AIP

Question 1

What do leads are present for anterior, lateral, inferior and posterior MI?

Answer 1

• V1, V2, V3 - LAD, anterior MI
• 1, aVL, V5, V6 - circumflex, lateral MI
• 2, 3, aVF, RCA, inferior MI
• V1, V2, V3 ST depression, RCA, posterior MI (also bradycardia)

Question 2

What investigations needed for ACS?

Answer 2

o Observations including ECG
o Bloods
 FBC, U+Es, LFTs and clotting, CRP
 Troponins T and I (3x normal limit, rising), CK, AST, LDH
o Imaging
 CXR to exclude differentials

Question 3

What is the management of STEMI?

Answer 3

Morphine (for pain), cyclizine for nausea, oxygen if <94%, GTN 2mg unless hypo, aspirin 300mg oral and prasugrel (P2Y12 antag), unfractionated heparin before PCI(within 2 hrs)- transfer to CCU.
If fails or triple vessel - do CABG, graft from long saphenous vein or internal mammary artery
thrombolysis - 12 hour - alteplase - repeat ecg after 90min. <50% better = PCI needed still

Question 4

Post MI complication? (DARTH VADER)

Answer 4

Death, Dressler’s, Arrhythmia, Aneurysm, Rupture, Recurrence, Tamponade, HF/CCF, Valve disease, Embolism

Fever, pleuritic pain relieved by leaning forwards, raised ESR
 Dressler’s syndrome tends to occur around 2-6 weeks following a MI
 Treated with NSAIDs
o Bradycardia
 AVN block can occur following inferior MI as the RCA supplies the AVN leading to bradycardia
Persistent ST elevation
 Aneurysm after MI
o Tamponade
 Beck’s triad of raised JVP, low BP, muffled heart sounds
o Acute fall in BP
 Cardiogenic shock following acute LVF - (inotropes and vasodilators eg. Noradrenaline)
o Systolic murmur and pulmonary oedema
 Acute mitral regurgitation due to ischaemia of papillary muscle causing fluid backlog
 POOR SOD (Pour away/stop fluids, sit up, oxygen, loop diuretic IV Furosemide)

Question 5

Secondary prevention of MI (ABCDE)

Answer 5

o Conservative
 Exercise, Mediterranean diet, less alcohol, smoking cessation, cardiac rehabilitation, HTN/DM management, avoid sex for 4 weeks, avoid driving for 4 weeks if not treated with PCI (1 week if treated with PCI)
o Medical ABCDE
 Ace inhibitor Ramipril 10mg OD
 BB (Atenolol)
 Cholesterol (Atorvastatin 80mg OD)
 Dual AP therapy (Aspirin 75mg OD for life + another antiplatelet (clopidogrel, ticagrelor, prasugrel) 12 months)
 ECHO +/- Eplerenone Aldosterone antagonist eg. Eplerenone/Spironolactone if LV dysfunction (EF < 50% on echo_

Question 6

NSTEMI and UA mangement

Answer 6

 Conservative
* Scans (stress ECG, myocardial perfusion scan)
* GRACE score to determine risk of death or MI within 6 months)
* If low risk <3% then conservative
* Diet, exercise, cardiac rehabilitation, HTN/DM management
 Medical
* Medium or high risk GRACE score >3%
o Aspirin plus Fondaparinux if PCI not planned immediately
o Then angiogram and PCI or CABG within 3 days/72 hours
 When to do an angiogram?
* Hypotensive – immediate
* GRACE score >3% - angiogram within 3 days
* GRACE score <3% - angiogram after 3 days

Question 7

Causes of Interstitial Lung Disease

Answer 7

Idiopathic Pulmonary Fibrosis

Iatrogenic
 Nitrofurantoin, methotrexate, amiodarone

Inflammatory
 Sarcoidosis -> Erythema nodosum, uveitis, hypercalcaemia

Infective
- TB

Toxins
- Coal, silicosis, asbestosis
- Farmers’, bird owner

Autoimmune
 SLE, RA

Question 8

What are the signs and symptoms of Interstitial Lung Disease?

