Acute Medicine Flashcards
What is sepsis?
= where body launches a large immune response to an infection causing systemic inflammation and organ dysfunction
What is disseminated intravascular coagulopathy (DIC)?
= when coagulation system gets activated formation of clots consumes platelets and clotting factors leading to > thrombocytopenia + uncontrolled bleeding (haemorrhage)
What 2 things are required to diagnose septic shock?
- low mean arterial pressure (below 65mmHg)
- raised serum lactate (above 2 mmol/L)
What 6 parameters are measured to create NEWS2 score?
- temperature
- heart rate
- respiration rate
- oxygen saturations
- blood pressure
- consciousness level
In patients with suspected sepsis, within how much amount of time should they be assessed and start treatment?
= 1 hour of presenting
What 3 tests + 3 treatments make up the Sepsis 6?
3 tests: serum lactate, urine output, blood cultures
3 treatments: oxygen to maintain oxygen saturations, empirical broad-spectrum antibiotics + IV fluids
What is neutropenic sepsis?
= refers to sepsis in someone with a neutrophil count below 1x10^9/L
Is a life threatening medical emergency
Key features that differentiate anaphylaxis from non-anaphylactic allergy reaction (3)
Compromise of airway, breathing, or circulation
If patient is suffering an anaphylaxis reaction, what position is best to put the patient in?
= lie patient flat to improve cerebral perfusion
Once diagnosis of anaphylaxis is established, what 3 medications are given to treat the reaction?
- IM adrenalin, repeated after 5 minutes if required
- Antihistamines (oral Chlorphenamine, or Cetrizine)
- Steroids (IV Hydrocortisone)
Anaphylaxis: what is a biphasic reaction?
= after a patient suffers an anaphylaxis reaction they can have a second reaction after successful treatment of the first
What can be measured to confirm diagnosis of anaphylaxis?
And how soon after onset must this be measured?
= serum mast cell try-take
within 6 hours of the event
What is a major burn?
= any burn with > 20% TBSA of partial or full-thickness burns (not including superficial burns)
What is an escharotomy?
= an emergency surgical procedure involving incising through areas of burnt skin to release the eschar and its constrictive effects, restore distal circulation, and allow adequate ventilation
What is the main marker of fluid balance status in a patient who has just suffered a burn?
= urine output
(should be maintained in adults at > 0.5ml/kg/hr)
What wound dressing should be used to initially dress a burn?
= clingfilm can be used to allow for full evaluation of burn depth, whilst minimising fluid losses from affected wounds
Patient presents with a burn which is painful, and appears to be dry, blanching and erythematous, what type of burn is this likely to be:
- superficial (frist-degree)
- superficial partial-thickness (second degree)
- deep partial-thickness (secondary degree)
- full thickness (third degree)
- superficial (frist-degree)
Patient presents with a burn which is painful, and appears to be blistered, wet, blanching and erythematous, what type of burn is this likely to be:
- superficial (frist-degree)
- superficial partial-thickness (second degree)
- deep partial-thickness (secondary degree)
- full thickness (third degree)
- superficial partial-thickness (second degree)
Patient presents with a burn which has decreased sensation, it appears yellow (or white), dry and non-blanching, what type of burn is this likely to be:
- superficial (frist-degree)
- superficial partial-thickness (second degree)
- deep partial-thickness (secondary degree)
- full thickness (third degree)
- deep partial-thickness (secondary degree)
Patient presents with a burn which is painless, appears leathery or waxy white, is non-blanching and dry, what type of burn is this likely to be:
- superficial (frist-degree)
- superficial partial-thickness (second degree)
- deep partial-thickness (secondary degree)
- full thickness (third degree)
- full thickness (third degree)
What is the ‘Modified Parkland Formula’ used for?
= acts as a guide and describes the volume of crystalloid fluid (ideally Hartmanns solution) to be administered in the first 24-hours post-burn
What is the ‘modified parkland formula’ for adults?
initial 24 hours: 4mL (Hartmann’s) x weight (kg) x %TBSA burned
How should the calculated volume of fluid resuscitation using the ‘modifies parkland formula’ be given?
= 50% given within the first 8 hours post-burn, and remaining 50% is give in the remaining 16 hours
What can be measured on an ABG to look for carbon monoxide poisoning?
= carboxyhaemoglobin levels
What is inhalation injury?
= damage to airway, secondary to inhalation of hot air
What is acute mesenteric ischaemia?
= lack of blood flow through the mesenteric vessels supplying the intestines, typically caused by rapid blockage in the blood flow through the superior mesenteric artery
Main risk factor in acute mesenteric ischaemia?
= atrial fibrillation (AF)
Imaging used to diagnose acute mesenteric ischaemia?
= contrast CT
Patients with acute mesenteric ischaemia will have:
- metabolic acidosis
- metabolic alkalosis
- metabolic acidosis
(and raised lactate)
ACEi affect on kidneys?
= long-term they are kidney protective. However, stopped during AKI as they reduce filtration pressure
Most common intrinsic cause of AKI?
= acute tubular necrosis
What do muddy brown clasts on urinalysis suggest?
= acute tubular necrosis
NICE guidelines for diagnosing an AKI? (3)
- rise in creatinine more than 25 micromol/L in 48 hours
- rise in creatinine of more than 50% in 7 days
- urine output of less than 0.5ml/kg/hour over at least 6 hours
Patient being treated for DKA develops headache, and shows altered behaviour. What should be concerned about?
= cerebral oedema
What is hypoglycaemia defined as? (value)
= blood glucose < 3.0 mmol/L
Patient is experiencing severe hypoglycaemia however, has no IV access, what is an alternative to dextrose?
= Glucagon IM, 1mg/kg
3 key features in DKA?
- ketoacidosis
- dehydration
- potassium imbalance
What is thyrotoxic storm?
= life-threatening condition caused by an excess of thyroid hormone. Rare complication of hyperthyroidism, occurring with untreated or inadequately treated disease
Signs + symptoms associated with thyrotoxic storm? (3)
- tachycardia
- fever
- altered mental status
What is used for symptom control in thyrotoxic storm?
= beta-blockers (IV Propranolol)
What is used to reduce thyroid activity in thyrotoxic storm?
= Propylthiouracil
What is a PE?
= blood clot (thrombus) in the pulmonary arteries
What effect can a PE have on the heart?
= strains the right side of the heart
Risk factors for a PE or DVT (VTE) (9)
- Immobility
- Recent surgery
- Long-haul flight
- Pregnancy
- Hormone therapy with oestrogen (e.g., combined oral contraceptive pill or hormone replacement therapy)
- Malignancy
- Polycythaemia (raised Hb)
- Systemic lupus erythematous (SLE)
- Thrombophilia
What are patient’s with a high risk of developing a VTE given for prophylaxis?
= low molecular weight Heparin (unless contraindicated)
What is the PERC rule?
