Acute Medicine

Question 1

Drugs given for bradycardia?

Answer 1

atropine, isoprenaline and adrenaline

Question 2

Left Bundle branch block on ECG?

Answer 2

Broad QRS complexes

Question 3

ECG abnormalities in PE?

Answer 3

Right bundle branch block
sinus tachycardia
ST segment depression or elevation
the classical S1Q3T3 pattern

Question 4

ECG pericarditis?

Answer 4

Widespread ST elevation and PR depression

Question 5

What is an escape rhythm on ECG?

Answer 5

Escape Rhythms. occurs when sinus node fails to produce an impulse, another focus in the heart takes over the duty and the ensueing rhyhtm is called escape rhythm.

e.g. ventricular escape rhythm

Question 6

Why does complete heart block often have broad QRS complex?

Answer 6

because the ventricular escape rhythm is usually slower

Question 7

ECG changes in hyperkalaemia?

Answer 7

starts with tenting of t waves progresses to extreme bradycardia with sinusoidal pattern where there is no atrial activity and the t wave and qrs are broad and both tall

Question 8

How much adrenaline do you give in anaphylaxis?

Answer 8

500 micrograms IM for adults and children over 12

Question 9

Management of anaphylaxis as well as adrenaline?

Answer 9

establish airway and give high flow O2
IV fluid challenge
chlrophenamine
hydrocortisone

Question 10

Who should you consider anaphylaxis in?

Answer 10

Acute onset
Life threatening ABC issues
usually skin changes

Question 11

Management of acute exacerbation of COPD?

Answer 11

Antibiotics (if purulent sputum or ?pneumonia)
O2 therapy - do an early ABG, usually give O2 through a venturi (titrated using ABG results - maximise without them retaining CO2) unless they are very acutely unwell
Nebulised salbutamol and ipratropium
Steroids - prednisolone 30mg for 5 days

iSOAP - ipratropium, salbutamol, oxygen, antibiotics if required, prednisolone

Question 12

Investigations if COPD exacerbation?

Answer 12

ABG to allow O2 titration
ECG
CXR - rule out pneumonia and check they do not have a pneumothorax
Baseline bloods including a CRP - FBC UandEs
Consider throat swab and sputum sample

Question 13

Explain the difference between NIV and CPAP?

Answer 13

NIV:
this assists with ventilation (which is the whole process of breathing in O2 and breathing out CO2), it has two different pressures to allow this. You use this in type 2 resp failure as you are helping them both breathe in more O2 but also get rid of CO2.

CPAP: this only has one pressure and helps with oxygenation only, it is used in type 1 resp failure where only oxygen is an issue

Question 14

Type 1 vs Type 2 respiratory failure?

Answer 14

type 1 failure is low O2
type 2 is low O2 and high CO2

Question 15

Primary indication for NIV?

Answer 15

Acute exacerbation of COPD where they have not responded to medical therapy (dont use in end of life care though) - often used as last trial before intubating and ventilating someone

Question 16

Criteria for moderate asthma exacerbation?

Answer 16

PEF: 50-75%
RR < 25
HR < 110
can talk in full sentences
PaCO2 low

Question 17

Criteria for severe asthma exacerbation?

Answer 17

PEF: 33-50%
RR > 25
HR >110
cannot talk in full sentences
PaCO2 low

Question 18

Criteria for life threatening asthma exacerbation?

Answer 18

PEF: <33%
Silent chest
Bradycardia
Altered conscious level
Cyanosed
PaCO2 is normal

Question 19

Near fatal asthma attack criteria?

Answer 19

PaCO2 is high
Requires ventilation

Question 20

Explain PaCO2 in asthma?

Answer 20

In asthma you expect PaCO2 to be low as they are hyperventilating. If it is normal this suggests life threatening as ventilation is therefore failing.

Question 21

Management of asthma exacerbation?

Answer 21

any features of life threatening asthma needs referral to ICU urgently

high flow O2 (can reassess if still needs high flow later on with ABG)
nebulised salbutamol
50mg oral prednisolone if can swallow if not 100mg IV hydrocortisone

If poor response
can try nebulised ipratropium

magnesium sulfate and aminophylline are other options but these should involve a senior

Question 22

List the CURB 65 score?

Answer 22

C - new onset confusion
U - urea > 7
R - RR > 30
B - SBP < 90, DBP < 60
65- > 65 yo

score 3-5 = severe, usually need to admit, antibiotics are co-amoxiclav and doxy - admit to hospital
scrore 0-2 = mild/ moderate - antibiotic is amoxicillin - can usually be managed from home

Question 23

Blood pressure =

Answer 23

cardiac output x systemic vascular resistance

Question 24

Causes of hypotension ?

Answer 24

Causes that reduce systemic vascular resistance:
septic shock, neurogenic shock, anaphylactic shock

Causes that reduce cardiac output:
hypovolaemic shock, cardiogenic shock

Question 25

Hypoglycaemia is defined as?

Answer 25

BM < 4 mmol/L

Question 26

Management of hypoglycaemia?

Answer 26

15-20g oral glucose if conscious

if unconsciousness 150-200ml IV 10% glucose or 75ml 20% glucose (ie 15-20 glucose)

Question 27

Define DKA?

Answer 27

blood ketones > 3 mmol or urinary ketones +++
metabolic acidosis
hyperglycaemia

Question 28

Management of DKA?

Answer 28

Fluids and IV insulin
When glucose is < 14 mmol/L commence 10% glucose
Continue usual long acting insulin (omit short acting)

Question 29

Define HHS?

Answer 29

Hypovolaemia
Marked hyperglycaemia
Osmolality > 320 mmol

Question 30

How to calculate serum osmolality?

Answer 30

2Na + glucose + urea

normally 275-295

Question 31

Management of HHS?

Answer 31

Give fluids 0.9% saline
usually do not need to give insulin
identify underlying cause