Answer 8

• Signs and symptoms
  o Gradual onset sob, non-productive cough, haematemesis, wheeze, chest pain, fever and myalgia
  o Occupational history - smoking, farming, dust, birds, asbestos, coal
  Examination
  o Finger clubbing, cyanosis, wheeze, fine end-inspiratory crackles, tachycardia, RHF

Question 9

What are the investigations needed for Interstitial Lung Disease?

Answer 9

Observations
 Temp, BP, HR, RR, sats
o Blood tests
 FBC, U+E, LFT, CRP, ESR
 Antibodies RF, anti-CCP, ANA, dsDNA

Bedside
 ABG, peak flow, spirometry, ECG
 Restrictive pattern with FEV1/FVC > 0.7 and reduced total lung capacity

o Imaging
CXR, HRCT (honeycombing, nodular opacities, BHL, ground-glass changes), lung biopsy

Question 10

Management of Interstitial Lung Disease?

Answer 10

o Conservative
 Smoking cessation
 Avoid triggers - dust, allergens, coal, asbestos, bird droppings
 Seasonal influenza vaccinations
 Physio
 LTOT
o Medical
 Corticosteroids (if symptomatic) - not for EAA
 Pirfenidone (antifibrosis) - especially for IPF
o Surgical
 Lung transplantation

Question 11

What are the causes of PE?

Answer 11

Cause
o Thrombosis from DVT
o Fat embolism (surgery), amniotic fluid (pregnancy), tumour (cancer), air (trauma)
Pathophysiology
o Causes reduced blood flow to lungs resulting in VQ mismatch
o A massive PE will increase right ventricle afterload and cause right ventricular failure leading to haemodynamic compromise

Question 12

PE presentation

Answer 12

Symptoms
 Pleuritic pain and haemoptysis
 Isolated SOB/dyspnoea/cough
 Circulatory collapse and LOC (a massive PE)/light headedness
Signs
 DVT (cause)
 Hypotension, raised JVP, parasternal heave (RV failure)
 Tachypnoea (most common sign), Tachycardia
 Decreased O2 (VQ mismatch)

Question 13

PE Investigations

Answer 13

NOTE: IF PE SUSPECTED, START DOAC IMMEDIATELY
Observations
Bloods: FBC, U&Es, LFTs, clotting, CRP, d-dimer, troponin
Bedside: ECG (Sinus tachycardia, S1Q3T3)
Wells PE is used to determine the investigations used
o D dimer IF WELLS SCORE IS <4
 If negative, then stop DOAC
 If positive, then CTPA or VQ
 If PE suspected, start DOAC
 If Wells PE <4, do d dimer
 D dimer negative then stop DOAC
If Wells PE >4 or D dimer positive, then do CTPA (gold standard)
If CTPA contraindicated (renal impairment or contrast allergy) then do VQ scan instead
 If CTPA or VQ is negative, stop DOAC
 If CTPA or VQ is positive, continue DOAC

Question 14

WELLs Score for PE

Answer 14

Wells PE is used to determine the investigations used
 Suspected DVT: 3
 PE most likely diagnosis: 3
 Tachycardia: 1.5
 3 days immobilisation in past 30 days: 1.5
 Hx of thrombosis DVT/PE: 1.5
 Haemoptysis/coughing blood: 1
 Malignancy/cancer: 1

Question 15

PE management

Answer 15

Immediate
 A to E and stabilisation
 Senior input as the patient is unwell
Conservative
 If PESI score is low, can be managed as outpatient
Medical
 Start DOAC immediately if PE suspected (Rivaroxaban, Apixaban)
* If provoked: 3 months DOAC
* If unprovoked: 6 months DOAC
 IF ANTIPHOSPHOLIPID SYNDROME OR SEVERE RENAL IMPAIRMENT (<15/min): LMWH plus VKA (Warfarin) instead
 IF MASSIVE PE WITH HYPOTENSION: thrombolysis with 50mg Alteplase bolus is first line
Surgical
 IF REPEATED PEs: can try an IVC filter to stop clots getting into pulmonary circulation

Question 16

PE in pregnancy management

Answer 16

PE in pregnancy
 D-dimer cannot be used as it will be raised
 If leg symptoms, do leg USS first
 If PE suspected, do CXR
 If CXR normal, do leg USS
 If normal, do VQ scan (preferable to CTPA)
 Consult obstetrician

Question 17

What are the causes of COPD excarcebations

Answer 17

 Most common cause is H.Influenza (annual influenza vaccine) and S.pneumoniae (one-off pneumococcal vaccine), or Moraxella
 Rhinovirus is the most common viral cause

Question 18

Investigations for COPD exacerbations?