= pulmonary embolism rule-out criteria - recommended when the clinician estimates less than a 15% probability of a PE to decide whether further investigation for a PE is required
Criteria which make up the Wells Score for a PE
- clinical signs + symptoms of a DVT (yes, +3)
- PE is #1 diagnosis or equally likely (yes, +3)
- HR > 100 (yes, +1.5)
- immobilisation at least 3 days OR recent surgery in the last 4 weeks (yes, +1.5)
- previous, objectively diagnosed PE or DVT (yes, +1.5)
- haemoptysis (yes, +1)
- malignancy with treatment within 6 months of palliative (yes, +1)
What wells score indicates a PE is likely?
= more than 4
What are the different outcomes regarding a Wells score?
If likely (>4): perform a CTPA, or alternative imaging
If unlikely (<4): d-dimer, if +ve perform a CTPA
Causes of a raised d-dimer (excluding PE) (5)
- pneumonia
- malignancy
- HF
- surgery
- pregnancy
3 different imaging options for investigating a suspected PE?
- CTPA (first-line)
- ventilation-perfusion single photon emission computer tomography (V/Q SPECT)
- plantar ventilation-perfusion (VQ) scan
What may you see on an ABG for a patient with a PE?
= respiratory alkalosis
(low pO2)
What other reasons may a patient have a respiratory alkalosis (excluding a PE)?
= hyperventilation syndrome
(however, patients will have a high pO2)
Management of PE: what is the first-line for anticoagulation?
What is the alternative?
= DOAC, Apixaban or Rivaroxaban
(alternative: LMWH)
Management of PE: When might continuous infusion of unfractionated Heparin used?
= massive PE with haemodynamic compromise
Options for long-term anticoagulation after a PE (3)
- DOACs
- Warfarin
- LMWH
When might DOACs not be appropriate for long-term anticoagulation after a PE?
- severe renal impairment
- antiphospholipid syndrome
- pregnancy
What can be used instead of a DOAC for long-term anticoagulation in a patient with a PE and with antiphopholipid syndrome?
= Warfarin
What can be used instead of a DOAC for long-term anticoagulation in a pregnant patient with a PE?
= LMWH
PE: How long should you continue with anticoagulation if the cause is ‘reversible’?
= 3 months
PE: How long should you continue with anticoagulation if the patient has active cancer?
= 3-6 months, then review
3 key causes of pancreatitis?
- gallstones
- alcohol
- post-ERCP
Causes of pancreatitis (11)
Mnemonic: I GET SMASHED
I - idiopathic
G - gallstones
E - ethanol
T - trauma
S - steroids
M - mumps
A - autoimmune
S - scorpion bite
H - hypercalcaemia, hypertriglyceridemia, hypothermia
E - ERCP
D - Drugs
Which kind of drugs can cause acute pancreatitis?
HINT: FAT SHEEP
F - Furosemide
A - Azathioprine, Asparaginase
T - Thiazide, Tetracycline
S - Statins, Sulphonamides, Sodium Valproate
H - Hydrochlorothiazide
E - Estrogens, Ethanol
P - Protease inhibitors + NRTIs
What are Grey-Turner’s + Cullen’s sign suggestive of?
= haemorrhagic pancreatitis
What is Grey-Turner’s sign?
= bruising along the flanks
(suggestive of haemorrhagic pancreatitis)
What is Cullen’s sign?
= bruising around peri-umbilical area
(suggestive of haemorrhagic pancreatitis)
Which enzymes are important to check in suspected pancreatitis? Which is more sensitive + specific?
- amylase (threefold elevation in levels)
- lipase (more sensitive + specific)
What is the Glasgow Score used for?
= used to assess the severity of pancreatitis
Management of acute pancreatitis
- aggressive fluid resuscitation
- catheterisation
- analgesia
- anti-emetics
What imaging may be useful in suspected pancreatitis complications?
= CT abdomen
What is the most widely abused substance in the UK?
= alcohol
When will signs of alcohol withdrawal typically present?
(hours)
= 6-12 hours
When will signs of alcohol hallucinosis typically present?
(hours)
= 12-24 hours
When will signs of deliriums tremens typically present?
(hours)
= 72 hours post-drink
Management of delirium tremens?
= oral Lorazepam (parenteral Lorazepam if oral treatment refused)
Management in alcohol withdrawal used to prevent Wernicke’s encephalopathy?
= Pabrinex
Pharmacological management of alcohol withdrawal
= Chlordiazepoxide, in a reducing regime
What is an anastomotic leak?
= postoperative complication, where the contents of a hollow organ, which were surgically joined, leak through a defect in the join
Possible anastomotic leak complications (3)
- peritonitis
- colonic abscess formation
- abdominal sepsis
How may a small anastomosis leak be managed (3)
Conservative management:
- bowel rest
- IV fluids
- antibiotics
(coupled with abdominal management)
How may a large anastomosis leak be managed (3)
= emergency laparoscopic exploration and potential further surgery
What is ascending cholangitis?
= severe, acute infection and inflammation of the biliary tree
Most common cause of ascending cholangitis?
= biliary calculi (stones)
Causes of ascending cholangitis (3)
- biliary calculi (stones)
- benign biliary strictures
- malignancy
What is the Charcot’s triad made up of, and what is this suggestive of?
- RUQ pain
- fever
- jaundice
= suggestive of ascending cholangitis
What is the Reynold’s triad made up of, and what is this suggestive of?
- RUQ pain
- fever
- jaundice
- hypotension
- mental confusion
(Charcot’s triad + 2 more symptoms)
= suggestive of severe case of ascending cholangitis
First-line scan in suspected ascending cholangitis
= USS
Which scan is most accurate in determining causative disease in ascending cholangitis?
= MRCP
Management of ascending cholangitis (3)
- IV fluids
- antibiotics
- biliary drainage
(include assessment and management of underlying cause)
What is disseminated intravascular coagulation (DIC)?
= complex condition that described the inappropriate activation of the clotting cascades, resulting in thrombus formation and subsequently leading the depletion of clotting factors and platelets
Type of haematological malignancy associated with DIC?
= sub-type of AML - acute promyelocytic leukaemia (APL)
Patient with DIC would have: (high or low)
- PT time
- APTT
- fibrinogen
- PT time - prolonged
- APTT: increased
- Fibrinogen: low
What is infectious mononucleosis also known as?
= glandular fever
Cause of glandular fever?
= Epstein Barr virus
Most prominent symptom in teenagers with glandular fever?
= debilitating fatigue
Signs and symptoms of glandular fever (4)
- fever
- sore throat
- fatigue
- hepatomegaly and/ or splenomegaly
What is the ‘Paul Bunnell’ test used to diagnose?
= glandular fever
Why is it recommended for patients with glandular fever to avoid contact sports?
= to minimise risk of splenic rupture
What is a haemorrhagic stroke?
= cerebrovascular event that occurs when the wall of a blood vessel in the brain weakens and ruptures
This causes bleeding in the brain, leading to haematoma formation, and consequently neuronal injury
Are ischaemic or haemorrhagic strokes more common?
= ischaemic storke
Are haemorrhagic strokes more common in women or men?
= men
First-line imaging used to quickly identify haemorrhagic stroke?
= CT scan
Why is BP control important in haemorrhagic stroke management?
= poor control in acute phase is associated with worse long-term outcomes
What is Horner’s syndrome?
