throat and tongue →hoarse voice and stridor Breathing: respiratory wheeze and dyspnoea Circulation: hypotension and tachycardia

Answer 38

That they are not in true anaphylaxis

Answer 39

Generalised pruritus Widespread erythematous or urticarial rash

Answer 40

Clinical diagnosis Later: Serum mast cell tryptase (measured within 15 min–3 h after onset of symptoms)= elevated up to 12 hours post event Histamine levels (measured preferably within 30 min after symptom onset) and urinary metabolites of histamine (which may remain elevated for several hours after symptom onset) ABG: elevated lactate ECG: Non-specific ST ECG changes are common post-adrenaline

Answer 41

Intramuscular adrenaline 500 micrograms (0.5ml 1 in 1,000) Can be repeated every 5 minutes if necessary Best site for IM injection is the anterolateral aspect of the middle third of the thigh Other medications (not as important): Oxygen Chlorphenamine - only when patient is stabilised

Answer 42

Defined as respiratory and/or cardiovascular problems persist despite 2 doses of IM adrenaline IV fluids should be given for shock Expert help should be sought for consideration of an IV adrenaline infusion

Answer 43

Non-sedating oral antihistamines, in preference to chlorphenamine, may be given following initial stabilisation especially in patients with persisting skin symptoms (urticaria and/or angioedema) Establish if it is true anaphylaxis: Serum tryptase levels All patients with a new diagnosis of anaphylaxis should be referred to a specialist allergy clinic An adrenaline injector should be givens an interim measure before the appointment

Answer 44

Patients should be prescribed 2 adrenaline auto-injectors Training should be provided on how to use it

Answer 45

Risk-stratified approach to avoid biphasic reactions (can occur 1–72 h after the first reaction in up to 20% of patients)

Answer 46

1. Fast-track discharge (after 2 hours of symptom resolution): - good response to a single dose of adrenaline - complete resolution of symptoms - has been given an adrenaline auto-injector and trained how to use it - adequate supervision following discharge 2. Minimum 6 hours after symptom resolution: - 2 doses of IM adrenaline needed, or previous biphasic reaction 3. Minimum 12 hours after symptom resolution: - severe reaction requiring > 2 doses of IM adrenaline - patient has severe asthma - possibility of an ongoing reaction (e.g. slow-release medication) - patient presents late at night - patient in areas where access to emergency access care may be difficult - observation for at 12 hours following symptom resolution

Answer 47

Respiratory failure Shock Death

Answer 48

Good if prompt treatment given

Answer 49

A procedure to measure the acidity (pH) and the levels of oxygen and carbon dioxide in the blood from an artery

Answer 50

Respiratory failure - in acute and chronic states. Any severe illness which may lead to a metabolic acidosis: - Cardiac/ Liver/ Renal failure - Hyperglycaemic states associated with diabetes mellitus - Multiorgan failure - Sepsis - Burns Poisons/toxins Ventilated patients

Answer 51

Local hematoma Arterial vasospasm Arterial occlusion Air or thrombus embolism LA anaphylactic reaction Infection at the puncture site

Answer 52

Tibia + fibula + talus

Answer 53

Medial and lateral ligament (originating from the corresponding malleolus)

Answer 54

Plantarflexion: muscles in posterior compartment of leg (gastrocnemius, soleus, plantaris and posterior tibialis) Dorsiflexion: muscles in anterior compartment of leg (tibialis anterior, extensor hallucis longus and extensor digitorum longus)

Answer 55

Aterial supply = Malleolar branches of anterior tibial, posterior tibial and fibular arteries Innervation is provided by tibial, superficial fibular and deep fibular nerves

Answer 56

Achilles tendon disorders

Answer 57

Tendinopathy (tendinitis) Partial tear Complete rupture of the Achilles tendon

Answer 58

Quinolone use (e.g. ciprofloxacin) is associated Hypercholesterolaemia → predisposes to tendon xanthomata

Answer 59

1. Gradual onset of posterior heel pain that is worse following activity 2. Morning pain and stiffness are common

Answer 60

Typically supportive 1. Simple analgesia 2. Reduction in precipitating activities 3. Calf muscle eccentric exercises (self-directed or through physiotherapy)

Answer 61

Suspected if the patient reports the following whilst playing a sport or running: 1. An audible 'pop' in the ankle 2. Sudden onset significant pain in the calf 2. Inability to walk or continue the sport

Answer 62

Simmond's triad 1. Ask the patient to lie prone with their feet over the bed 2. Look for an abnormal angle of declination - there will be a greater dorsiflexion of the injured foot compared to the other 3. Feel for a gap in the tendon and gently squeeze the calf muscles: if there is a rupture the achilles tendon injured foot will stay in a neutral position

Answer 63

Ultrasound

Answer 64

Lack of plantar flexion when calf is squeezed

Answer 65

Acute referral to orthopaedic specialist 1. Non-operative : functional bracing/ casting in resting equinus 2. Operative: open end-to-end achilles tendon repair (for acute ruptures < 6 weeks) or percutaneous repair

Answer 66

Re-rupture: higher with non-operative management Wound healing complications Sural nerve injury (percutaneous repair)

Answer 67

Very common injuries which generally occur due to a twisting mechanism

Answer 68

Breakdown by fracture type: 1. Isolated malleolus fracture = 70% 2. Bimalleolar = 20% 3. Trimalleolar = 7%

Answer 69

Male Younger age (mainly 15-24 years) Obesity Smoking Alcohol consumption

Answer 70

Twisting injuries

Answer 71

1. Deltoid 2. Lateral ligament complex 3. Syndesmosis

Answer 72

1. Peroneal tendons: peroneus longus and brevis 2. Posterior tibial tendon

Answer 73

1. Anterior tibial artery and depot peroneal nerve 2. Posterior tibial artery and tibial nerve 3. Superficial peroneal nerve 4. Sural nerve