Answer 18

 Observations
* Temp, BP, HR, RR, sats
 Routine bloods
* FBC, U+Es, LFTs and clotting, CRP
 Bedside
* ABG, peak flow, ECG
 Sepsis six and infection screen
* UOP, lactate, blood cultures, sputum culture
 Imaging
* CXR
o If consolidation then pneumonia, otherwise infective exacerbation of COPD

Question 19

What is the management of COPD Excacerbation

Answer 19

 Immediate
* A to E assessment and stabilisation
* Senior input as this is an unwell patient
* 15L non-rebreathe mask if life threatening, otherwise Venturi titrated to 88 - 92% O2
* REPEAT ABG to assess for hypercapnic respiratory acidosis (need NIV)
 Medical
* OSHIT AE (NV)
* Nebulised SABA salbutamol (2.5mg) +/- SAMA Ipratropium (0.5mg)
* Prednisolone 30mg for 5 days (40mg in Asthma exacerbation)
* IV theophylline with senior input
* Oral antibiotics ONLY IF purulent YELLOW or GREEN sputum or signs of pneumonia
o Amoxicillin (not if penicillin allergy) or clarithromycin (not if long QT syndrome) or doxycycline
* Non-invasive ventilation
o If respiratory acidosis <7.35, then NIV needed in an ITU setting (better outcomes than ET)
o Bilevel positive airway pressure with IPAP and EPAP
o Next step up could be intubation and ventilation

Question 20

What are the different types of bowel ischaemia?

Answer 20

o Acute mesenteric ischaemia
o Chronic mesenteric ischaemia
o Ischaemic colitis

Question 21

What are the causes of mesenteric ischaemia?

Answer 21

 Mostly arterial embolus due to AF, as well as MI, IE
 Venous due to hypercoagulation, tumours, infection
 Also, non-occlusive due to hypovolaemia and blood vessel constriction (COCAINE –> acute mesenteric ischaemia)
Blocks the small bowel

Question 22

Investigations for mesenteric ischaemia

Answer 22

 Observations
 Bloods – FBC, U+Es, LFT, CRP, lactate (ischaemic)
 Bedside – urinalysis, ECG/echo
 Imaging
* CXR and AXR (may show thumb printing due to oedema and inflammation)
* CT Angiography is gold standard

Question 23

Management of mesenteric ischaemia?

Answer 23

 Immediate
* A to E
* Senior input
* Morphine, Oxygen, anti-emetic, NBM
 Medical
* Antibiotics
* Possibly thrombolytics or heparin
 Surgery
* Embolectomy or angioplasty if bowel if viable
* Emergency laparotomy with resection usually required due to necrosis or sepsis

Question 24

Chronic Mesenteric Ischaemia causes investigation and management

Answer 24

o Atherosclerosis of gut blood vessels
o Post-prandial (after food) colicky, transient pain
o Intestinal angina, (also have TIA, angina etc)
o Examination
 Upper abdominal bruit (atherosclerosis)
o Investigation
 Bloods, ECG, CVD RFx, ANGIOGRAPHY is gold standard
o Management
 Surgery
* Angiography and stenting (stent)
* Bypass graft

Question 25

Ischaemic Colitis (large bowel ischaemia usually in spenic region - watershet between inferior and SMA supply

Presentation, investigation, managment

Answer 25

o Can lead to inflammation (thumb-printing), ulceration (bleeding in colonoscopy), and haemorrhage (loose stool with blood)
o Presentation
 Acute abdominal pain in LIF, transient, less severe than acute mesenteric ischaemia, N/V/D, loose stools with BLOOD
o Investigations
 CXR and AXR
 CT
 Colonoscopy: blue swollen mucosa with bleeding
 Barium enema: thumb-printing (mucosal oedema and inflammation)
o Management
 Usually conservative (acute mesenteric ischaemia needs urgent surgery usually)
* IV fluids and rest
 Surgery
* If perforation, necrosis, strictures

Question 26

What is epilepsy?

