Day 1 Flashcards
A 26-year-old male has attended the pre-operative assessment clinic before undergoing a tonsillectomy for recurrent tonsillitis.
The anaesthetist elicits a family history from the patient, which reveals that his father and paternal grandfather both experienced malignant hyperthermia following the administration of a general anaesthetic.
His mother and his paternal grandmother have never had an adverse reaction following a general anaesthetic.
What is the chance of this patient having the same reaction after a general anaesthetic?
50%
Susceptibility to malignant hyperthermia is inherited in an autosomal dominant fashion
A 55-year-old woman is scheduled for an elective total hip replacement in 4 months time.
She has a past medical history of troublesome menopausal symptoms, hypothyroidism and hypertension. Her currently prescribed medications are Femoston (estradiol and dydrogesterone), levothyroxine, labetalol and amlodipine.
What advice should be given to her regarding her medications before the surgery?
Stop Femoston 4 weeks before surgery
Advise women to stop taking their COCP/HRT 4 weeks before surgery
Women who take hormone replacement therapy, such as Femoston, should stop taking it 4 weeks before any elective surgeries due to increase in venous thromboembolism risk.
General risk factors for VTE
(11)
- active cancer/chemotherapy
- aged over 60
- known blood clotting disorder (e.g. thrombophilia)
- BMI over 35
- dehydration
- one or more significant medical comorbidities (e.g. heart disease; metabolic/endocrine pathologies; respiratory disease; acute infectious disease and inflammatory conditions)
- critical care admission
- use of hormone replacement therapy (HRT)
- use of the combined oral contraceptive pill
- varicose veins
- pregnant or less than 6 weeks post-partum
Types of VTE prophylaxis
(5)
Mechanical:
- Correctly fitted anti-embolism (aka compression) stockings (thigh or knee height)
- An Intermittent pneumatic compression device
Pharmacological:
- Fondaparinux sodium (SC injection)
- Low molecular weight heparin (LMWH)
- reduced doses should be used in patients with severe renal impairment*
- Unfractionated heparin
- used as an alternative to LWMH in patients with chronic kidney disease*
Advice for patients
Pre-surgical interventions:
Post-surgical interventions:
Pre-surgical interventions:
- Advise women to stop taking their combined oral contraceptive pill/hormone replacement therapy 4 weeks before surgery
Post-surgical interventions:
- Try to mobilise patients as soon as possible after surgery
- Ensure the patient is hydrated
POST EXPOSURE PROPHYLAXIS
Elective Knee surgery
Elective Hip surgery
Elective Knee surgery
- *LMWH for 10 days followed by aspirin (75 or 150 mg) for a further 28 days**
- or*
- *LMWH for 28 days combined with anti-embolism stockings until discharge**
- or*
- *Rivaroxaban**
Elective Hip surgery
- *Aspirin (75 or 150 mg) for 14 days**
- or*
- *LMWH for 14 days combined with anti-embolism stockings until discharge**
- or*
- *Rivaroxaban**
A 73 year old man due to have an elective septoplasty attends the pre-op assessment clinic.
He has a past medical history of hypertension and a ST-elevation myocardial infarction 3 months ago treated with a drug-eluting stent.
His current medications include aspirin 75mg OD, clopidogrel 75mg OD, atorvastatin 80mg ON, ramipril 5mg OD, bisoprolol 5mg OD. Physical examination shows no abnormalities.
His latest ECG and echocardiogram are normal.
Which of the following is the most appropriate peri-operative management for this patient in regards to his current cardiovascular medications? (3)
Discuss with cardiology before changing medications
Usually aspirin and clopidogrel are stopped a week before surgery due to the increased bleeding risk.
However, in patients with drug-eluting stents, altering these medications may lead to stent stenosis.
It is advisable to discuss such patients with cardiology.
A 62 year old undergoes a Whipple’s pancreaticoduodenectomy for early stage pancreatic cancer.
In recovery she is re-catheterised.
You are called to recovery as nurses are concerned that her urine output was previously 40ml/hour but over the last hour she has passed 0ml.
What is the most appropriate initial management?
Check patency of catheter
A patient who has sudden reduction of urine output is a common scenario encountered post-operatively.
In this patient a key piece of information is that their catheter was recently changed.
In patients with a new catheter who suddenly report absolute anuria, the first step is to ensure catheter patency by flushing with water for injection.
A 65 year old gentleman is first on the list to have an elective inguinal hernia repair tomorrow morning.