Answer 74

Severe ankle pain Difficulty or inability to walk

Answer 75

Ecchymosis and swelling Deformity Limited ankle motion

Answer 76

State that x-rays are only necessary if there is pain in the malleolar zone and: 1. Inability to weight bear for 4 steps 2. Tenderness over the distal tibia 3. Bone tenderness over the distal fibula

Answer 77

Describe ankle fractures related to the level of the fibular fracture: Type A = below the syndesmosis Type B = fractures start at the level of the tibial plafond and may extend proximally to the syndesmosis Type C = above the syndesmosis which may itself be damaged

Answer 78

Type A: infrasyndesmotic Type B: transsyndesmotic Type C: Suprasyndesmotic

Answer 79

Ankle sprain Syndesmotic injury Achilles tendon rupture

Answer 80

May be able to weight bear Positive anterior drawer or talar tilt test Radiographs without fracture

Answer 81

Depends on the stability of the ankle joint and patient's comorbidities All fractures should be promptly reduced to remove pressure on the overlying skin and subsequent necrosis Young patients = usually require surgical repair often using a compression plate Elderly patients = usually fare better with conservative management as their thin bones do not hold metalwork well

Answer 82

Short-leg AO splint Short-leg cast CAM boot (for stable ankle fractures and those unfit for surgery)

Answer 83

Open reduction internal fixation External fixation

Answer 84

An x-ray is only required if there is any pain in the malleolar zone and one of the following: 1. Bony tenderness at the lateral malleolar zone 2. Bony tenderness at the medial malleolar zone 3. Inability to walk 4 weight bearing steps immediately after the injury

Answer 85

Type A: Usually stable → reduction and cast →ORIF occasionally needed Type B: Stability variable → may require ORIF Type C: Unstable fracture → ORIF

Answer 86

When bones in the midfoot are broken or ligaments that support the midfoot are torn

Answer 87

Stress fracture = tiny cracks in the bone caused by repetitive force often from overuse A hairline fracture in one of the long metatarsal bones in the foot from overly stressing the foot when using it in the same way repeatedly

Answer 88

Excess ingestion of salicylates e.g. aspirin causing toxicity

Answer 89

Deliberate self-harm Suicidal intent By accident e.g. in children

Answer 90

Hyperventilation (centrally stimulates respiration) Tinnitus Lethargy Sweating, pyrexia Nausea/vomiting Hyperglycaemia and hypoglycaemia Seizures Coma

Answer 91

Mixed respiratory alkalosis and metabolic acidosis

Answer 92

1. Early stimulation of the respiratory centre leads to a respiratory alkalosis via hyperventilation 2. Later the direct acid effects of salicylates (combined with acute renal failure) may lead to an acidosis

Answer 93

1. Aspirin increases respiratory rate and depth by stimulating the CNS respiratory centre 2. This hyperventilation produces respiratory alkalosis in the early phase 3. The body then compensates by increasing urinary bicarbonate and K+ excretion, causing dehydration and hypokalaemia 4. Loss of bicarbonate together with the uncoupling of mitochondrial oxidative phosphorylation by salicylic acid and build up of lactic acid can lead to metabolic acidosis

Answer 94

ABC management ABG: initially respiratory alkalosis; later concomitant metabolic acidosis Salicylate levels - determines management Bloods e.g. U&Es for hypokalaemia (and hypocalcaemia), FBC, LFTs ECG: signs of hypokalaemia = flattening and inversion of T waves, visible U wave and some ST depression in severe

Answer 95

Moderate = 500- 750mg/L Severe = >750mg/L * >700mg/L is an indication for haemodialysis

Answer 96

ABC approach Charcoal if early enough Urinary alkalisation with IV sodium bicarbonate → enhances elimination of aspirin in the urine Haemodialysis

Answer 97

Serum concentration > 700mg/L Metabolic acidosis resistant to treatment Acute renal failure Pulmonary oedema Seizures Coma

Answer 98

Chronic inflammatory airway disease characterised by: 1. Variable reversible airway obstruction 2. Airway hyper-responsiveness 3. Bronchial inflammation

Answer 99

Affects around 8% in the UK More common in boys until teenage years More common in women

Answer 100

Chronic airway inflammation (often eosinophilic inflammation) Bronchial hyperreactivity to a variety of stimuli causing reversible airway obstruction

Answer 101

Allergens e.g. pets, house dust mites Emotion Exercise Change in air temperature Pollution (indoors and outdoors) Viruses Occupational exposure e.g. flour dust, latex, chemicals (hairdresser)

Answer 102

Wheeze Chest tightness Cough Breathlessness Symptoms can be diurnal e.g. nocturnal cough Ask about triggers Ask about smoking history which exacerbates asthma

Answer 103

Mouth: oral candida (inhaled steroids without rinsing mouth out), nasal polyps Hands: fine tremor (excess bronchodilator use) HR: high (exacerbation or excess bronchodilator use) Skin: eczema Chest: audible expiratory wheeze, cough (poor control or acute exacerbation), high RR (acute), polyphonic expiratory wheeze (poor control or acute exacerbation)

Answer 104

Audible expiratory wheeze Polyphonic expiratory wheeze = poor control or acute exacerbation

Answer 105

1. Ask if their symptoms are better on days away from work/ during holidays - could be occupational asthma 2. Spirometry with a bronchodilator reversibility (BDR) test 3. All patients should have a FeNO test

Answer 106

Fractional exhaled nitric oxide Levels of NO correlate with levels of eosinophils inflammation which is found in asthma Considered positive is equal to or above 40 parts per billion (35 ppb for children)

Answer 107

FEV1/FVC ratio less than 70% is considered obstructive

Answer 108

Indicated by an improvement in FEV1 of 12% or more and increase in volume of 200ml or more

Answer 109

No gold standard test Evidence of airway obstruction: 1. Peak flow diary showing diurnal variation > 20% 2. Spirometry: FEV1/FVC < 0.7, after bronchodilation FEV1 improved by 12% and 200ml 3. FeNO > 40 ppb for eosinophil inflammation Blood test: eosinophil count and IgE levels Skin prick test (alternative to IgE blood tests) Chest x-ray: should be normal, may show hyperinflation