= condition characterised by a set of signs and symptoms that occur due to a disruption in the sympathetic nerve supply to the eye
Causes of Horner’s syndrome (3)
- pancoast tumour (non-small cell lung carcinoma)
- stroke (lateral medullar infarction or Wallenberg’s syndrome)
- carotid artery dissection
Young person presents with Horner’s syndrome, accompanied by neck pain - what is the likely cause?
= carotid artery dissection
Symptoms a person with Horner’s syndrome may present with? (5)
- ptosis (drooping eyelid)
- miosis (constricted pupil)
- anhidrosis (lack of sweating on affected side of the face)
- enophthalmos (eye appears sunken)
- heterochromia (eye colour may change, associated with congenital Horner’s syndrome)
Horner’s syndrome: In pharmacological pupil testing, what occurs when OH-Amphetamine is placed in affected eye for the following:
- pre-ganglionic cause
- post-ganglionic cause
Pre-ganglionic cause: patient’s eye dilates
Post-ganglionic cause: patient’s eye will not dilate
(OH-amphetamine promotes the release of norepinephrine from the postganglionic nerve terminals)
Imaging used first-line to investigate hyperthyroidism
= USS of the thyroid
Antithyroid drugs used first-line in hyperthyroidism (2)
- Carbimazole
- Propylthiouracil
Test to help determine the cause of hyperthyroidism
= radioiodine uptake test
Which antithyroid drug is recommended for pregnant women, or those planning pregnancy?
= Propylthiouracil
Important side effect of Carbimazole
= agranulocytosis
Patients should be advised to seek immediate medical attention if they experience symptoms like fever, sore throat, mouth ulcers, or other signs of infection
What can be used for symptomatic relief in hyperthyroidism?
= beta-blockers (e.g., Propanolol)
Definitive treatment options for hyperthyroidism (2)
- radio-iodine
- surgery (thyroidectomy)
What is thyroid storm?
= rare, but life-threatening medical emergency, caused by untreated or inadequately managed hyperthyroidism
Often precipitated by stressors such as, surgery, trauma, or infection
Management of thyroid storm
- IV Propanolol + Digoxin: for cardiac symptoms
- Propylthiouracil through nasal gastric tube + Lugol’s iodine: to reduce thyroid hormone production
- Prednisolone or Hydrocortisone: inhibits peripheral conversion of T4 > T3
What is hypothermia (°C)?
= defined as core body temperature of < 35°C
What is severe hypothermia defined as?
= < 28°C
Patient presents with tachycardia, tachypnoea, vasoconstriction, and shivering, after being found outside on a cold winters day.
They have a temperature of 33°C
Which of the following types of hypothermia does this patient most likely have?
- mild hyperthermia
- moderate hyperthermia
- severe hyperthermia
- mild hyperthermia
Patient presents with cardiac arrhythmia, hypotension, respiratory depression, reduced consciousness and is not shivering, after being found outside on a cold winters day.
They have a temperature of 30°C
Which of the following types of hypothermia does this patient most likely have?
- mild hyperthermia
- moderate hyperthermia
- severe hyperthermia
- moderate hyperthermia
Patient presents with marked reduced consciousness/ coma, apnoea, arrhythmia with fixed dilated pupils, after being found outside on a cold winters day.
They have a temperature of 27°C
Which of the following types of hypothermia does this patient most likely have?
- mild hyperthermia
- moderate hyperthermia
- severe hyperthermia
- severe hyperthermia
The following ECG features are suggestive of?
- bradyarrhythmia
- Osborne waves (‘J’ waves)
- prolonged PR, QRS, and QT intervals
- ventricular ectopics
- cardiac arrest
= hypothermia
What are Osborne waves (‘J’ waves) pathognomonic for?
= hypothermia
What do ‘J waves’ look like on an ECG?
= positive deflection at the J point between the end of the QRS complex and beginning of the ST segment
What medical emergency are patients with hypothermia at risk of?
= cardiac arrest
What are Osborne waves on an ECG also known as?
‘J waves’
What is idiopathic intracranial hypertension?
= disorder of unidentifiable cause which leads to increased intracranial pressure
What opening pressure on lumbar puncture insinuate idiopathic intracranial hypertension?
= above 25 cmH2O
Is idiopathic intracranial pressure more common in women or males?
= usually more common in young + obese women
Which drugs are associated with raised intracranial pressure? (5)
- oral contraceptive pill
- steroids
- tetracycline
- vitamin A
- lithium
What may be seen on ophthalmoscopy in patient with idiopathic intracranial pressure?
= bilateral papilloedema
Key diagnostic tool in idiopathic intracranial hypertension
= lumbar puncture
(revealing an opening pressure above 20 cmH2O)
First-line management for idiopathic intracranial hypertension
= weight loss
First-line analgesia for patients with major trauma?
= IV morphine
Causative organism in meningococcal infection?
= Neisseria meningitides bacterium
Where does Neisseria meningitidis bacterium usually reside?
= nasopharynx of many children and young adults
How is meningococcal infection transmitted?
= via respiratory droplet spread
What is Waterhouse-Friderichsen Syndrome? and what disease is this associated with?
= a rare but life-threatening disorder associated with bilateral adrenal hemorrhage
In many cases, it is caused by fulminant meningococcemia (associated with meningococcal infection)
How is meningococcal infection diagnosed? (2)
= blood cultures, or CSF (where appropriate)
PCR also highly sensitive + another key investigative tool
Management in suspected meningococcal infection
Early antibiotic treatment (broad-spectrum IV), until pathogen identified
Abx adjusted to penicillin-based treatment
Notifiable disease - contact public health authorities
Meningococcal infection: for all household, or close contacts, what can be given as post-exposure prophylaxis?
= Ciprofloxacin or Rifampicin
Is meningococcal infection a notifiable disease?
= yes, need to contact the public health authorities
What is myxoedema coma?
= aka, severe decompensated hypothyroidism - most severe form of hypothyroidism
Typically triggered by an acute event such as infection, MI or drug use
Primary cause of myxoedema coma
= severe or untreated hypothyroidism
Signs and symptoms of myxoedema coma (7)
- profound lethargy or coma
- hypothermia
- bradycardia + hypotension
- hypoventilation
- hypoglycaemia
- hyponatraemia
- generalised myxoedema
What is seen in patients in a myxoedema coma:
- hyperventilation
- hypoventilation
- hypoventilation
Management of myxoedema coma (5)
- IV T3/T4
- 50-100mg IV Hydrocortisone
- Oxygen + mechanical ventilation
- IV fluids
- correction of hypothermia, hypoglycaemia + treatment of many HF
What is necrotising fasciitis?
= severe life-threatening infection characterised by rapidly progressing inflammation and necrosis of the fascia and subcutaneous tissue
While it spreads along the fascial planes, it typically spares the underlying muscle
Common causative organism of necrotising fasciitis
= group A Streptococcus
What gas-forming organism can cause necrotising fasciitis?
(causes type III NF)
= Clostridium perfringens
What is Fournier’s gangrene?
= necrosis fasciitis of the perineum
Who is at a higher risk of developing Fournier’s gangrene?