Answer 26

• A tendency towards unprovoked seizures (2 or more within a year)
• Seizures are synchronised neuronal discharge leading to disturbance of consciousness, behaviour, emotion, motor function, or sensation

Question 27

What are the causes of seizures?

Answer 27

o The majority of cases are idiopathic
o Vascular (stroke, hypertensive encephalopathy, pre-eclampsia), infection (encephalopathy/meningitis), trauma (head injury or cranial surgery), toxins (hepatic, alcohol, TCAs), autoimmune (vasculitis), metabolic (hypoglycaemia, hypocalcaemia, hyponatraemia), neoplasm, neurodegenerative, CNS (tuberous sclerosis, hamartomas)

Question 28

Epilepsy differentials

Answer 28

o LOC
 Vasovagal syncope: short post-ictal period but CAN be associated with twitching/jerking
 Cardiac syncope
o Seizures
 Febrile convulsions
* Recurrent tonic-clonic seizures in children <5 due to viral infection
 Alcohol withdrawal seizures
 Psychogenic non-epileptic seizures/Non-epileptic attack disorder (NEAD)
* Female, mental/psychiatric health, pelvic thrusting, crying, gradual onset
* No tongue biting or raised serum prolactin
* Important to refer to psychiatry

Question 29

Classifiction of epilepsyy

Answer 29

 Generalised
* Motor:
o Stiffening (tonic - contraction and cyanosis)
o Loss of tone (atonic drop attacks)
o Jerking (clonic, myoclonic)
o Tonic-clonic/Grand mal (stiffening/contraction and extension, back arching, then jerking)
* Non-motor:
o Absence/Petit mal (child unresponsive staring for 10 seconds with eyelid fluttering and no loss of tone)
 Focal
* Motor:
o Twitching, jerking
o Automatisms (brief unconscious behaviours): lip licking, rubbing hands
o Spreading from one area to another: Jacksonian march
* Non-motor:
o Auras: thinking, sensation, emotion, experience (Déjà vu, Jamais vu)
 If it lasts more than 5 minutes: status epilepticus
 Other seizure syndromes in children: West’s syndrome, Lennox-Gastaut, benign Rolandic, juvenile myoclonic

Question 30

Seizure history

Answer 30

o Onset: trigger, prodrome, onset
o Character: duration, awareness, motor symptoms (rigid jerking/myoclonic, stiffness/tonic, tonic-clonic, floppy body/drop attack (atonic), absence, automatisms (lip licking, rubbing hands), changing (Jacksonian march))
o Associated symptoms: Aura, light headedness, dizziness palpitations, LOC, seizures, cyanosis, incontinence, trismus/lateral tongue biting, frothing at the mouth, >2 minutes post-ictal phase confusion, fatigue, headache, myalgia, speech difficulty, Injuries (shoulder dislocation), Brief period of ipsilateral paralysis/weakness: Todd’s post-ictal paresis (key stroke ddx)

Question 31

Ix for Epilepsy

Answer 31

o Observations
o Bloods
 Routine, glucose
o Bedside
 Urinalysis, ECG, 24-hr ECG, lying and standing BP, tilt table
o Imaging
 CT
 MRI
 LP
 EEG

Question 32

Immediate and conservative Mx of Epilepsy (including DVLA informing)

Answer 32

o Immediate
 A to E
 Senior input
o Conservative
 Ketogenic diet (high fat, low carb)
 Must inform DVLA and Cannot drive for 12 months after a seizure

Question 33

Generalised(same as myoclonic and tonic seizure) and focal seizure medication

Answer 33

Generalised seizures
* Sodium valproate is 1st line (NOT for women of child-bearing age)
* Lamotrigine is 2nd line (for females)
myoclonic female - levetiracetam

Focal seizures
first line: lamotrigine or levetiracetam
second line: carbamazepine, oxcarbazepine or zonisamide