Answer 110

Asthma GORD

Answer 111

Investigate for other more likely diagnoses Test for airway obstruction: spirometry and bronchodilator reversibility If positive then follow intermediate possibility of asthma

Answer 112

Test for airway obstruction: spirometry and bronchodilator reversibility Test for variability: reversibility, PEF charting, bronchial challenge Test for eosinophilic inflammation or atopy: FeNO, IgE, eosinophil count Then either watchful waiting if asthmatic or commence treatment

Answer 113

Initiate treatment and assess response objectively e.g. lung function. validated system score Adjust maintenance dose Provide self-management advice Arrange on-going review

Answer 114

1. Short acting beta-2 agonist (SABA) 2. SABA + low dose ICS 3. SABA + low dose ICS + leukotriene receptor antagonist (LTRA) 4. SABA + low dose ICS + Long acting beta-agonist (LABA) ± LTRA 5. SABA ± LTRA + MART 6. SABA ± LTRA + medium dose MART (or moderate dose ICS +LABA separately) 7. SABA ± LTRA and either: a) high dose ICS b) trial of an additional drug e.g. LAMA c) Seeking advice from specialist

Answer 115

SABA = salbutamol ICS = Flovent® (fluticasone) Pulmicort® (budesonide) LTRA = montelukast LABA = Serevent (salmeterol)

Answer 116

Regular asthma review - either GP or specialist Trigger avoidance e.g. pets Adherence Inhaler technique Asthma management (action) plan Vaccinations = flu, covid Smoking cessation Cormorbid management e.g. obesity, allergic rhinitis

Answer 117

Frequent asthma exacerbations e.g 4 per year Raised eosinophils/ FeNO/ IgE/ atopy

Answer 118

Maintenance and reliever therapy Form of combined ICS and LABA treatment in which a single inhaler contained both Used for both daily maintenance therapy and relief of symptoms as required

Answer 119

Low = < 400 mcg budesonide Moderate = 400-800 mcg budesonide High = > 800 mcg budesonide

Answer 120

Consider stepping down treatment every 3 months or so (taking into account duration of treatment, side effects and patient preference) When reducing dose of ICS, do this by 25-50% at a time

Answer 121

COPD (can have an overlap with asthma) Allergic bronchopulmonary aspergillosis (ABPA) Bronchiectasis Bronchiolitis

Answer 122

Wheeze Cough (nocturnal) Breathlessness Chest tightness History of triggers and diurnal variation

Answer 123

History of asthma Worsening dyspnoea, wheeze and cough that is NOT responding to salbutamol (SABA) May be triggered by a respiratory tract infection

Answer 124

Moderate Severe Life-threatening

Answer 125

PEFR 50-75% best or predicted Speech normal RR < 25/ min Pulse < 110 bpm

Answer 126

PEFR 33-50% at best Can't complete sentences RR > 25/min Pulse > 110 bpm

Answer 127

PEFR < 33% at best Oxygen saturations < 92% PaO2 < 8kPa, "normal" PaCO2 Silent chest Cyanosis Poor respiratory effort Bradycardia Arrhythmia Hypotension Exhaustion Altered conscious level (confusion or coma)

Answer 128

Raised PaCO2 and/or requiring mechanical ventilation with raised inflation pressures

Answer 129

ABCDE assessment Call for help: ITU/HDU Oxygen: aim for sats 98% Bronchodilators: nebuliser salbutamol ± ipratropium bromide, IV magnesium Steroids: PO prednisolone, if not IV hydrocortisone Re-assess Later → ventilatory support

Answer 130

Continue bronchodilators and steroids (5-7 days) Wean off oxygen Serial PEF, discharge if PEF over 75% TAME asthma: 1. Technique 2. Avoid triggers 3. Monitor PEF 4. Educate

Answer 131

Oxygen (15L high flow or with nebulisers) Nebulised beta agonists: 2.5 mg salbutamol every 15 minutes Nebulised ipratropium: 0.5mg every max 4 hours Steroids: Oral 40/50mg OD or 100mg IV hydrocortisone

Answer 132

A lifesaving procedure to treat hemorrhages and to improve oxygen delivery to tissues

Answer 133

1. Packed red cells: for chronic anaemia 2. Platelet rich plasma: for patients who are thrombocytopaenic and are bleeding or require surgery 3. Platelet concentrate: for thrombocytopaenia 4. Fresh frozen plasma: used in correcting clotting deficiencies in patients with hepatic synthetic failure who are due to undergo surgery 5. Cryoprecipitate: Rich source of Factor VIII and fibrinogen

Answer 134

1. Packed red cells 2. Fresh frozen plasma 3. Cryoprecipitate 4. Whole blood (platelets can be ABO incompatible in adults)

Answer 135

1. Stop warfarin 2. Vitamin K (reversal within 4-24 hours, IV is quicker than oral) 3. Fresh frozen plasma 4. Human prothrombin complex (now first line for warfarin reversal, reversal within 1 hour)

Answer 136

1. Symptomatic anemia (causing shortness of breath, dizziness, congestive heart failure, and decreased exercise tolerance) 2. Acute sickle cell crisis 3. Acute blood loss of more than 30 percent of blood volume

Answer 137

Without ACS: 70 g/L (target for 70-90) With ACS: 80 g/L (target for 80-100)

Answer 138

Can be used for reversal of anticoagulant effects e.g. warfarin (but less commonly used)

Answer 139

To prevent haemorrhage in patients with thrombocytopenia or platelet function defects

Answer 140

Used in cases of hypofibrinogenemia, which most often occurs in the setting of massive hemorrhage or consumptive coagulopathy

Answer 141

1. Immunological: acute haemolytic, non-haemolytic febrile, allergic/ anaphylaxis 2. Infective 3. Transfusion related acute lung injury (TRALI) 4. Transfusion associated circulatory overload (TACO) 5. Others: hyperkalaemia, iron overload, clotting