(taking what medication)
= diabetics taking SGLT-2 inhibitors (-gliflozins)
3 types of necrotising fascinating
Type 1: poly microbial
Type 2: mono microbial (typically caused by Group A Streptococcus, or Staphylococci)
Type 3: often caused by gas-forming organisms, such as Clostridium perfringens, leading to ‘gas gangrene’
Management of necrotising fasciitis (2)
- urgent surgical debridement
- broad-spectrum antibiotic therapy (IV Clindamycin, Meropenem, and Vancomycin)
- haemodynamic support (IV fluids, vasopressors, and supportive care)
What is oesophagitis?
= inflammation of the oesophagus
Most common cause of oesophagitis?
= reflux of gastric contents
Investigation for oesophagitis (2)
- endoscopy: allows for direct visualisation, grading + allows biopsy
- oesophageal pH monitoring: to help determine whether symptoms timing and reflux correlate
Pharmacological treatment for oesophagitis
= full-dose PPI for 1 month
How long should a patient with oesophagitis be on PPIs?
= 1 month
Lifestyle changes which should be advised to patients with oesophagitis (3)
- weight loss
- cessation of smoking
- reduction in alcohol intake
What is a compound fracture?
= AKA open fracture, is a type of bone fracture characterised by a breach in the skin that allows the fractured bone to communicate directly with the outside environment
This exposes the injury site to potential contaminants, thereby increasing the risk of infection
Acetaminophen is also known as?
= Paracetamol
Most common agent for intentional self-harm in the UK?
= paracetamol overdose
Pathophysiology of paracetamol overdose
= normally, NAPQI is inactivated by glutathione, but during an overdose, glutathione stores are rapidly depleted, leaving NAPQI unmetabolised and resulting in liver and kidney damage
What is the toxic substance which builds-up in a paracetamol overdose?
= N-acetyl-p-benzoquinone-imine (NAPQI)
Patient comes in following a paracetamol overdose, ingestion < 1 hour ago + dose > 150mg/kg
What do you do?
- Administer activated charcoal
- Treat with N-acetylcysteine
- Wait 4 hours to take level, then treat with N-acetylcystine
- Administer activated charcoal
Patient comes in following a paracetamol overdose, ingestion < 4 hour ago
What do you do?
- Administer activated charcoal
- Treat with N-acetylcysteine
- Wait 4 hours to take level, then treat with N-acetylcystine
- Wait 4 hours to take level, then treat with N-acetylcystine
Patient comes in following a paracetamol overdose, ingestion within 4-8 hours ago + dose > 150mg/kg
What do you do?
- Administer activated charcoal
- Treat with N-acetylcysteine
- Wait 4 hours to take level, then treat with N-acetylcystine
- Treat with N-acetylcysteine
(immediately if there is going to be a delay of >/= 8 hours in obtaining paracetamol level
Patient comes in following a paracetamol overdose, ingestion > 24 hours ago
What do you do?
- Administer activated charcoal
- Treat with N-acetylcysteine
- Wait 4 hours to take level, then treat with N-acetylcystine
- Treat with N-acetylcysteine
Patient comes in following a staggered paracetamol overdose
What do you do?
- Administer activated charcoal
- Treat with N-acetylcysteine
- Wait 4 hours to take level, then treat with N-acetylcystine
- Treat with N-acetylcysteine
What is King’s College Criteria used for in paracetamol overdose? (2)
= used to predict mortality from paracetamol overdose
And to identify those patients who would potentially benefit from liver transplantation
What occurs in an acute aortic thoracic dissection?
= occurs when a tear in the tunica intima of the aorta creating a false lumen whereby blood can flow between the inner and outer layers of the walls of the aorta
Risk factors of aortic dissection (4)
- hypertension
- connective tissue disease (e.g., Marfan’s syndrome)
- valvular heart disease
- cocaine/ amphetamine use
Stanford Classifications of aortic dissections (type A + B)
Stanford type A: involves ascending aorta, arch of the aorta
Stanford type B: involves the descending aorta
Are aortic dissections more common in men or women?
= men
What is radio-radial delay?
(clinical sign)
= loss of synchronicity between the radial pulse on each arm, resulting in the pulses occurring at different time
Key investigation in diagnosing aortic dissection?
= CT angiogram
Aortic dissection, what is used to control BP?
= IV Metoprolol infusion
Definitive management options for both type A and B aortic dissections
Type A: usually requires surgical management (e.g., aortic graft)
Type B: normally managed conservatively with BP control
What is cardiac syncope?
= transient loss of consciousness as a result of inadequate cardiac output leading to cerebral hypoperfusion
Patient presents following collapse, seen to be found exertion syncope. What do you make of this?
= suggests cardiac cause
Exertional syncope is a red flag symptom and warrants serious investigation
Imaging which can be used to look for structural causes of cardiac syncope
= trans-thoracic echocardiogram (TTE)
DVLA advice if patient suffers an unexplained syncope
= 6 months off driving and need to inform the DVLA
What is serotonin syndrome?
= potential life-threatening condition resulting from increased serotoninergic activity within the CNS
Triad of clinical features seen in patients with serotonin syndrome
- mental status changes
- autonomic hyperactivity
- neuromuscular abnormalities
What is Cyproheptadine used for?
= is an antidote for serotonin syndrome
Types of shock and what causes them (6)
- Hypovolaemic: due to blood loss
- Septic: from severe systemic infection
- Anaphylactic: allergic reaction
- Cardiogenic: poor cardiac output
- Neurogenic: caused by damage to the nervous system
- Obstructive: caused by physical obstruction to vessels or the heart
Management of traumatic shock (hypovolaemia) (2)
- administer 1.5-2L warmed IV crystalloid, assess for response
- if inadequate response to fluid, arrange 0-negative blood. Give fully cross-matched blood as soon as possible
What is a space occupying lesion?
= refers to any pathological entity, such as tumours or abscesses, that occupy space within the cranial vault
Describe pathophysiology of Cushing’s reflex
Is a response to raised intracranial pressure. This results in reduced cerebral perfusion and so the resultant cerebral ischaemia, causes massive sympathetic activation (Cushing’s reflex)
Triad of Cushing’s reflex
- bradycardia
- irregular respirations
- high systolic BP (widened pulse pressures)
Initial imaging in acute setting where space-occupying lesion is suspected
= CT head
What is the Glasgow coma scale (GCS)?
= universal score used in the assessment of conscious level of a patient
Minimum score you can get on the GCS scale?
= 3
What does a GCS < 8 signify?
= suggests that patient is unable to maintain their own airway adequately, and warrants urgent assessment by the anaesthetic team
ECG finding, seen in person with tricyclic antidepressant overdose
= QT interval prolongation
What is given to treat TCA overdose?
= IV Sodium Bicarbonate
(if presents within 2-4 hours of overdose, consider activated charcoal)
What is Wolff-Parkinson-White Syndrome?
= congenital pre-excitation syndrome that occurs due to the presence of an accessory electrical pathway between the atria and ventricles
What arrhythmia does Wolff-Parkinson-White syndrome predispose you to?
= supraventricular tachycardias
Is wolff-parkinson-white syndrome more common in men or women?
