ASSCC 3

Question 1

Management of Addisonian crisis:

Answer 1

1) CCrISP
2) Hydrocortisone 100mg IV / IM bolus
3) Continuous infusion Hydrocortisone 200mg / 24hrs
4) 1L Normal saline IV over 1st hour
5) IV fluids usually 4-6L over 24hrs
6) Urgent endocrinologist r/v

Question 2

At what dose of daily steroid should you add steroid on day of surgery to prevent addisonian crisis?

Answer 2

> 10mg steroid/day

Question 3

Causes of post-thyroidectomy hypocalcaemia:

Answer 3

1) Removal of parathyroid glands

2) Ischaemia of parathyroid glands (inf thyroid artery damage)

Question 4

How is calcium transported in blood?

Answer 4

50% unbound, ionised
45% bound to plasma proteins
5% ass/w anions (citrate, lactate)

Question 5

7 functions of Ca2+:

Answer 5

1) Muscle contraction
2) Neurotransmitter
3) Bone mineralisation
4) Enzyme activation
5) Glycogen metabolism
6) Cell division
7) Blood coagulation

Question 6

3 hormones involved in calcium homeostasis:

Answer 6

1) Parathyroid hormone
2) Calcitriol
3) Calcitonin

Question 7

Effect of PTH on Ca2+:

Answer 7

1) Bone resorption ^Ca2+
2) Renal reabsorption ^Ca2+ (in exchange for phosphate)
3) Stimulates 1α-hydroxylase in kidneys = ^calcitriol formation

Question 8

Effect of calcitriol on Ca2+:

Answer 8

1) Gut absorption ^Ca2+
2) Renal reabsorption ^Ca2+ (and phosphate)
3) Bone resorption (+calcification)

Question 9

Effect of calcitonin on Ca2+ :

Answer 9

1) Inhibits bone resorption when Ca2+ > 2.6

2) Stimulates renal excretion Ca2+

Question 10

3 organs involved in calcitriol formation:

Answer 10

1) Skin
2) Liver
3) Kidneys

Question 11

Signs of hypocalcaemia:

Answer 11

1) Cramps
2) Irritation
3) Peripheral/circumoral parasthesia
4) Spasms/tetany
5) Chvostek’s sign - tap ant to tragus
6) Trosseau’s sign - tap on median nerve with BP cuff on

Question 12

Which muscle are you worried about in hypocalcaemia?

Answer 12

Laryngeal muscles - laryngospasm

Question 13

Treatment of hypocalcaemia:

Answer 13

1) CCrISP
2) Cardiac monitoring
3) 10ml of 10% Calcium gluconate IV
4) 10-40ml of 10% calcium gluconate in saline infusion over 4-8hrs
5) Fluid resuscitation

Question 14

7 ADRs of opioids:

Answer 14

1) Respiratory depression
2) N&V
3) Constipation
4) Hypotension
5) Confusion
6) Itching
7) Pin-point pupil

Question 15

7 Complications of pain:

Answer 15

1) ^HR
2) ^BP
3) MI
4) Delayed gastric emptying
5) Reduced bowel motility / paralytic ileus
6) Atelectasis + retained secretions, pneumonia
7) Immobility -> DVT

Question 16

5 problems with PCA:

Answer 16

1) Pt must be alert and orientated
2) May break/run out of battery
3) Sleep disturbance
4) Not suitable for confused pts or pts who physically cannot press button
5) Limits pts mobility

Question 17

Difference between T3 and T4:

Answer 17

T3 = more biologically active, less protein bound
T4 = less active, more protein bound

Question 18

5 steps of synthesis of T3 + T4:

Answer 18

1) Iodide ions enter follicular cell
2) Iodide to Iodine via TOP
3) Iodine + Tyrosine –> MIT + DIT
4) MIT + DIT -> T3
5) DIT + DIT -> T4

Question 19

? cause anaemia in hashimotos thyroiditis:

Answer 19

Macrocytic anaemia

Due to B12 deficiency (anti parietal autoantibodies = lack of intrinsic factor)

Question 20

5 causes of primary hypothyroidism:

Answer 20

1) Autoimmune- Hashimoto’s
2) Iatrogenic - Thyroidectomy, Carbimazole
3) Transient thyroiditis - Dequervains
4) Iodine deficiency
5) Infiltrative - Sarcoidosis, Amyloidosis

Question 21

8 signs hypothyroidism:

Answer 21

1) Cold intolerance
2) Weight gain
3) Constipation
4) Bradycardia
5) Myxoedema
6) Memory loss
7) Muscle weakness
8) Pretibial oedema

Question 22

7 Indications for CT head < 1 hr:

Answer 22

1) GCS < 13 initial assessment
2) GCS <15 2hrs post injury
3) >1 episode vomiting
4) Suspected open or depressed skull fracture
5) Any sign of basal skull fracture
6) Post traumatic seizure
7) Focal neuro deficit

Question 23

5 Indications for CT head < 8 hrs:

Answer 23

1) >65
2) Anticoagulation
3) Dangerous mechanism of injury
4) > 30 mins of retrograde amnesia
5) Bleeding or clotting disorder

Question 24

Normal ICP:

Answer 24

7-15 mmHg

Question 25

Describe Monroe-Kellie hypothesis in 3 sentences:

Answer 25

1) Skull is fixed bow containing 3 components: brain, CSF, blood
2) Increase in volume of 1 component = reduction in volume of another component to compensate
3) Once ICP >25mmHg, small increase in brain vol cause marked elevation in ICP

Question 26

Define lucid interval:

Answer 26

Temporary improvement in patient condition after traumatic brain injury after which the condition deteriorates with rapid decline of consciousness

Question 27

Cerebral perfusion pressure is defined as:

Answer 27

MAP - ICP

Question 28

MAP auto-regulation range is:

Answer 28

50 - 150 mmHg

Question 29

7 signs increased ICP:

Answer 29

1) Decreased GCS
2) Dilated pupil - oculomotor nerve palsy
3) Papilloedema
4) Defective lateral gaze - abducens nerve palsy
5) Headache
6) Nausea and vomiting
7) Cushings triad: ^sBP (widened pulse pressure), bradycardia, irregular RR

Question 30

8 Indications for intubation:

Answer 30

1) GCS <= 8
2) Risk of raised ICP due to agitation
3) Inability to control/protect the airway or loss of protective laryngeal reflexes
4) A fall of 2 or more points in the motor component of GCS
5) To optimise oxygenation and ventilation
6) Seizures
7) Bleeding into mouth/airway
8) Bilateral fractured mandible

Question 31

In case of raised ICP, how could you improve venous drainage?

Answer 31

• Elevate head of bed to 30’
• Good neck alignment, head in neutral position
• Ensure ties from ETT not compressing neck veins
• Immobilise neck with sandbag and collars rather than restrictive collars

Question 32

In case of raised ICP, how could you reduce cerebral oedema?

Answer 32

• Mannitol = osmotic diuretic
• Furosemide = loop diuretic
• Maintain serum Na+ within normal range

Question 33

In case of raised ICP, how could you reduce cerebral metabolic rate for oxygen?

Answer 33

• Close temperature regulation
• Use sedation and anaesthetic drugs
• If witnessed seizure consider anticonvulsant Levetiracetam (Keppra)
• If intractable consider Sodium Thiopental infusion

Question 34

In case of raised ICP, how could you reduce intracranial blood volume?

Answer 34

Induce hyperventilation

• Breath off CO2
• CO2 = vasodilator

Question 35

In case of raised ICP, what surgical procedures to relieve ?

Answer 35

1) External ventricular drain

2) Decompressive craniectomy