Answer 142

Thought to be caused by antibodies reacting with white cell fragments in the blood product and cytokines that have leaked from the blood cell during storage Features: 1. Fever 2. Chills Management: 1. Stop or slow the transfusion 2. Paracetamol 3. Monitor

Answer 143

Thought to be caused by foreign plasma proteins Features: 1. Pruritus 2. Utricaria Management: 1. Temporarily stop the transfusion 2. Anti-histamine 3. Monitor

Answer 144

Can be caused by patients with an IgA deficiency who have anti-IgA antibodies Features: 1. Hypotension 2. Dyspnoea 3. Wheezing 4. Angioedema Management: 1. Stop the transfusion 2. A to E approach (oxygen, fluids) 3. IM adrenaline

Answer 145

ABO incompatible blood e.g. secondary to human error Features: 1. Fever 2. Abdominal pain 3. Hypotension Management: 1. Stop the transfusion 2. Confirm diagnosis: check blood product against patient name, send blood for Coombs test 3. Supportive care: fluid resuscitation

Answer 146

Transfusion-associated circulatory overload from an excessive rate of transfusion/ pre-existing HF Features: 1. Pulmonary oedema 2. Hypertension Management: 1. Slow or stop transfusion 2. Consider IV loop diuretic e.g. furosemide and oxygen

Answer 147

Transfusion related acute lung injury: non-cardiogenic pulmonary oedema from increased vascular permeability Features: 1. Hypoxia 2. Pulmonary infiltrates on chest x-ray 3. Fever 4. Hypotension Management: 1. Stop the transfusion 2. Supportive care and oxygen

Answer 148

1. Minor allergic reaction (only temporarily) 2. Anaphylaxis 3. Acute haemolytic reaction 4. TRALI

Answer 149

TACO: hypertensive, TRALI: hypotensive Both have pulmonary oedema but one is from circulatory overload (TACO) and one is non-cardiogenic (TRALI)

Answer 150

A very common injury predominantly to skin and superficial tissues caused by heat from hot liquids, flame or contact with hot objects

Answer 151

1. Burn size (% of total body surface area) 2. Depth ( first to fourth degree)

Answer 152

Erythema Dry/ wet and painful Dry and lacking of physical sensation (insensate) Cellulitis If face affected- clouded cornea

Answer 153

Young children Age > 60 years

Answer 154

1. A to E approach 2. Assess carbon monoxide (ABG) and fluid loss (ABG, urinary catheter) 3. Chest x-ray and ECG 4. Bloods 5. Wound biopsy and histology

Answer 155

1. Initial first aid as above 2. Review referral criteria to ensure can be managed in primary care 3. Superficial epidermal: symptomatic relief - analgesia, emollients etc 4. Superficial dermal: cleanse wound, leave blister intact, non-adherent dressing, avoid topical creams, review in 24 hours

Answer 156

1. Airway, breathing, circulation 2. Burns caused by heat: a. remove the person from the source b. within 20 minutes of the injury irrigate the burn with cool (not iced) water for between 10 and 30 minutes c. cover the burn using cling film, layered, rather than wrapped around a limb 3. Electrical burns: switch off power supply and remove the person from the source 4. Chemical burns: a. brush any powder off then irrigate with water b. attempts to neutralise the chemical are not recommended

Answer 157

1. Wallace’s Rule of Nines: head + neck = 9% each arm = 9% each anterior part of leg = 9%, each posterior part of leg = 9% anterior chest = 9%, posterior chest = 9% anterior abdomen = 9%, posterior abdomen = 9% 2. Lund and Browder chart: the most accurate method the palmar surface is roughly equivalent to 1% of total body surface area (TBSA). Not accurate for burns > 15% TBSA

Answer 158

1. Superficial epidermal (first degree) = Red and painful, dry, no blisters 2. Partial thickness (superficial dermal) (second degree) = Pale pink, painful, blistered. Slow capillary refill 3. Partial thickness (deep dermal) (second degree) = Typically white but may have patches of non-blanching erythema. Reduced sensation, painful to deep pressure 4. Full thickness (third degree) = White (‘waxy’)/brown (‘leathery’)/black in colour, no blisters, no pain

Answer 159

1. All deep dermal and full-thickness burns 2. Superficial dermal burns of more than 3% TBSA in adults, or more than 2% TBSA in children 3. Superficial dermal burns involving the face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso, or neck 4. Any inhalation injury 5. Any electrical or chemical burn injury 5. Suspicion of non-accidental injury

Answer 160

1. Local response with progressive tissue loss and release of inflammatory cytokines 2. Systemically, there are cardiovascular effects resulting from fluid loss and sequestration of fluid into the third space 3. There is a marked catabolic response 4. Immunosupression is common with large burns and bacterial translocation from the gut lumen is a recognised event → Sepsis is a common cause of death following major burns.

Answer 161

The initial aim = stop the burning process and resuscitate the patient 1. Airway: Smoke inhalation can result in airway oedema Early intubation should be considered e.g. if deep burns to the face or neck, blisters or oedema of the oropharynx, stridor etc 2. IV fluids will be required for adults with burns greater than 15% (10% for children) of TBSA = Parkland formula, half of the fluid is administered in the first 8 hours 3. Urinary catheter should be inserted and analgesia should be given 4. Complex burns, burns involving the hand, perineum and face and burns >10% in adults and >5% in children should be transferred to a burns unit, circumferential burns affecting a limb or severe torso burns impeding respiration may require escharotomy to divide the burnt tissue (improve ventilation)

Answer 162

Conservative management is appropriate for superficial burns and mixed superficial burns that will heal in 2 weeks More complex burns may require excision and skin grafting

Answer 163

Parkland formula: 1. (Crystalloid only e.g. Hartman’s solution/Ringers’ lactate) 2. Total fluid requirement in 24 hours = 4 ml x (total burn surface area (%)) x (body weight (kg)) 3. 50% given in first 8 hours, then 50% given in next 16 hours 4. Resuscitation endpoint:Urine output of 0.5-1.0 ml/kg/hour in adults (increase rate of fluid to achieve this) Points to note: Starting point of resuscitation is time of injury, deduct fluids already given