= men
Which of the following is Type A vs Type B Wolff-Parkinson-White Syndrome
- pathway between L atrium + ventricle
- pathway between R atrium + ventricle
Type A: pathway between L atrium + ventricle
Type B: pathway between R atrium + ventricle
First-line investigation in patient with Wolff-Parkinson-White syndrome you can do bedside?
= ECG
In what condition do you see the following ECG changes:
- delta waves
- short PR interval
- broadened QRS complex
= wolff-parkinson-white syndrome
Anti-arrhythmic used in long-term management of wolff-parkinson-white syndrome (2)
- Amiodarone
- Sotalol
Amiodarone + Sotalol (anti-arrhythmics) are contraindicated in patients with…?
= structural heart disease
Definitive management of Wolff-parkinson-white syndrome
= radio frequency ablation (or open-heart performed in complex cases)
Patient with wolff-parkinson white presents with tachyarrhythmia
If there are adverse signs such as shock, syncope, HF, or myocardial ischaemia, what is first-line management?
= synchronised DC cardioversion
Patient with wolff-parkinson white presents with tachyarrhythmia
If patient is stable but presenting with a narrow complex tachycardia with short PR intervals, what is the first + second-line management?
First-line: vagal manoeuvres
Second-line: Adenosine
Success rate of WPW syndrome being treated with ablation
= high, 95% success rate
What is primary angle closure glaucoma (PACG)?
= type of glaucoma characterised by the blockage or narrowing of the drainage angle formed by the cornea and iris, resulting in sudden increase in intraocular pressure
Risk factors for developing angle closure glaucoma (4)
- hyperopia (long-sightedness) and short axial length of eyeball
- age
- ethnicity: Inuit or Asian population
- pupillary dilation (iatrogenically or environmental)
What is hyperopia?
= long-sightedness
What do the following symptoms suggest:
- painful eye that develops rapidly
- eyes appear red, ciliary flush with hazy cornea
- burred vision
- systemically unwell
- patient desired seeing haloes around lights
- raised IOP detected
= acute angle closure glaucoma
Definitive management of acute angle closure glaucoma
= peripheral iridotomy
What is peripheral iridotomy?
= laser used to make hole in the peripheral iris to allow free flow of aqueous
(definitive treatment for acute angle closure glaucoma)
IOP-lowering agents (3)
- beta-blockers
- Pilocarpine
- IV acetazolamide
Which of the following peak expiratory flow readings suggests moderate asthma in an acute attack?
- PEF >50-75%
- PEF >35-50%
- PEF 33-50%
- PEF < 35%
- PEF < 33%
- PEF >50-75%
Which of the following peak expiratory flow readings suggests severe asthma in an acute attack?
- PEF >50-75%
- PEF >35-50%
- PEF 33-50%
- PEF < 35%
- PEF < 33%
- PEF 33-50%
Which of the following peak expiratory flow readings suggests life-threatening asthma in an acute attack?
- PEF >50-75%
- PEF >35-50%
- PEF 33-50%
- PEF < 35%
- PEF < 33%
- PEF < 33%
Why might patients with life-threatening asthma have a normal PCO2, between 4.6-6.0?
= unable to ventilate appropriately (as you’d expect this group to have low PCO2 level)
What is raised PCO2 a sign of, in an acute asthma attack?
= near-fatal sign of asthma
Immediate management of an acute asthma attack (4)
- sit-up
- 100% O2 via non-rebreathe mask (aim for 94-98%)
- Nebulised Salbutamol (5mg) +/- Ipratropium (0.5mg) depending on response to Salbutamol
- Hydrocortisone 100mg IV, or Prednisolone 50mg PO
Life-threatening asthma attack management (3)
- inform intensive care team
- Magnesium sulphate 2g IV over 20 minutes
- Nebulised Salbutamol every 15 minutes
3 things to keep an eye on whilst monitoring a patient who presented with acute asthma attack
- peak flow (every 15 minutes, pre- and post-Salbutamol)
- SpO2
- ABG measurements
How Is unstable angina differentiated from NSTEMI?
Unstable angina: no rise in troponin
NSTEMI: rise in troponin
How is STEMI differentiated from NSTEMI?
= ECG changes
STEMI: ST-elevation, or LBBB
NSTEMI: new ST-depression, T-wave inversion
Which type of patients are more likely to experience a ‘painless’ MI (2)
= diabetics, and older patients
Initial treatment of STEMI
‘MMONAC’
M - Morphine
M - Metoclopramide
O - Oxygen
N - Nitrates (GTN spray)
A - Aspirin 300mg
C - Clopidogrel 300mg
Patient admitted with STEMI, has presented within 12 hours of symptoms onset, and within 2 hours of medical contact.
What procedure is most appropriate?
= PCI
Patient admitted with STEMI, has presented within 12 hours of symptoms onset, but after 2 hours of medical contact.
What procedure is most appropriate?
= thrombolysis
What can be offered to patients with NSTEMI who are deemed high risk of death and further ischaemic events - if presented within 12-24 hours?
= re-vascularisation
What oxygen should be given to a patient experiencing an acute exacerbation of COPD
= 24% O2 via Venturi mask
(SpO2: 88-92%)
In patient experiencing an acute exacerbation of COPD, what should be considered if their pH<7.26?
= invasive intervention
What non-invasive ventilation can be used in patients’s suffering an acute exacerbation of COPD?
= BiPAP (bilevel positive airway pressure)
What is acute pulmonary oedema?
= accumulation of excess fluid in the pulmonary system, particularly within the lung parenchyma and alveoli
What is an open book pelvis?
= fracture of the pubic rami with a posterior pelvic disruption of the sacro-iliac joint
Treatment of acute pulmonary oedema
- position patient upright
- administer oxygen
- IV Furosemide
Consider non-invasive ventilation
In patients with HF and renal impairment, would diuresis help or worsen the situation?
= under-perfusion likely due to poor output from the heart and therefore, by off-loading fluid with diuresis, SV improves and perfusion to kidneys improve
Potential option in patients with acute pulmonary oedema on a background of HF, persistent hypotension, and evidence of end-organ perfusion?
= Vasopressors
What is ethylene glycol found in?
= anti-freeze
Management options in ethylene glycol poisoning?
- gastric lavage (stomach pump), or NG aspiration (if < 1 hour since ingestion)
- Fomepizole (prevents metabolism of ethylene glycol into toxic metabolites)
- haemofiltration can be used in severe cases to remove toxic metabolites from the blood
What is Fomepizole used for?
= antidote used in ethylene glycol poisoning (anti-freeze)
Which of the following would you see in someone with ethylene glycol poisoning?
- normal anion gap metabolic acidosis
- raised anion gap metabolic acidosis
- normal anion gap metabolic alkalosis
- raised anion gap metabolic alkalosis
- raised anion gap metabolic acidosis
What is pericarditis?
= inflammation of the pericardium which is 2 layers of tissue that surround the heart
Important to test to do in someone with suspected pericarditis?
= ECG
What ECG findings suggest pericarditis? (2)
- PR depression
- global saddle-shaped ST elevation
Emergency management of pericarditis
= analgesia (NSAIDs) + bed rest
(Colchicine + steroids may be used if necessary. Must also treat underlying cause)
What is a pneumothorax?
