ASSCC 4

Question 1

What is Cushings triad?

Answer 1

1) Bradycardia
2) Increased systolic BP (increased pulse pressure)
3) Irregular respiratory pattern

Question 2

7 steps to manage pt with high ICP:

Answer 2

1) ABC
2) Intubate if GCS <= 8
3) Sit up
4) Mannitol / furosemide / manage Na+
5) Hyperventilate
6) External ventricular drain
7) Decompressive craniectomy

Question 3

Old lady, critically ill, LIF pain + tenderness. Give 6 ddx:

Answer 3

1) Gastroenteritis
2) Diverticulitis
3) Sigmoid volvulus
4) Acute constipation
5) Pelvic tumour
6) Ureteric colic

Question 4

Define shock:

Answer 4

Acute circulatory failure, with inadequate tissue perfusion causing cellular hypoxia

Question 5

Define sepsis:

Answer 5

Life-threatening organ dysfunction caused by dysregulated host response to infection

Question 6

Quick SOFA score looks at which 3 parameters to assess organ dysfunction?

Answer 6

1) RR >22
2) sBP <100
3) Altered mentation/ reduced GCS

Question 7

Septic shock defined by 3 states:

Answer 7

1) Infection + persistent hypotension after fluid resuscitation
2) Infection + persistent lactate >2 after resuscitation
3) Infection + vasopressor requirement to maintain MAP > 65 in absence of hypovolaemia

Question 8

Mortality of septic shock:

Answer 8

40%

Question 9

Sepsis 6:

Answer 9

1) Give high flow O2
2) Take blood cultures
3) Take blood for serum lactate + Hb
4) IVI fluid resuscitation
5) Measure urine output
6) Give IV Abx

Question 10

Management options of septic pt + diverticular abscess:

Answer 10

1) IR drainage
- No wound infection, less hospital stay, ability to insert pig-tail catheter
- Less adequate drainage, no ability to create stoma

2) Open drainage
- Peritoneal wash-out, ability to create stoma if necessary
- Risk wound infection, high morbidity

Question 11

Risk of performing surgery on 34wk pregnant female:

Answer 11

1) IUFD
2) DVT
3) Pre-term labour

Question 12

Define pre-load:

Answer 12

End diastolic volume which stretches the right or left ventricle to its greatest dimensions

Question 13

What is the body response to decreased blood pressure?

Answer 13

1) Baroreceptors stimulate SNS = ^HR, ^SV, ^SVR = maintains CO + BP
2) Catecholamines from adrenal medulla = peripheral vasoconstriction = ^SVR
3) Mineralocorticoids from adrenal cortex = salt and water retention = maintain BP

Question 14

What are baroreceptors?

Answer 14

• Mechanoreceptors detect pressure change via change in stretch of arterial wall
• Located in carotid sinus + aortic arch
• Supplied by carotid branch of CN IX

Question 15

5 factors affecting venous return:

Answer 15

1) Muscle pump
2) Posture
3) Circulating blood volume
4) Venous tone
5) Inspiration (drop in intrathoracic P = ^venous return)

Question 16

Devices used in DVT prophylaxis:

Answer 16

1) TED stockings

2) Intermittent pneumatic compression devices (flowtrons)

Question 17

Polytrauma pt, assess Airway:

Answer 17

• Cervical spine control, sandbag + tape/hard collar
• If can speak = secure
• If cannot speak:
• Look in mouth for FB
• Assess face for maxillofacial injury
• Jaw thrust
• Oropharyngeal airway
• ETT
• Cricothyroidotomy
• Tracheostomy

Question 18

Polytrauma pt, assess Breathing:

Answer 18

• Inspect any obvious chest injury + symmetrical chest wall mvt
• Count RR
• Palpate for central trachea and surgical emphysema
• Percuss + auscultate for obvious pneumo/haemothorax
• High flow O2
• Needle thoracotomy or chest drain
• Occlusive dressing for open pneumothorax

Question 19

What kind of shock in pneumothorax?

Answer 19

Obstructive

Tension pneumothorax prevents blood from entering right heart during diastole

Question 20

How to assess circulation?

Answer 20

• Inspect any obvious source bleeding
• Pulse rate and character
• Blood pressure
• Class of haemorrhage shock

Question 21

How to manage circulation in polytrauma pt:

Answer 21

• Stop any obvious source of bleeding
• 2 large bore cannula
• Take blood for FBC, U&Es, LFTs, Clotting, G&S, XM, Lactate, Glucose
• XM 4 units
• IV fluid resuscitation
• Blood transfusion if no response to fluid
• Consider Tranexamic acid

Question 22

Polytrauma pt, HR 125, ?class of shock?

Answer 22

Class 3

Question 23

Polytrauma pt, RR 42 ?class of shock?

Answer 23

Class 4

Question 24

Polytrauma pt, HR 112, RR 22, ?class of shock?

Answer 24

Class 2

Question 25

Polytrauma pt, HR 143 ?class of shock?

Answer 25

Class 4

Question 26

What is the estimated blood loss in each class of shock?

Answer 26

Class 1: <750 ml
Class 2: 750-1500ml
Class 3: 1500 - 2000ml
Class 4: >2000ml

Question 27

Grades of liver injury:

Answer 27

Grade 1: Sub-capsular haematoma <10% SA or <1cm capsular tear
Grade 6: Vascular: hepatic avulsion

Question 28

Mx of liver tear:

Answer 28

Conservative: blood transfusion, monitoring
Operative: damage control (perihepatic packing), repair, resection

Question 29

4 areas examined for free fluid on FAST scan:

Answer 29

1) Perihepatic space
2) Perisplenic space
3) Pericardium
4) Pelvis

Question 30

Normal bilirubin levels:

Answer 30

3-30 umol/l

Question 31

At what bilirubin level is jaundice apparent?

Answer 31

> 35 umol/l

Question 32

Why is clotting deranged in liver damage?

Answer 32

• Liver synthesises most clotting factors
• Vit K required to activate clotting factors 2, 7, 9, 10
• In severe liver damage or biliary obstruction = reduced absorption of vitamin K
  = Increased prothrombin time

Question 33

What is alkaline phosphatase?

Answer 33

• Enzyme
• Found in bile canaliculi + bone + placental tissue
• Increases in cholestasis

Question 34

What is the function of bile?

Answer 34

• Emulsification of fat into micelles

- Providing greater SA for enzyme pancreatic lipase

Question 35

What are the constituents of bile?

Answer 35

• Water
• Bile pigment (bilirubin + biliverdin)
• Bile acid
• Bile salt
• Cholesterol
• Lecithin (phospholipid)

Question 36

Give example of bile salt / acid

Answer 36

Sodium glycocholate

Sodium taurocholate