Answer 164

1. Indication = >15% total body area burns in adults (>10% children) 2. The main aim of resuscitation is to prevent the burn deepening 3. Most fluid is lost 24h after injury 4. First 8-12h fluid shifts from intravascular to interstitial fluid compartments a. Therefore circulatory volume can be compromised b. However fluid resuscitation causes more fluid into the interstitial compartment especially colloid (therefore avoided in first 8-24h)

Answer 165

Acute cessation of cardiac function

Answer 166

4 Hs and 4Ts: Hs: 1. Hypo/ hyperkalaemia 2. Hypothermia 3. Hypovolaemia 4. Hypoxia Ts: 1. Tamponade 2. Tension pneumothorax 3. Thromboembolism 4. Toxins

Answer 167

Unconscious Patient is not breathing Absent carotid pulses

Answer 168

Ventricular fibrillation (VF) (Pulseless) Ventricular tachycardia (VT)

Answer 169

Asystole Pulseless-electrical activity (PEA)

Answer 170

Crash call 2222 MEDICAL EMERGENCY Adult advanced life support: 1. Determine rhythm via cardiac monitor 2. Begin chest compressions to ventilation at a ratio of 30:2 3. Defibrillate if shockable rhythms 4. Adrenaline 1mg Management depends on cardiac rhythm

Answer 171

A to E assessment/ 2222/ medical emergency 1. Deliver shock 2. Resume chest compressions 30:2 3. Administer adrenaline (1 mg IV) after second defibrillation and again every 3–5 min. 4. If ‘shockable rhythm’ persists after third shock, administer amiodarone 300 mg IV bolus (anti-arrhythmic)

Answer 172

Medical emergency/ 2222 1. CPR for 2 min at 30:2, and then return to assessing rhythm 2. Administer adrenaline (1 mg IV) every 3–5 min

Answer 173

A to E approach Aim for SpO2 sats of 94-98% 2 IV wide bore cannulas ABG 12 lead ECG Treat precipitating cause Targeted temperature management

Answer 174

1. Defibrillate once 2. Resume CPR immediately for 2 min, and then defibrillate 3. Administer adrenaline (1 mg IV) after second defibrillation and again every 3–5 min. 4. If ‘shockable rhythm’ persists after third shock, administer amiodarone 300 mg IV bolus (anti-arrhythmic)

Answer 175

1. CPR for 2 min, and then return to assessing rhythm 2. Administer adrenaline (1 mg IV) every 3–5 min No longer give atropine!

Answer 176

1. Hypothermia: Warm slowly 2. Hypo- or hyperkalaemia: Correction of electrolytes 3. Hypovolaemia: IV colloids, crystalloids or blood products 4. Hypoxia: oxygen

Answer 177

1. Tamponade: Pericardiocentesis under xiphisternum up and leftwards 2. Tension pneumothorax: Aspirate: needle into second intercostal space, mid-clavicular line 3. Thromboembolism: management for PE, MI 4. Toxins: antidotes

Answer 178

Irreversible hypoxic brain damage → death

Answer 179

1. Resuscitation is less successful in the arrests that occur outside hospital 2. Duration of inadequate effective cardiac output is associated with poor prognosis

Answer 180

Defined as a clinical syndrome where the heart is unable to pump enough blood to meet the metabolic needs of the body

Answer 181

1. By ejection fraction 2. Acute or chronic 3. Left or right 4. High-output

Answer 182

Refers to a 'normal' heart is unable to pump enough blood to meet the metabolic demands of the body

Answer 183

1. Anaemia 2. Arteriovenous malformation 3. Paget's disease 4. Pregnancy 5. Thyrotoxicosis 6. Thiamine deficiency (Beri-Beri)

Answer 184

1. Increased left ventricular afterload e.g. arterial hypertension, aortic stenosis 2. Increased left ventricular preload e.g. aortic regurgitation

Answer 185

Pulmonary oedema: 1. Dyspnoea 2. Orthopnoea 3. Paroxysmal nocturnal dyspnoea 4. Bibasal fine crackles

Answer 186

1. Increased right ventricular afterload e.g. pulmonary hypertension 2. Increased right ventricular preload e.g. tricuspid regurgitation

Answer 187

1. Peripheral oedema e.g. pedal/sacral oedema 2. Raised jugular venous pressure 3. Hepatomegaly 4. Weight gain due to fluid retention 5. Anorexia 'cardiac cachexia'

Answer 188

By echocardiography

Answer 189

1. Reduced ejection fraction (HF-rEF) = < 35-40% 2. Preserved ejection fraction (HF-pEF)

Answer 190

Reduced EF: 1. Ischaemic heart disease 2. Dilated cardiomyopathy 3. Myocarditis 4. Arrhythmias Preserved EF: 1. Hypertrophic obstructive cardiomyopathy 2. Restrictive cardiomyopathy 3. Cardiac tamponade 4. Constrictive pericarditis

Answer 191

10% of those over 65 years, usually presents at this age

Answer 192

1. A life threatening emergency 2. Used to describe the sudden onset or worsening of symptoms of HF 3. Usually has a background of pre-existing HF: decompensated 4. If there is no history of HF: de-novo AHF

Answer 193

1. Acute coronary syndrome 2. Hypertensive crisis 3. Acute arrhythmia 4. Valvular disease e.g. AS

Answer 194

1. Usually ischaemia 2. Other causes e.g. viral myopathy, toxins, valve dysfunction

Answer 195

1. With or without hypoperfusion 2. With or without fluid congestion

Answer 196

1. Breathlessness 2. Reduced exercise tolerance 3. Oedema 4. Fatigue

Answer 197

1. Cyanosis 2. Tachycardia 3. Elevated jugular venous pressure 4. Displaced apex beat 5. Chest signs: bibasal crackles (pulmonary oedema), may have wheeze 6. S3 heart sound *Over 90% of patients with have a normal or increased BP