= presence of air within the pleural space
Which patients are at a higher risk of developing a spontaneous primary pneumothorax?
= tall, thin, young men
Management of a primary pneumothorax if rim of air < 2cm AND patient NOT SOB
= consider discharge
Management of a primary pneumothorax if rim of air < 2cm AND patient is SOB
= needle aspiration
Management of a primary pneumothorax if rim of air > 2cm AND patient is still SOB
= chest drain
Management of a secondary pneumothorax if rim of air is between 1-2cm?
= needle aspiration
Management of a secondary patient > 50 + rim of air > 2cm, and/ OR patient is SOB?
= insert chest drain
Signs of a tension pneumothorax (compared to simple pneumothorax) (2)
- haemodynamic instability
- mediastinal shift
How is a tension pneumothorax diagnosed?
= should be a clinically diagnosis
Management of a tension pneumothorax
= immediate needle decompression using a large-bore needle (2nd intercostal space, mid-clavicular line)
Insert chest drain to prevent immediate recurrence of the tension pneumothorax
What is encephalitis?
= inflammation of the brain parenchyma, aka the encephalon
Most common cause of encephalitis?
= herpes simplex virus type I (viral)
What should be suspected in a patient presenting with sudden onset behavioural changes, new seizures, and unexplained acute headache accompanied by meningism?
= encephalitis
What are the triad of symptoms of meningism?
- nuchal rigidity
- photophobia
- headache
Herpes simplex virus encephalitis affects which lobe in the brain more commonly?
= temporal lobes
Management of suspected encephalitis (2)
- broad-spectrum antimicrobial cover with 2g IV Ceftriaxone BD
- 10mg/kg Acyclovir TDS for 2 weeks (anti-viral)
What is hyperosmolar hyperglycaemic state?
= serious complications of type II diabetes (T2DM), characterised by severe hyperglycaemia, hypotension and hyperosmolarity without significant ketosis or acidosis
Diagnostic criteria for hyperosmolar hyperglycaemic state (3)
- severe hyperglycaemia (>/= 30 mmol/L)
- hypotension
- hyperosmolarity (usually, > 320 mismos/kg)
Management of hyperosmolar hyperglycaemic state (3)
- fluid resuscitation with 0.9% saline
- insulin at 0.05 units/kg/hour, only if ketones > 1 mmol/L or if glucose fails to fall
- VTE prophylaxis
Patients with hyperosmolar hyperglycaemic state are at higher risk of what?
= venous thromboembolism (VTE)
What is addisonian crisis?
= characterised by body’s inability to produce a sufficient amount of cortisol
What would you expect to sodium, potassium and glucose levels in addisonian crisis?
Sodium - low
Potassium - high
Glucose - low
Test to confirm diagnosis of addisonian crisis?
= ACTH (short synacthen) test
Management of addisonian crisis (3)
- fluid resuscitation
- IV Hydrocortisone 100mg
- IV glucose is hypoglycaemic
- consider Fludrocortisone if there is adrenal disease present
(transition back to oral steroids after 3 days)
What oxygen saturations would you expect in a patient with carbon monoxide poisoning?
= 100% (saturation probe cannot distinguish between oxygenated + carboxyhemoglobin bound to Hb)
Patient presents with confusion, nausea + vomiting, tachycardia + cherry red skin. Oxygen saturations are 98%.
What do you suspect is going on here?
= carbon monoxide poisoning
How do you diagnose CO poisoning?
= venous or arterial blood gas - carboxyhemoglobin concentration > 20% is diagnostic
Management of CO poisoning
- administer 100% oxygen via non-rebreathe mask
- hyperbaric oxygen therapy (gold-standard)
What is hyperbaric oxygen therapy used to treat?
= carbon monoxide poisoning
Electrolyte imbalance which puts you at an increased risk of digoxin toxicity?
= hypokalaemia
Which kind of toxicity can cause vision with a yellow-green tint?
= digoxin toxicity
Why are people with hypokalaemia more at risk of digoxin toxicity?
=because digoxin binds to the K+ site of the Na+/K+-ATPase pump, low serum potassium levels increase the risk of digoxin toxicity
Conversely, hyperkalemia diminishes digoxin’s effectiveness
What is digibind used for?
= antidote used in digoxin toxicity
What type of hypersensitivity reaction is anaphylaxis?
= severe type 1 IgE-mediated hypersensitivity reaction
What can be measured to confirm an anaphylaxis reaction? (after patient stabilised)
= serum levels of mast cell tryptase
Immediate management of patient presenting with anaphylaxis
- ABCDE approach
- oxygen
- lay flat, legs up
- administer Adrenaline IM 500 micrograms (for adult)
- if no response after 5 minutes, repeat IM adrenaline + IV fluid bolus
What should be given to patient who presented with anaphylaxis and has been stabilised with IM adrenaline? (2)
= Chlorphenamine (antihistamine) + Hydrocortisone
What is a biphasic anaphylactic response?
= describes the recurrence of anaphylaxis symptoms soon after the initial episode.
Occurs in 5% of cases
If 2 doses of IM adrenaline have been given, what is the minimum time patient must be observed for?
= minimum 6 hours
What makes up Beck’s triad?
- raised JVP
- hypotension
- muffled heart sounds
What is Kussmaul’s sign?
= paradoxical rise in JVP during inspiration
What is pulsus paradoxus?
= decrease in systolic BP by > 10mmHg during inspiration
Diagnostic imaging used to diagnose cardiac tamponade
= echocardiogram
Treatment for cardiac tamponade
= pericardiocentesis
What ECG findings can be seen in cardiac tamponade?
= electrical alternans
(non-specific but suggestive of tamponade)
What is electrical alternates on ECG?
= alternating height of QRS complexes
ECG shows: polymorphic VT that twists around isoelectric line + QT prolongation (> 460ms)
= torsades de pointes
Initial management of patient with torsades de pointes, if patient haemodynamically unstable?
= DC cardioversion
Initial management of patient with torsades de pointes, if patient haemodynamically stable?
= 2mg IV Magnesium Sulphate over 1-2 minutes
1st line long-term treatment in patients with torsades de pointes with congenital LQTS?
= beta-blockers
What may be considered to stop patient’s with torsades de pointes from having further episodes?
= inserting an implantable cardioverter defibrillator (ICD)
Which arrhythmia increases a patients risk of developing torsades de pointes?
= long QT syndrome (LQTS)
What is a broad complex tachycardia characterised as?
(HR + QRS width)
- HR > 100bpm
- QRS width > 120
Electrolyte abnormalities which may cause ventricular tachycardia?
(K + Mg)
= hypokalaemia + hypomagnesaemia
Main medical treatment option for stable patients with a regular broad complex tachycardia
= IV Amiodarone
Drugs that cause QT prolongation (2)
- Clarithromycin
- Erythromycin
Can you use Adenosine in people with asthma?
= no
What can be used as an alternative to Adenosine in patients with asthma?
= Verapamil
What is important to mention to a patient before they are given Adenosine?