He has a past medical history of hypertension and type 2 diabetes.
His current medications include
amlodipine 5mg OD
metformin 500mg BD
and gliclazide 40mg BD
Physical examination shows no abnormalities.
His latest HbA1c taken last week is 48mmol/mol.
Which of the following is the best advice to give the patient in regards to his diabetic medication on the day of surgery?
- Omit morning dose of gliclazide
- take metformin as normal
The patient’s recent HbA1c suggests his diabetes is well controlled.
He is first on the operating list and due to have a relatively short procedure.
Therefore there is no clinical need to omit metformin.
Gliclazide is a sulfonylurea and must be admitted due to the risk of hypoglycaemia.
More on the management of diabetic drugs peri-operatively can be found here
A 29 year old female with a history of anxiety presents to the emergency department with shortness of breath and ‘feeling like her heart is beating too quickly’.
She is complaining of bilateral paresthesia in her hands and around her lips.
Given the likely diagnosis, what is her blood gas most likely to demonstrate?
Respiratory alkalosis
This patient is likely to be suffering from panic attacks leading to hyperventilation. This causes a decrease in the partial pressure of carbon dioxide, and a respiratory alkalosis.
Causes of Type I Respiratory Failure (6)
Decreased atmospheric pressure
Ventilation-perfusion mismatch
Shunt
Pneumonia
ARDS
Pulmonary embolism
Definition of Type I Respiratory Failure (2)
Type I respiratory failure shows a low pO2 but a normal pCO2
Definition of Type II Respiratory Failure
(3)
Type II respiratory failure shows a
low pO2
high pCO2
causing an acidosis
Definition of respiratory failure
(3)
Respiratory failure leads to a decrease in the partial pressure of oxygen in the blood due to:
- inadequate ventilation
- poor perfusion
What can cause metabolic alkalosis in terms of ions?
(2)
Metabolic alkalosis is caused either by:
- the loss of hydrogen ions
- excess of bicarbonate ions
A 34 year old gentleman undergoes anaesthesia for a tonsillectomy.
He has never previously undergone general anaesthesia and has a family history of difficult ventilation following anaesthesia.
He is induced with IV propofol and suxamethonium to aid intubation.
His surgery is uncomplicated, however 30 mins later in recovery the patient appears apnoeic and difficulty is encountered with bag mask ventilation.
His observations are as follows:
- blood pressure 120/79mmHg
- pulse rate 76bpm
- respiratory rate 10 breaths per minute
- oxygen saturations 81%
What is the most likely diagnosis?
Suxamethonium apnoea
Pertinent features in the history include no history of previous anaesthesia, suxamethonium use, a family history, rapid desaturation and apnoea.
This points to a diagnosis of suxamethonium apnoea.
It occurs when a patient does not possess the enzymes (plasma cholinesterase) to metabolise suxamethonium leading to sustained activation of the drug on the post-synaptic membrane of the neuromuscular junction.
What is suxamethonium? (2)
How does suxamethonium work? (1)
In which patients is it contraindicated? (2)
What is suxamethonium?
- it is a neuromuscular blocking drug used mainly in surgery as an adjunct to anaesthetic agents
- it causes muscle paralysis which is a necessary prerequisite for mechanical ventilation.
How does suxamethonium work?
- Binding of suxamethonium to the nicotinic acetylcholine receptor results in opening of the receptor’s monovalent cation channel; a disorganized depolarization of the motor end-plate occurs and calcium is released from the sarcoplasmic reticulum.
In which patients is it contraindicated?
- suxamethonium increases intra-ocular pressure
- in patients with penetrating eye injuries or acute narrow-angle glaucoma, as
A 76 year old gentleman attends the pre-op assessment clinic for a total hip replacement.
His past medical history includes hypertension, osteoarthritis, type 2 diabetes and stage 4 chronic kidney disease.
His current medications include:
- ramipril
- metformin
- adcal-D3
He is currently asymptomatic and physical examination shows no abnormalities.
A routine set of bloods reveals a haemoglobin of 85g/L (normal range 135-180g/L) with a mean cell volume of 85fL (normal range 80-100fL).
What is the most appropriate management of this patient’s haemoglobin peri-operatively?
No action required
Generally it is important to screen for and treat underlying anaemia before surgery.
However, in patients with stage 4 CKD a Hb of 85g/L can be a normal baseline and does not necessarily need urgent correction.