 Starting treatment
* Only started after a confirmed diagnosis - after a second seizure
* Start with monotherapy and gradually titrate up to maximum
* Consistent supplier
* Baseline FBCs, U+Es, and LFTs before starting

Stopping medication
* If seizure-free for 2 years, consider SLOW withdrawal over 2-3 months
* Relapse risk is highest in first year

Question 34

Tx for Absence seizures (Petit mal)

Answer 34

first line: ethosuximide
second line:
male: sodium valproate
female: lamotrigine or levetiracetam
carbamazepine may exacerbate absence seizures

Question 35

Surgical treatment for epilepsy

Answer 35

 Vagal nerve stimulation
 DBS
 Surgical focal resection

Question 36

GBS signs and symptoms

Answer 36

o Acute ascending neuropathy due to campylobacter infection in the past week leading to cross-reaction of antibodies leading to demyelination
- Signs and symptoms
o Ascending neuropathy from the lower limbs
o Sensory: reduced sensation
o Motor: weakness and reduced reflexes (LMN)

Question 37

GBS Ix

Answer 37

o Observations
 Temp, BP, HR, RR, sats
o Bloods
 FBC, U+Es, LFTs, CRP, lactate, glucose
o Bedside
 Diagnosis: Nerve conduction studies are diagnostic
 Cause: Infection screen (blood, sputum, stool, urine, LP cultures), urinalysis
 Impact:
* LP will show raised protein
* Spirometry is important - reduced FEV1/FVC is an indication for ITU admission
 Cauda equina: DRE
 Claudication: ABPI
 Peripheral neuropathy: B12, folate, glucose

Question 38

Mx of GBS

Answer 38

Immediate
 A to E assessment and stabilisation
 Senior input
 Monitor spirometry for the need for ventilatory support
Medical
 Plasma exchange or IVIG to remove the autoantibodies
 DVT prophylaxis

Question 39

Stroke Differentials

Answer 39

o Todd’s paresis (post epilepsy weakness)
o VITAMIN CDEF
o TIA, amaurosis fugax, cerebellar
o Carotid/vertebral artery dissection

Question 40

Bamford classification of strokes

Answer 40

Question 41

Stroke recognition scoring tools

Answer 41

 General public: FAST criteria
 Medical professionals: ROSIER score (FAST + LV) - Recognition Of Stroke In ER
o Severity of a stroke
* NIH Stroke Severity Scale (NIHSS)
* 11 items: Face, arms, legs, aphasia, dysarthria, visual fields, gaze palsy, inattention, consciousness, ataxia

Question 42

Stroke Examination findings

Answer 42

o CN exam (visual inattention, visual field defect), upper limb, lower limb (UMN lesion - acutely diminished tone, and absent reflexes, weakness –> becomes hypertonic, hyperreflexia, spastic paralysis, Babinski positive), speech (receptive or expressive aphasia, dysarthria), cerebellar (DANISH)
o General examination (AF, carotid bruit - carotid dissection is an important cause)
o Special test: Hoover’s test to differentiate organic/psychogenic cause (if organic, when asked to raise normal leg, the supposed weak leg will flex at the hip)

Question 43

Cerebellar Signs (DANISH)

Answer 43

dysdiadochokinesis
ataxia
nystagmus
intention tremor
scanning dysarthria(stuttered speech)
heel-shin test positivity

Question 44

Ix for strokes

Answer 44

o Observations
o Bloods
* FBC, U&Es, LFTs, ESR/CRP
* CK, glucose, lipids
* NOTE: IF ‘young’ <55 year old with no obvious cause: thrombophilia and autoimmune screening is indicated (syphilis serology, antibodies, clotting)
o Bedside
* ECG, urinalysis, BP lying standing
o Imaging
* CT head
* Urgent NON CONTRAST CT head if within 4.5 hours (candidate for thrombolysis - to exclude haemorrhagic), taking anticoagulants (DOACs, warfarin), GCS <13, getting worse, meningism (headache, neck stiffness, photophobia, N/V, Kernig (pain on extending knee when hip flexed), Brudzinski (knees bend when head is raised lying down)), or severe headache (SAH)
* Indicated in ALL suspected stroke within 24 hours
* Diffusion weighted MRI is gold standard (done at QE)
* Carotid doppler (stenosis, dissection)