Answer 198

Medical emergency- A to E approach 1. Bloods: look for underlying abnormality e.g. anaemia, infection 2. Chest x-ray: cardiomegaly, pulmonary oedema: venous congestion, interstitial oedema, Kerley B lines 3. Echocardiogram: ejection fraction, pericardial effusion, cardiac tamponade 4. BNP (B-type natriuretic peptide): > 100mg/L is supportive of dx

Answer 199

IV loop diuretics e.g. furosemide

Answer 200

(Sit patient up) 1. Oxygen: aim for saturations 94-98% 2. Vasodilators e.g. nitrates (not to all patients) 3. Opiates (again not to all patients) 4. Continue any regular medication for HF e.g. ACE inhibitors

Answer 201

If patients have concomitant myocardial ischaemia, severe hypertensionor regurgitant aortic or mitral valve disease

Answer 202

Hypotension (cardiogenic shock)

Answer 203

1. < 10% of patients- seek senior support 2. IV loop diuretics and nitrates may worsen hypotension 3. Consider inotropic agents e.g. dobutamine 4. Vasopressors e.g. norepinephrine 5. Mechanical circulatory assistance e.g. intra-aortic balloon

Answer 204

1. Continue ACE inhibitors 2. Continue B blockers (but if HR is < 50 bpm, second or third degree heart block or shock then stop)

Answer 205

1. Dyspnoea 2. Cough: worse at night, associated with pink/ frothy sputum 3. Orthopnoea 4. Paroxysmal nocturnal dyspnoea 5. 'Cardiac' wheeze 6. Weight loss: 'cardiac cachexia'/ weight gain secondary to oedema 7. Bibasal crackles on examination 8. Signs of right sided HF: raised JVP, ankle oedema, hepatomegaly

Answer 206

Used to classify the severity of HF: Class 1: No symptoms/ no limitation Class 2: Mild symptoms, some limitation of physical activity Class 3: Moderate symptoms, marked limitation of physical activity (less than normal activity results in symptoms) Class 4: Severe symptoms, unable to carry out any physical activity without discomfort (symptoms present even at rest)

Answer 207

N-terminal pro-B-type natriuretic peptide (NT‑proBNP)

Answer 208

1. If 'high': arrange specialist assessment (incl echo) within 2 weeks 2. If 'raised': arrange specialist assessment (incl echo) within 6 weeks

Answer 209

1. Hormone produced mainly by the left ventricular myocardium in response to strain 2. Very high levels are associated with a poor prognosis: a. High = > 400pg/ml b. Raised = 100-400ph/ml c. Normal = < 100pg/ml

Answer 210

1. Left ventricular hypertrophy 2. Ischaemia 3. Tachycardia 4. Hypoxaemia (including PE) 5. GFR < 60ml/min 6. Sepsis 7. COPD 8. DM 9. Aged > 70 years 10. Liver cirrhosis

Answer 211

1. Obesity 2. Diuretics 3. ACE inhibitors 4. B blockers 5. ARBs 6. Aldosterone antagonists e.g. spironolactone

Answer 212

(manage lifestyle and optimise comorbidities) 1. ACE inhibitors (ARB if intolerant) 2. Beta Blockers (start one at a time)

Answer 213

1. ACE inhibitors + beta blockers 2. Add an aldosterone antagonist e.g. spironolactone

Answer 214

Potassium levels: both ACE inhibitors and aldosterone antagonists cause hyperkalaemia

Answer 215

SGLT-2 inhibitors: 1. For patients with a reduced EF 2. Reduce glucose reabsorption and increase urinary glucose excretion 3. E.g. dapagliflozin

Answer 216

1. Only initiated by a specialist 2. Options include ivabradine, sacubitril-valsartan, hydralazine in combination with nitrate, digoxin and cardiac resynchronisation therapy

Answer 217

If there is coexistent atrial fibrillation

Answer 218

Widened QRS (e.g. left bundle branch block) complex on ECG

Answer 219

1. Annual influenza vaccination 2. One-off pneumococcal vaccine (if the patient has asplenia, splenic dysfunction or chronic kidney disease they need a booster every 5 years)

Answer 220

1. Third line specialist treatment 2. If sinus rhythm > 75/min and a left ventricular EF < 35%

Answer 221

1. Third line specialist treatment 2. When left ventricular EF < 35% and still symptomatic on ACE inhibitors and ARBs 3. Should be initiated following ACEi/ ARB wash-out period

Answer 222

1. Block the effects of chronically activated sympathetic system, slow progression of the heart failure and improve survival 2. The benefits of ACE inhibitors and b-blockers are additive*

Answer 223

e.g. enalapril, perindopril, ramipril) 1. Inhibit intracardiac renin-angiotensin system which may contribute to myocardial hypertrophy and remodelling 2. ACE inhibitors slow progression of the heart failure and improve survival

Answer 224

May be added in patients (particularly in Afro-Caribbeans) with persistent symptoms despite therapy with an ACE inhibitor and b-blocker

Answer 225

Drugs that can adversely affect patients with heart failure due to systolic dysfunction, e.g. NSAIDs, non-dihydropyridine calcium channel blockers (i.e. diltiazem and verapamil)

Answer 226

1. Respiratory failure 2. Cardiogenic shock 3. Death

Answer 227

50% of patients with severe heart failure die within 2 years

Answer 228

1. Type of poisoning 2. Carbon monoxide has a high affinity for haemoglobin and myoglobin leading to tissue hypoxia

Answer 229

Around 50 deaths per year in the UK from accidental carbon monoxide poisoning

Answer 230

1. Carbon monoxide has a high affinity for haemoglobin and myoglobin 2. This leads to a decrease in the oxygen saturation of haemoglobin leading to an early plateau in the oxygen dissociation curve 3. Resulting in tissue hypoxia

Answer 231

Badly maintained housing e.g student housing

Answer 232

1. Headache (90%) 2. Nausea and vomiting (50%) 3. Vertigo (50%) 4. Confusion (30%) 5. Subjective weakness (20%)

Answer 233

1. 'Pink' skin and mucosae 2. Hyperpyrexia 3. Arrhythmias 4. Extrapyramidal features 5. Coma 6. Death