= warn patient they may experience difficulty breathing, chest tightness and flushing
What is status epilepticus defined as?
- single seizure lasting > 5 minutes
- > /= 2 seizures within 5 minutes, without person returning to normal between them
Reversible causes which should be initially checked in a patient who is seizing (2)
- blood sugar levels
- oxygen saturations
In pre-hospital setting what may be given initially in status epilepticus (2 + doses)
- buccal Midazolam (10mg)
- PR Diazepam (10mg)
In hospital what is given initially to treat status epilepticus? (+dose)
= IV Lorazepam (4mg)
Patient presents with status epilepticus and is treated with 4mg Lorazepam IV, what is the next step if seizure activity does not cease?
= repeat IV Lorazepam (4mg) after 5-10 minutes
Patient presents with status epilepticus and is treated with 4mg Lorazepam IV, this is then repeated. What is the next step if seizure activity does not cease?
= add a second-line agent - Levetiracetam
Status epilepticus: if no response to treatment within 45 minutes from onset, what options should be considered? (2)
- induction of general anaesthesia
- phenobarbital
What is a deep vein thrombosis?
= refers to intra-luminal occlusion of any vein within the deep system of a limb (either arm or leg) or the pelvis
Causes and risk factors for a DVT
(‘THROMBOSIS’)
T – trauma, thrombophilia
H – hormonal (COPD, pregnancy, HRT)
R – relatives (Fhx of VTE), recent surgery (orthopaedic/ pelvic in particular)
O – old (age > 60), obesity
M - malignancy
B – bone fractures
O – obesity
S - smoking
I – immobilisation (long distance travel, or recent surgery)
S - sickness
How far below the tibial tuberosity should a calf circumference be measured in suspected DVT?
= 10cm below
When measuring calf circumference in patient with suspected DVT, what difference between the 2 legs increases the probability of a DVT?
= > 3cm
For which kind of patients should you arrange a same-day assessment and management if DVT is suspected?
= pregnant women or if has given birth within the past 6 weeks
Non-pregnant patient is suspected of having a DVT, how can the probability be calculated?
= 2-level Well’s score
What score on the 2-level Well’s scoring system makes a DVT ‘likely’?
= 2 points or more
If a DVT is ‘likely’ on the Well’s score, what is the next step?
- primal leg vein USS scan within 4 hours, if NOT possible,
- d-dimer should be performed + interim anticoagulation should be administered
DVT: what do you do if USS scan is negative, but d-dimer comes back as positive?
= stop interim anticoagulation and offer repeat USS 6-8 days later
What anticoagulation is used in management of a DVT?
DOAC (such as Apixaban or Rivaroxaban)
(other options Warfarin, LMWH, unfractionated Heparin)
Target INR in those taking Warfarin?
= INR between 2-3
What can be used as interim anticoagulation in patient with suspected DVT?
= low-molecular weight heparin
(or NICE update can use anticoagulant you wish to continue with such as DOAC)
What do you do if DVT is ‘unlikely’ on Well’s score?
= d-dimer test (within 4 hours)
How long should a patient be on anticoagulation if they have a ‘provoked’ DVT?
= 3 months
How long should a patient be on anticoagulation if they have a ‘unprovoked’ DVT?
= 6 months
DVT: How long should a patient be on anticoagulation if they have non-modifiable risk factors?
= lifelong
DVT: How long should a patient be on anticoagulation if they have an active cancer?
= 3-6 months
What is an extradural haemorrhage?
(where does blood collect, which vessel is often implicated?)
= blood collects between dura mater (outmost meningeal layer), and surface of skull
Middle meningeal artery often implicated
Extradural haemorrhage is common in which kind of patients?
= young patients who have experienced a head injury
Scan of choice used to investigate an extradural haemorrhage
= CT scan
18 y.o. patient was involved in a road traffic accident and has a headache. CT scan shows biconvex hyper dense extra-axial collection
What is the diagnosis?
= extradural haemorrhage
Management options for an extradural haemorrhage (mild + severe) (2)
Mild: conservative treatment + close observation
Severe: urgent neurosurgical evaluation
Signs of an upper GI bleed (2)
- haematemesis (coffee-ground like)
- Malena (black, tarry stool)
Upper GI bleed: which of the followings signs suggests < 15% blood volume loss?
- resting tachycardia
- orthostatic hypertension
- supine hypotension
- resting tachycardia
Upper GI bleed: which of the followings signs suggests at least 15% blood volume loss ?
- resting tachycardia
- orthostatic hypertension
- supine hypotension
- orthostatic hypertension
Upper GI bleed: which of the followings signs suggests over 40% blood volume loss ?
- resting tachycardia
- orthostatic hypertension
- supine hypotension
- supine hypotension
What is used in an upper GI bleed to reduce portal hypertension?
= IV Terlipressin
What is the Glasgow-Blatchford Score used for?
= used in upper GI bleed - risk scoring tool used to predict need to treat in patients with an endoscopy
How to manage an upper GI bleed?
- ABCDE approach
- stabilise patient, may require blood transfusion or FFP + platelet transfusions
- Terlipressin - reduce portal hypertension
- Broad spectrum antibiotics
- urgent endoscopy
What is the treatment of choice for a variceal bleed at endoscopy?
= variceal band ligation
What is a Sengstaken-Blakemore tube? And when may it be used?
= used in variceal bleed if its uncontrollable. Tube inserted as a temporary measure to tamponade the bleeding variceal
Pharmacological prevention of variceal bleeds?
= Propranolol (non-selective beta-blockers)
Patient is found to have liver cirrhosis, what is important to screen for? and how is it done?
= important to screen for oesophageal varices, using endoscopy
If patient with liver cirrhosis has no signs of oesophageal varices on diagnosis, when do you repeat endoscopy? if ever?
= after 2-3 years
Endoscopic prevention of variceal bleeds?
= variceal band ligation
Where Propranolol and band ligation fails to prevent variceal bleeds, what can be used?
= TIPSS (transjugular intrahepatic portosystemic shunt)
What is The Rockall Score, and what is it used for?
= used in upper GI bleeds - risk assessment tool that predicts mortality in these patients
What is bradycardia defined as?
= HR < 60
Most common medications used to increase ventricular rate (used in bradycardia) (3)
- IV Atropine
- Epinephrine
- Dopamine
If medical therapy does not work at increased ventricular rate in bradycardia, what can be used?
= temporary pacing (transcutaneous + transvenous)
Name 2 non-shockable rhythms
- pulseless electrical activity
- asystole
What is pulseless electrical activity?
= where the ECG shows electrical activity that should produce a pulse, but cardiac output is absent, or insufficient, such that a pulse is not clinically detectable
What asystole?
= cardiac arrest rhythm which no discernible electrical activity on the ECG monitor
ALS: Management of pulseless electrical activity (PEA) OR asystole
= commence CPR immediately
Adrenaline 1mg IV given in 1st cycle + if persists, every other cycle
(e.g., cycle 1, 3, 5 etc.)
[these are non-shockable rhythms]
Name 2 types of shockable rhythms
- pulseless ventricular tachycardia
- ventricular fibrillation
Which rhythm presents as a broad complex tachycardia on cardiac monitoring?