Question 45

Mx of stroke

Answer 45

o Overall: Imaging, medication, surgery, secondary prevention. CT angiography within 4.5 hours, Aspirin 300mg for 2 week and Clopidogrel 75mg for life, Thrombolysis with alteplase if within 4.5 hours, Thrombectomy within 6 hours (24 if viable penumbra), Carotid endarterectomy if >70% stenosis. Then Anticoagulation if AF after 2 weeks, Atorvastatin if high cholesterol after 2 days,
o Immediate
* A to E assessment and stabilisation
 Maintain oxygen, fluid status, temperature, glucose (IV insulin)
 Senior input
o Conservative
* Physio, OT, SALT, MUST score +/- NGT/PEG
o Medical
* Aspirin 300mg oral or rectal (if dysphagia) ONCE HAEMORRHAGE EXCLUDED
 Different to MI: Continued for 2 weeks DAILY 300mg Aspirin
 Then 75mg Clopidogrel daily indefinitely
 OR Aspirin PLUS MR Dipyridamole if Clopidogrel not tolerated (diarrhoea, constipation)
* Thrombolysis with Alteplase (tPA) ONCE HAEMORRHAGE EXCLUDED
 IF 1) within 4.5 hours from onset and 2) Once haemorrhage excluded on non-contrast CT head and 3) No contraindications - seizure, head injury, uncontrolled HTN, INR >1.7, GCS <8, abnormal blood glucose, rapidly improving signs
* Anticoagulation and statins
 If AF: start ANTICOAGULATION 14 DAYS AFTER THE STROKE
 If cholesterol >3.5mmol/L: start ATORVOSTATIN 48 HOURS AFTER STROKE
o Surgical
* Thrombectomy (PLUS Aspirin and thrombolysis)
 Within 6 hours
 Within 24 hours IF evidence of salvageable brain matter “viable penumbra” (small infarct volume on CT angiogram or MRI)
* Carotid endarterectomy if >70% stenosis (continue antiplatelets due to risk of clot)

Question 46

TIA definition and key differential

Answer 46

 NEW DEFINITION: transient neurological dysfunction caused ischaemia without infarction
 Hemiparesis, hemisensory loss, cortical signs (dysphagia), vision (monocular loss, amaurosis fugax, hemianopia), cerebellar signs
 Key differential is hypoglycaemia

Question 47

Management

Answer 47

 Conservative
* Not allowed to drive until seen by specialist
* If dysphagia, consider a variable rate insulin
* Specialist neuro rehab ward
 Medical
* Same: 300mg aspirin once bleed excluded
* 75mg Clopidogrel for life
* OR If Clopidogrel not tolerated (diarrhoea), then Aspirin plus MR Dipyridamole
 Referral criteria
* IF repeated “crescendo” TIAs, carotid stenosis, or AF: urgent referral
* IF TIA in the past 7 days: referral within 24 hours
* IF TIA >7 days ago: referral within 1 week
 Surgical
* Same: IF carotid stenosis (doppler US) >70% occlusion : carotid endarterectomy - to remove atherosclerosis

Question 48

Falls Ix and Mx

Answer 48

 Observations
 Bloods including glucose, lipids, clotting, CK
 Bedside urinalysis, ECG
 Imaging consider CXR, AP and Lat hip XR
Management
 Immediate
* A to E
* Senior input
* MDT discussion
 Conservative
* Physio, OT, MUST score (NGT or PEG)
* Close follow-up with GP

Question 49

What is counted as a paracetamol overdose?

Answer 49

> 4g a day
1 dose <1 hour or staggered over 1 hour needs NAC
Dx is with Nomogram, Tx is with charcoal, NAC, and vitamin K, KCH criteria is used for transplantation

Question 50

How does paracetamol overdose present

Answer 50

o The first 24 hours there is some nausea, vomiting, and abdominal pain
o After 24 - 72 hours there is jaundice, RUQ pain, hypoglycaemia, encephalopathy, as well as increased INR
o A key feature is lactic acidosis