Answer 234

ABG/ VBG Pulse oximetry may be falsely high because of similarities between oxyhaemoglobin and carboxyhaemoglobin

Answer 235

1. Non-smokers = < 3% 2. Smokers = <10% 3. Symptomatic poisoning (headache, vomiting) = 10-30% 4. Severe toxicity = >30%

Answer 236

A and E management: 1. ABG/VBG for carboxyhaemoglobin levels 2. ECG: look for cardiac ischaemia

Answer 237

1. Managed in A&E 2. 100% high flow oxygen via a non-rebreather mask (generally given until all symptoms have resolved)

Answer 238

1. Decreases the half-life of carboxyhemoglobin (COHb) 2. Should be administered as soon as possible, with treatment continuing for a minimum of six hours 3. Target oxygen saturations are 100% 4. Given until symptoms resolve

Answer 239

1. Hyperbaric oxygen 2. For more severe cases: if carboxyhaemoglobin levels are > 25% 3. Indications also include: a. Loss of consciousness at any point b. Neurological signs other than headache c. Myocardial ischaemia or arrhythmia d. Pregnancy

Answer 240

1. Thin flexible tubes which are used to draw blood and give treatments 2. Inserted into usually the superior vena cava 3. Can stay in place for weeks or months

Answer 241

Internal jugular route is preferred over femoral lines: Femoral lines are easier to insert and iatrogenic injuries easier to manage in this site however they are prone to high infection rates

Answer 242

Ultrasound guided

Answer 243

IV fluids, drugs, blood products (lumens are relatively narrow so do not allow particularly rapid rates of infusion)

Answer 244

Peripheral cannulas are unsuitable for the administration of vasoactive drugs, such as inotropes and irritant drugs such as TPN

Answer 245

1. Failure to place catheter 2. Arterial puncture/ iatrogenic arterial injury 3. Catheter malposition 4. Pneumothorax 5. Subcutaneous haematoma 6. Haemothorax 7. Cardiac arrest (<1%)

Answer 246

Peripherally inserted central cannula: popular methods for establishing central venous access whilst minimising major complications relating to device insertion than conventional central lines

Answer 247

A tube inserted into the pleural cavity which creates a one way valve: allows the movement of air or liquid out of the cavity

Answer 248

1. Pleural effusion 2. Pneumothorax not suitable for aspiration or conservative management 3. Empyema 4. Haemothorax/ haemopneunomothorax 5. Some cases of penetrating chest wall injuries in ventilated patients

Answer 249

1. INR > 1.3 2. Platelet count < 75 3. Pulmonary bullae 4. Pleural adhesions

Answer 250

1. Patient positioned in a supine position or at 45 degrees 2. Identify the 5th intercostal space in the mid-axillary line (can be ultrasound guided especially if fluid in the pleura) 3. LA (lidocaine max 3mg/kg) 4. Drainage tube inserted using a Seldinger technique 5. Drain tubing should then be secured using either a straight stitch or an adhesive dressing

Answer 251

1. The desired vessel is punctured with a sharp hollow needle 2. The syringe is detached and a guide wire is advanced through the lumen of the needle 3. The needle is then withdrawn

Answer 252

1. Aspiration of fluid from the drainage tube ‘2. Swinging’ of the fluid within the drain tubing when the patient inspires 3. On chest x-ray

Answer 253

1. Failure of insertion (may go into the wrong place- should be removed and re-sited) 2. Bleeding: around the site of the drain or into the pleural space 3. Infection 4. Penetration of the lung 5. Re-expansion pulmonary oedema

Answer 254

1. Uncommon complication following drainage of a pneumothorax or pleural effusion 2. Features: Cough and/or shortness of breath

Answer 255

Prevention: the drain tubing should be clamped regularly in the event of rapid fluid output i.e. drain output should not exceed 1L of fluid over a short period of time (less than 6 hours) Management: the chest drain should be clamped and an urgent chest x-ray should be obtained

Answer 256

Dependent on the indication for insertion: 1. If for fluid drainage = the drain should be removed when there has been no output for > 24 hours and imaging shows resolution of the fluid collection 2. For pneumothorax = the drain should be removed when it is no longer bubbling spontaneously or when the patient coughs and ideally when imaging shows resolution of the pneumothorax

Answer 257

An umbrella term encompassing chronic bronchitis and emphysema

Answer 258

1. Airflow limitation that is not fully reversible 2. Chronic bronchitis + emphysema

Answer 259

1. Bronchial and alveolar damage as a result of environmental toxins (e.g. cigarette smoke) 2. Overlaps and may co-exist with asthma

Answer 260

Alpha -1 antitrypsin deficiency (not as common as smoking)

Answer 261

Not as common 1. Cadmium (used in smelting) 2. Coal 3. Cotton 4. Cement 5. Grain

Answer 262

1. Cough, often productive 2. Dyspnoea 3. Wheeze 4. In severe cases = right-sided HF may develop leading to peripheral oedema

Answer 263

1. Spirometry with bronchodilator: demonstrate airflow obstruction, FEV1/FVC < 70% 2. Chest x-ray 3. Bloods: FBC to exclude secondary polycythaemia 4. BMI index

Answer 264

1. Hyperinflation 2. Bullae: if large can mimic a pneumothorax 3. Flat hemidiaphragm 4. Exclude lung cancer

Answer 265

May underestimate the degree of airflow obstruction

Answer 266

FEV1: forced expiratory volume in 1 second

Answer 267

If over 35 years who are smokers or non-smokers and have symptoms such as: 1. Exertional breathlessness 2. Chronic cough 3. Regular sputum production

Answer 268

< 0.7 (< 70%)

Answer 269

Stage 1 (>80%): Mild, symptoms should be present to diagnose COPD in these patients Stage 2 (50-79%): Moderate Stage 3 (30-49%): Severe Stage 4 (<30%): Very severe