= ventricular tachycardia
Which rhythm presents as a chaotic irregular deflections of varying amplitude?
= ventricular fibrillation
ALS: Management of ventricular fibrillation + pulseless ventricular tachycardia
= CPR + defibrillation
If persistent, Amiodarone 300mg IV (one-off dose) AND Adrenaline 1mg IV (can be given after the 3rd shock has been delivered)
(e.g., cycle 3, 5, 7 etc.)
[shockable rhythms]
Investigation of choice in suspected spinal cord compression?
= urgent whole MRI
(aim to surgically decompress within 48 hours)
Management for spinal cord compression (2)
- urgent surgical decompression, typically within 24 hours
- Dexamethasone (indicated in those with demonstrated malignancy on MRI, or those with high suspicion) - 16mg daily in divided doses - along with PPIs
What is atrial fibrillation (AF)?
= characterised by irregular, uncoordinated atrial contraction usually at a rate of 300-600 beats per minute
Commonest sustained cardiac arrhythmia?
= AF
Definition of acute AF
= lasts < 48 hours
Definition of paroxysmal AF
= lasts < 7 days, and is intermittent
Definition of persistent AF
= lasts > 7 days but is amenable to cardioversion
Definition of permanent AF?
= lasts > 7 days and is not amenable to cardioversion
How do you define ‘fast’ vs ‘slow’ AF?
Fast AF: >/= 100 bpm
Slow AF: </= 60 bpm
Most common cause of AF in the UK
= ischaemic heart disease
Most common cause of AF in a less developed countries
= rheumatic heart disease
Bedside test which can definitively diagnosis AF?
= 12-lead ECG
ECG findings which suggest AF
= absence of p-waves, with irregularly irregular rhythm
First-line treatment in a patient presenting with AF who is haemodynamically unstable
= synchronised DC cardioversion (+/- Amiodarone)
Which of the following drugs can be used in AF rhythm control if patient has no structural heart disease?
- Amiodarone
- Flecainide
- Flecainide
Which of the following drugs can be used in AF rhythm control if patient has structural heart disease?
- Amiodarone
- Flecainide
- Amiodarone
Which of the following is the best option for stable patients presenting with AF - onset > 48 hours (or if onset unclear)?
- rate + rhythm control
- rate control only
- rhythm control only
- rate control only
If patient presents with AF - onset > 48 hours, how long do they need to be anticoagulation for prior to attempting cardioversion?
= 3 weeks prior
(risk of throwing off a clot)
How can you exclude a mural thrombus in patient with AF awaiting anticoagulation?
= TOE (transoesophageal echocardiogram)
Is rate or rhythm control used first-line in most patients with AF?
= rate control
1st line option for rate control in AF?
= beta-blocker (Bisoprolol) or, rate-limiting calcium channel blocker (Diltiazem)
Final option for rhythm control in AF if cardioversion + pharmacological options don’t work?
= catheter ablation
AF: What may be used for rate control in patients who have hypotension or have co-existing HF?
= Digoxin
Why is Sotalol not used as a rate control agent in AF?
= because it also has rhythm control action
AF: Which of the following rhythm control drugs are preferred in younger patients who have structurally normal hearts?
- Flecainide
- Amiodarone
- Sotalol
- Flecainide
(can induce fatal arrhythmias in those with structural heart disease)
AF: Which of the following rhythm control drugs have a large number of significant SEs and so should only be given in older, sedentary patients?
- Flecainide
- Amiodarone
- Sotalol
- Amiodarone
What can be used to stratify the risk of stroke in AF patients?
= CHADS2VASc Score
CHADS2VASc Scoring System
C: congestive heart failure (1 point)
H: HTN (1 point)
A2: age >/= 75 (2 points)
D: DM (1 point)
S2: previous stroke or TIA (2 points)
V: vascular disease (1 point)
A: age 65-74 (1 point)
Sc: female (1 point)
Score on CHADS2VASc which suggests patient should be anticoagulated?
(M + F)
Male: >/= 1
Female: >/= 2
What is the ORBIT Score used for?
= used to assess risk of bleeding in patients with AF who are on anticoagulation
First-line anticoagulation option in AF?
= DOACs
Positives (2) and limitations (1) of using DOACs as anticoagulant in AF?
Positives:
- doesn’t require monitoring
- associated with fewer bleeding risks
Limitations:
- half-life approximately 12 hours, therefore if patient misses dose they are not covered
Only oral anticoagulation licensed for valvular AF?
= Warfarin
Why does initiating Warfarin require patient to have a cover with LMWH for 5 days?
= Warfarin is initially prothrombotic
What is an acute thoracic dissection?
= occurs when a tear in the tunica intima of the aorta creates a false lumen whereby blood can flow between the inner and outer layers of the walls of the aorta
Aortic Dissections: Standford Type A vs. Standford Type B
Stanford Type A: involves the ascending aorta, arch of the aorta
Stanford Type B: involves the descending aorta
Imaging of choice to diagnose an aortic dissection?
= CT angiogram
Management of aortic dissection (type A vs type B)
Type A: requires surgical management
Type B: normally managed conservatively with BP control
(if evidence of end organ damage than endovascular/ open repair may be performed
Moderate asthma is characterised by which PEF range?
PEF > 50-70%
Severe asthma is characterised by which PEF range?
= PEF 33-50%
33,92 CHEST - mnemonic for features of life-threatening asthma
PEF < 33%
SO2 < 92%
Cyanosis
Hypotension
Exhaustion
Silent chest
Tachyarrhythmias
What is ASA grading used for?
= allows anaesthetists to stratify the overall risk of a patient prior to surgery, and predicts short- and long-term outcomes
ASA grade I
= normal healthy patients, who are non-smokers and with no/ minimal alcohol intake
ASA grade II
= defined as patients with mild systemic disease e.g., well controlled diabetes, or hypertension, current smoker, obesity (BMI 30-40), and mild lung disease
ASA grade III
= defined as patients with severe systemic disease e.g., poorly controlled diabetes or hypertension, COPD, morbid obesity (BMI >40), history of ACS/ stroke/ TIA < 3 months ago
ASA guide IV
= defined as patients with severe systemic disease that is a constant threat to life e.g., MI/ stroke/ TIA within 3 months, severe valve dysfunction, severe reduction in ejection fraction, sepsis
ASA grade V
= defined as moribund patients not expected to survive the operation e.g., ruptured abdominal aortic aneurysm, massive bleed, intracranial haemorrhage with mass effect
ASA grade VI
= defined as a patient declared brain-dead whose organs are being removed for donation
Simple airway manoeuvres (3)
- suction
- head tilt + chin lift
- jaw thrust
Which simple airway manoeuvre can be used when c-spine injury is suspected?
= jaw thrust
Contraindication of using nasopharyngeal airway (NPA)?
= contraindicated in base of skill fracture
What is NEXUS criteria used for?
= used to identify patients at low risk of C-spine injury. C-spine injury is unlikely if all of the criteria is met
Imaging used in suspected c-spine injury
= CT c-spine
(plain x-rays are of limited value and not recommended)