Question 51

Paracetamol OD Ix

Answer 51

o NOTE: if paracetamol overdose is likely from the history, initiate treatment before results come back
o Observations
o Bloods
 FBC, U+E, LFTs, clotting, glucose, plasma paracetamol
o Bedside
 ABG (lactic acidosis), ECG

Question 52

Mx of Paracetano,

Answer 52

o Immediate
 A to E and stabilisation + ABG to assess acidosis
 Senior input
 Plot plasma paracetamol on Nomogram
o Conservative
 Refer to psych liaison team
o Medical
 Consult TOXBASE for latest guidelines
 IF WITHIN 1 HOUR: activated charcoal
 Antidote is NAC N-acetylcysteine AKA Parvolex
 Also, a 10mg single dose of vitamin K
- NAC guidelines
o Indications:
 Paracetamol above treatment line on the Nomogram (>150mg/kg at 4 hours (OR if staggered overdose, persistent high LFTs or detectable after 24 hours)
o Infusion over 21 hours
 Bag 1 (150mg/kg in 200ml 5% glucose 1 hr) (repeat blood tests after first bag - stop NAC if fine)
 Bag 2 (50mg/kg in 500ml 4hrs
 Bag 3 (100mg/kg 1000ml 16hrs)
o Commonly causes NON-IgE mediated mast cell release anaphylactoid reaction - urticaria rash and facial flushing (not angioedema)
 Treated by stopping the infusion then restarting at a lower rate. 50mg/kg over 4 hours
 If bronchospasm or O2 saturations fall, give nebulised salbutamol
 IM adrenaline or a peri-arrest call is UNNECESSARY

Question 53

KCH criteria for liver transplantation

Answer 53

o Arterial pH <7.3 at 24 hours after ingestion
o OR ALL OF these 3:
 PT >100 seconds (11 - 13.5) or INR >6.5 (0.8 - 1.1)
 Creatinine >300umol/L
 Grade 3/4 encephalopathy (1: irritability, 2: confusion, 3: incoherence, 4: coma) - asterixis is at grade 2

Question 54

What do you need to examine in a pre op anaesthetic examination?

Answer 54

Neck movement limitation/jaw opening limitation/dentures

Airway assessment: use Mallampati classification and note BMI
See all soft palate and uvula
See half of uvula
See a small gap at end of soft palate
Can only see hard palate

Back examination (if having spinal/epidural): look for skeletal malformations

Question 55

Pre op multisystem examination what do you need to check in general, hands, neck, check, abdomen, calves

Answer 55

General: GCS, limb movements

Hands: cyanosis, warm peripheries, cap refill, peripheral pulses

Neck: JVP, carotid bruits

Chest: heaves/thrills, chest expansion, percussion resonance, lung and heart sounds

Abdomen: tenderness, masses/organomegaly, bowel sounds

Calves: swelling/tenderness, oedema

Question 56

Pre op investigations

Answer 56

Tests that may be required for patients having surgery include:

Blood tests: FBC, U&Es, LFTs, clotting, group and save

ECG

Other tests may be considered in advance
Pregnancy test (if chance of pregnancy)
Echocardiogram (if murmur/heart failure/cardiac symptoms)
Spirometry (if significant lung disease)
Pacemaker check(if have pacemaker)
TFTs (if on known thyroid disease)

Question 57

When do you need to stop warfarin, DOAC, LMWH, unfractionated heparin, aspirin/clipidogrel/pasugrel, insulin, oral hypoglycaemic, diuretic, steroid, COCP

Answer 57

Warfarin 5 days
DOAC - 24 hr (48 for major surg)
LMWH - 24 hr
Heparin - 4 hr
Aspirin - 7 days
Insulin - avoid morning dose
Oral hypoglycaemic- avoid on day of operation
Diuretics - on the day
Steroid - change to hydrocortisone
COCP - 4 weeks

Question 58

What do you need to correct before surgery?

Answer 58

INR - if >1.4, 5-10mg Vit K repeat INR in 6 hrs, if still hgih then prothrombin complex concentrate - discuss with haem,
INR due to liver - 10mg IV vit K, repeat INR in 6 hours
Blood transfusion - <9g/dl,<10g/dl if elderly
Platelet concentrate if platelet <50 x 10^9
correct electrolytes
Correct iron - iron tablet or infusions