Answer 270

Stage 1, mild COPD (even though their FEV1 is over 80% it is still COPD, but must have symptoms for diagnosis)

Answer 271

1. Smoking cessation advice (includes offering nicotine replacement therapy) 2. Annual influenza vaccination, one-off pneumococcal vaccination 3. Pulmonary rehabilitation 4. Bronchodilator therapy, first-line SABA or SAMA

Answer 272

1. SABA or SAMA 2. Determine whether they have asthmatic/ steroid responsive features a. If yes: SABA or SAMA as required, LABA + ICS (often one inhaler) b. If no: SABA as required, LABA + LAMA regularly 3. If patient remains breathlessness or have exacerbations: SABA as required, triple therapy regularly = LABA + LAMA + ICS

Answer 273

1. Any previous secure diagnosis of asthma/ atopy 2. Higher blood eosinophil count (as part of the recommended FBC) 3. Substantial variation in FEV1 over time ( at least 400ml) 4. Substantial diurnal variation in PEF (at least 20%)

Answer 274

1. Only after trials of short and long-acting bronchodilators or to people who cannot use inhaled therapy 2. The dose should be reduced if macrolide or fluoroquinolone antibiotics are co-prescribed

Answer 275

1. Azithromycin in select patients 2. Patients should not smoke, have optimised standard treatments and continue to have exacerbations 3. Need to have a CT thorax to exclude bronchiectasis 4. Need to have a sputum culture to exclude atypical infections and TB 5. ECG prior to starting to exclude QT prolongation (as azithromycin can cause this) and LFTs

Answer 276

Should be considered in patients with a chronic productive cough and continued if symptoms improve

Answer 277

1. Peripheral oedema (due to right-sided heart failure) 2. Raised jugular venous pressure 3. Systolic parasternal heave 4. Loud P2

Answer 278

1. Use a loop diuretic for the oedema 2. Consider long-term oxygen therapy (NOT ACEi, CCB or alpha blockers)

Answer 279

1. Smoking cessation 2. Long-term oxygen therapy in patients who fit the criteria 3. Lung volume reduction surgery in selected patients

Answer 280

Smoking cessation

Answer 281

Chronic cough and sputum production on most days for at least 3 months per year over 2 consecutive years

Answer 282

Pathological diagnosis of permanent destructive enlargement of air spaces distal to the terminal bronchioles

Answer 283

Narrowing of the airways resulting from: 1. Bronchiole inflammation (bronchiolitis) and 2. Bronchi with mucosal oedema 3. Mucous hypersecretion

Answer 284

1. Destruction and enlargement of the alveoli 2. Results in loss of the elastic traction that keeps small airways open in expiration 3. Progressively larger spaces develop, termed bullae (diameter is >1 cm)

Answer 285

1. Very severe outflow obstruction, FEV1 <30% (considered if FEV1 is 30-49%) 2. Cyanosis 3. Polycythaemia 4. Peripheral oedema 5. Raised jugular venous pressure 6. Oxygen saturations < 92% on room air

Answer 286

Measure ABG on 2 occasions at least 3 weeks apart in patients with stable COPD on optimal management

Answer 287

1. ABG: pO2 of <7.3 kPa 2. ABG pO2 of 7.3-8 kPa and one of the following: a. Secondary polycythaemia b. Peripheral oedema c. Pulmonary hypertension

Answer 288

Do not offer long-term oxygen therapy to people who continue to smoke despite being offered smoking cessation advice and treatment and referral to specialist

Answer 289

1. Risk of falls from tripping over the equipment 2. Risk of burns and fires (increased risk for people who live in homes where someone smokes)

Answer 290

Where patients with COPD experience more severe symptoms, often due to an infective cause

Answer 291

1. Haemophilus influenzae (most common) 2. Streptococcus pneumoniae 3. Moraxella catarrhalis

Answer 292

Haemophilus influenzae

Answer 293

1. Respiratory viruses, account for 30% of exacerbations 2. Human rhinovirus is most important

Answer 294

1. Increase in dyspnoea, cough and wheeze 2. May be increase in sputum (suggestive of infective cause) 3. Patients may be hypoxic and in some cases have acute confusion

Answer 295

1. Severe breathlessness 2. Acute confusion or impaired consciousness 3. Cyanosis 4. O2 sats < 90% on pulse oximetry 5. Social reasons e.g. inability to cope at home/ living alone 6. Significant comorbidity e.g. cardiac disease, insulin dependent DM

Answer 296

1. Increase the frequency of bronchodilator use (and consider giving via a nebuliser) 2. Give prednisolone 30mg daily for 5 days 3. Antibiotics if sputum is purulent or clinical signs of pneumonia: oral amoxicillin, clarithromycin or doxycycline

Answer 297

1. Oxygen therapy 2. Nebulised bronchodilator 3. Steroid therapy: prednisolone 30mg daily for 5 days or IV hydrocortisone 4. Consider IV theophylline 5. Non-invasive ventilation if T2RF development

Answer 298

1. Risk of hypercapnia therefore aim for oxygen target of 88-92% 2. Initially use 28% Venturi mask at 4L/min, aim for 88-92% whilst waiting for ABG results 3. Adjust target range to 94-98% if the pCO2 is normal

Answer 299

1. Beta adrenergic agonist: salbutamol 2. Muscarinic antagonist: ipratropium bromide

Answer 300

For patients not responding to nebulised bronchodilators

Answer 301

1. If the patient develops type 2 respiratory failure: low O2 and high CO2 2. Typically used for COPD with respiratory acidosis: pH 7.25-7.35 (can be for <7.25 but require more monitoring and has a lower threshold of intubation and ventilation)

Answer 302

Bi-level positive airway pressure (BiPAP), initial settings: 1. Expiratory Positive Airway Pressure (EPAP): 4-5 cm H2O 2. Inspiratory Positive Airway Pressure (IPAP): RCP advocate 10 cm H20 whilst BTS suggest 12-15 cm H2O

Acute Care and Trauma (1) Flashcards

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