Acute care + trauma

Question 1

Acute respiratory distress syndrome (ARDS) - acute and persistent lung inflammation with increased vascular permeability.
Characterised by…

Answer 1

• acute onset
• bilateral infiltrates consistent w/ pulmonary oedema
• hypoxaemia
• no clinical evidence for increased L atrial pressure (pulmonary capillary wedge pressure <18)

Question 2

Aspirin overdose (10g-20g) clinical features

Answer 2

Resp alkalosis
Met acidosis
Hyperventilation (resp failure)
HypoK+ (high HCO3- and K+ excretion)
High lactic acid
CNS depression

(flushed appearance, sweating, confusion, lethargy, deafness)

Question 3

Investigations for aspirin overdose

Answer 3

Blood: salicylate levels, FBC, U+Es (hypoK+), clotting screen (high PT)
ECG: hypoK+

Question 4

Alcohol dependence CAGE screening questions

Answer 4

Cut down on intake?
Annoyed by criticism of drinking?
Guilty about how much you drink?
Eye-opener - drink when you wake up?

Question 5

Alcohol withdrawal symptoms

Answer 5

Nausea+vomiting
Sweating, fever
Restlessness/tremor
Hallucination
Confusion
Seizures
Deliriums tremens

Question 6

Alcohol dependence is characterised by 3 or more of…

Answer 6

Withdrawal on cessation
Tolerance
Compulsion
Time spent only on alcohol
Neglects other interests
Continued despite problems

Question 7

Patient presents with acute onset on symptoms on exposure to allergen: wheeze, SOB, sensation of choking, swelling of lips and face, pruritis, rash

Answer 7

Anaphylaxis

Complications: resp failure, shock, death

Question 8

Anaphylaxis treatment

Answer 8

ABCDE, 100% O2
Treat with IM 0.5mg adrenaline
IV antihistamine, steroids
IV colloid to maintain BP
Treat bronchospasm with salbutamol ±ipratropium inhaler. IV aminophilline may be required.

Question 9

Types of burns include thermal (scalds), airway, chemical, electricity and radiation burns. Classification into…

Answer 9

Superficial
Partial thickness
Full thickness (3rd degree)
Full thickness to bone (4th)

Question 10

Sepsis 6 management

Answer 10

1. High flow O2
2. IV antibiotics
3. IV fluid resuscitation
4. Blood cultures
5. Check lactate (ABG/VBG)
6. Urine output (catheter)

Question 11

SIRS definition

Answer 11

2 or more of:
Temperature <36 or >38
HR >90bpm
RR >20 or pCO2 <4.3
WCC >12000 or <4000/mm3

Question 12

Sepsis definition

Answer 12

SIRS + infection

Question 13

Severe sepsis definition

Answer 13

Sepsis + end organ damage or hypoperfusion or hypotension

±DIC

Question 14

Septic shock definition

Answer 14

Severe sepsis + hypotension

despite adequate fluid resuscitation. BP <90mmHg

Question 15

After suspected anaphylaxis, what should be measured acutely

Answer 15

Mast cell tryptase 1-6hr after suspected diagnosis of anaphylaxis

It is the most abundant mediator stored in mast cells released alongside histamine.

Question 16

3 pathological stages of acute resp distress syndrome (ARDS)

Answer 16

1. exudative
2. proliferative
3. fibrotic

Question 17

Anaphylaxis after the attack investigations

Answer 17

Allergin skin testing

IgE immunoassays

Question 18

Alcohol withdrawal aetiology

Answer 18

Abrupt alcohol cessation leads to overactivation of the excitatory NMDA system relative to the GABA system

Question 19

Alcohol withdrawal Rx

Answer 19

IV vitamin B
Benzodiazepine/carbamazepine
Reducing doses of chlordiazepoxide
Lactulose + phosphate enemas to avoid encephalopathy
Lorazepam for seizures

Monitor dehydration, electrolyte imbalances, infections, nutrition

Question 20

Paracetamol overdose (>8g/day) can result in…

Answer 20

hepatic necrosis (>12g)

0-24hr - asymptomatic. N+V
24hr-72hr - RUQ pain, hepatomegaly, tender, N+V
>72hr - encephalopathy, jaundice, hypoglycaemia, coagulopathy, renal angle pain

Question 21

A 17yr old woman presents with wheeze and marked perioral swelling. PaO2 7.0kPa on 28% oxygen, PACO2 4.1kPa. What is the likely diagnosis and appropriate treatment?

Answer 21

This is a presentation of acute anaphylaxis

e.g. a type I IgE-mediated hypersensitivity reaction. Treat with 0.5ml adrenaline IM

Question 22

A 45yr old man has an accident with an open fracture of the tibia. He is in severe pain and the lower left limb is cold and pulseless. The muscles of the distal limb are brownish-black in colour. What is the likely diagnosis and causative organism?

Answer 22

Gas gangrene - due to Clostridium perfringens

Thrives in relative anaerobic conditions of necrotic tissue. Lethal and can lead to hypotension. Severe pain is present. Will change to a blue-black colour eventually and blebs will secrete discharge (watery fluid and blood).

Question 23

Acute asthma attack Rx

Answer 23

O2
Nebulised salbutamol
Prednisolone
(±nebulised ipratropium bromide, IV magnesium sulfate)

Monitor HR, PEF, O2 sats, K+, glucose. Do ABG

Question 24

Severe asthma attack includes

Answer 24

PEFR <50%
HR >110
RR >25
Cannot complete sentences

Question 25

Life-threatening asthma attack includes

Answer 25

PEFR <33%
Silent chest
Cyanosis
Bradycardia
Hypotension
Confusion
Coma