Critical Care

Question 1

Dilated pupils
Dry mouth and skin
Hypotension
Urinary Retention
Tachycardia

Answer 1

Tricyclic Antidepressant Overdose

Question 2

Tricyclic antidepressant overdose investigations

Answer 2

ECG: Widened QRS and broad complex tachycardia
ABG: Metabolic acidosis

Question 3

Tricyclic antidepressant overdose management

Answer 3

IV sodium bicarbonate (50mL of 8.4%)
IV fluids (NS)
ECG monitoring

Question 4

Right upper quadrant pain
Nausea and vomiting
Liver failure
-Jaundice
-Encephalopathy
-Lactic acidosis

Answer 4

Paracetamol overdose

Question 5

Paracetamol overdose investigations

Answer 5

Paracetamol (4 hrs post intake)
↑ ALT
↑PT/INR
Hypoglycemia

Question 6

Management of paracetamol overdose

Answer 6

Activated charcoal if presented <1h after intake

IV N-acetylcysteine if at 4h after intake, paracetamol value is above the Tx line

IV N-acetylcysteine of staggered dosing or ingestion of unknown amount irrespective of paracetamol value

Liver transplant in case of liver failure

Question 7

Px with hypophosphatemia, hypomagnesaemia and hypokalaemia in a px that just started with parenteral feeding.

Answer 7

Refeeding syndrome

Question 8

Management of refeeding syndrome

Answer 8

Correction of electrolyte imbalance
IV fluids
Prevention: Feeds should be given slowly with electrolyte supplementation.

Question 9

A 21 YO woman with BMI of 12 was admitted to the medical ward for feeding through nasogastric tube. What electrolyte abnormality should be expected?

Answer 9

Hypophosphataemia.

Starvation> Low glucose = low insulin/high glucagon = increased gluconeogenesis
Depletion of phosphate sotres = hypophosphatemia

Refeeding> high glucose = high insulin = increased cellular uptake of phosphate

Hypophosphatemia from starvation and from refeeding (↑ phosphate demand)

Question 10

Sudden and severe headache (thunderclap headache) with neck stiffness or pain.

Answer 10

Subarachnoid haemorrhage

RF: Hypertension, smoking and polycystic kidney disease (↑berry aneurysm)

Question 11

A 35 YO man attends ED with a severe headache and vomiting for a day. He has neck stiffness and photophobia. His BP is normal and he has mild tachycardia. His CT shows hyperintense areas in the subarachnoid basal cisterns. Which is the most useful drug in this case?
Aspirin, Clopidogrel, Sumatriptan or Nimodipine?

Answer 11

Subarachnoid hemorrhage (the hyperintense areas in the CT is blood)

In SAH cerebral vasospasm can occur 4-12 days later and it is serious.
To diminish this anticipated vasospasm we give Calcium Antagonist for 5-14 days. (Nimodipine)

Question 12

A 32YO presents with the worst headache of his life. He has photophobia, neck stiffness and has vomited multiple times. The CT scan shows no evidence of intracranial bleeding. What is the most appropriate next step?

Answer 12

Lumbar puncture.

When suspecting a SAH but the CT is inconclusive then a LP should be done after 12 hours of the onset of the headache.

CSF is bloody then xanthochromic (yellow) due to billirubin.

Question 13

Skull fracture
Loss of consciousness immediately then lucid interval then deterioration of condition
Blown pupil or pupillary asymmetry due to ↑ ICP

Answer 13

Extradural (epidural) haematoma

Collection of blood between the dura and the skull

The skull fracture causes rupture of the middle meningeal artery

Question 14

Epidural haematoma investigation

What should I look for?

Answer 14

CT head

Bi-convex or lentiform shaped haematoma

Question 15

Extradural haematoma management

Answer 15

Craniotomy or burr hole (in big haematomas)

Conservative in small haematomas

Question 16

Gradually evolving focal neurological deficits, speech difficulties and drowsiness.
It is associated with blunt head injury and may have Hx of anticoagulation.

Answer 16

Subdural haematoma

Question 17

Subdural haematoma investigation.

What should I look for?

Answer 17

CT-Crescent-shaped haematoma

Mx: Craniotomy or burr hole (big haematomas)
Conservative (small haematoma)

Question 18

Chest pain
Shortness of breath
Cough
Triggered by infection (most commonly pneumonia)
Hx of sickle-cell disease

Answer 18

Acute Chest Syndrome

Question 19

Acute Chest Syndrome investigations

Answer 19

Chest X Ray

Monitoring oxygen saturation

Question 20

Acute Chest Syndrome management

Answer 20

Oxygen supplementation
Analgesia
IV fluids
Antibiotics to treat pneumonia

Question 21

Px with breathlessness, haemodynamic instability and leg swelling.

Answer 21

Massive pulmonary embolism

Leg swelling = DVT

Question 22

Pulmonary embolism investigation and management

Answer 22

CT pulmonary angiography

Thrombolysis or surgical embolectomy.

Question 23

Road traffic accident.
Px has chest and abdominal pain. Diminished breath sound on the affected side and the X-ray shows gas bubbles in the pleural cavity.

Answer 23

Diaphragm rupture

Question 24

Road traffic accident. Px has abdominal pain, tenderness in epigastrium and left flank, hypotension.

Answer 24

Splenic rupture.

A FAST scan should be done and a splenectomy may be needed in severe injury.

Question 25

Px with diaphragm rupture. What is the most accurate method for checking the correct placement of a nasogastric tube?

Answer 25

Chest X Ray

Question 26

FAST vs CT scan in a splenic rupture

Answer 26

FAST is done when clinically unstable

CT when clinically stable

Question 27

Px falls form a ladder and receives a bump on his flank. Has haematuria and is hypotensive. What is the most appropriate management?

Answer 27

IV fluids

Urgent CT scan or FAST if CT is not available.

Question 28

Px with hx of asthma, acute breathlessness, ↓SpO2 and poor respiratory a effort.

Answer 28

Status asthmaticus

Salbutamol nebulisation + oxygen
Then
IV hydrocortisone
Then
Ipratropium bromide nebulisation
Then
IV magnesium sulphate
Then
IV salbutamol or aminophylline (by senior clinician)
Then
Intubation and ventilation (by senior clinician)

Question 29

A 6YO boy with breathlessness for the past 12 h presents to the ED. He is drowsy with poor respiratory effort and has a silent chest. He has 86% SpO2 with high flow oxygen and has not taken his nebulisers for a day. What is the most appropriate initial management?
CPAP
IV aminophylline
IV magnesium sulphate
Intubate and ventilate?

Answer 29

Intubate and ventilate

Desaturating despite high flow O2 + SILENT CHEST+ Going into respiratory failure = intubate

Question 30

Complications of electrolyte disturbances post massive blood transfusion
(10 or more units of blood within 24h or 1/2 of his blood volume)

Answer 30

Hypocalcaemia
Hypomagnesaemia
Hyper or hypokalaemia
Metabolic alkalosis

The most importat hypocalcaemia and hyperkalaemia

Hypocalcaemia is caused by citrate toxicity. Each unit of blood contains 3g of citrate that binds easily to calcium. A healthy adult can metabolize 3g of citrate within 5 minutes in the liver, however if the transfusion is greater that 1 unit per 5 minutes, citrate accumulates in the blood and binds to calcium leading to hypocalcaemia.