As noted from the medication list this patient does not receive erythropoietin injections, however they may be a good candidate in terms of their ongoing management.
A 72 year old lady who underwent epidural anaesthesia for a total knee replacement is recovering on the ward.
She reports ongoing pain which is being managed with regular analgesia via her in situ epidural.
On examination her blood pressure is 90/50 mmHg, heart rate 104bpm, respiratory rate 18bpm, oxygen saturations 98% on room air.
She has received a fluid bolus with 500mL of 0.9% saline with no response.
What is the most definitive management of this patient?
Remove epidural
A well-recognised side effect of epidural anaesthesia is hypotension due to local anaesthesia of sympathetic nerves.
This leads to unopposed parasympathetic activity and therefore the only method of counteracting profound hypotension is removal of the epidural.
A 30 year old male is reviewed in recovery after an open reduction internal fixation of his right lower limb following a fall off a ladder.
He is hypertensive and tachycardic and is complaining of severe, worsening pain in his right leg.
Popliteal and tibial pulses are not palpable.
He has been given 10mg intravenous morphine, 100mg intravenous tramadol and 1g paracetamol in recovery.
What is the next step in the management of this patient?
Urgent fasciotomy
This patient is displaying signs of compartment syndrome, which is due to swelling and an increase in pressure within the fascia of the muscle compartment.
This can quickly lead to loss of blood supply and limb ischaemia, and treatment is with an urgent fasciotomy.
A 76 year old lady has just undergone an emergency laparotomy and is now waiting in recovery.
Her past medical history includes hypertension, peptic ulcer disease and hypercholesterolaemia and osteoarthritis.
Physical examination shows no abnormalities, however she is complaining of ongoing pain despite two oral doses of codeine 30mg and has vomited twice.
What is the most appropriate step in analgesic management?
Morphine 5mg intravenous via patient controlled analgesia
Patient controlled analgesia (PCA) is commonly used to manage post-operative pain.
A PCA will usually have a specified ‘lockout period’ whereby another dose of analgesia cannot be given until this time has elapsed.
Morphine is a strong opioid and is therefore appropriate given that codeine has been ineffective.
A 12 year old boy is brought into the emergency department after a road traffic accident.
He is talking and complaining of pain in his left leg, and discomfort in the back of his neck.
He has been stabilized in a collar and blocks and is awaiting review from the trauma team.
He weighs 40kg.
What is the most appropriate treatment for the management of pain in this patient?
IV morphine
This patient has been involved in a serious, high impact road traffic accident and is likely to be in a lot of pain.
Unlike for patients on the ward, where following the WHO pain ladder is more appropriate, rapid assessment and treatment of his pain with intravenous morphine is the most suitable treatment for him.
A 65 year old gentleman is recovering on the ward 3 hours after a cerebrovascular angiography and coiling for an intracranial aneurysm.
He remains drowsy and has not taken fluid orally since fasting for his procedure.
He has a past medical history of polycystic type 2 diabetes and chronic liver disease.
His current medications include metformin 500mg BD and ramipril 5mg OD.
An arterial blood sample is taken and the results are as follows:
- pH = 7.31 (7.35-7.45)
- pCO2 = 4.8kPa (4.5-6.0)
- pO2 = 11kPa (10-14)
- HCO3 = 18mmol/L (22-28)
- Lactate = 6mmol/L (<2)
What is the most appropriate next step in management?
What does he have?
- 500mL 0.9% saline bolus
- The patient’s arterial blood gas shows a metabolic acidosis.
Metformin can cause a lactic acidosis by impairing lactic acid metabolism in the liver.
In a patient with chronic liver disease this risk is more likely.
Another possible cause of the lactic acidosis may be through pre-renal acute kidney injury from mild dehydration.
A lactic acidosis is initially managed with a fluid bolus. This will improve the renal component to his acidosis although it may not fully treat the liver component.
Causes of Type A lactic acidosis
(7)
Tissue hypoxia (Type A)
- Shock (e.g. cardiogenic, hypovolaemic, haemorrhagic)
- Hypoxia
- Acute mesenteric ischaemia
- Limb ischaemia
- Severe anaemia
- Seizures
- Vigorous exercise
Causes of type B lactic acidosis
(5)
Abnormalities in metabolism of lactate (Type B)
- Diabetic ketoacidosis
- Cancer
- Liver disease
- Inborn errors in metabolism
- Drugs:Aspirin, Metformin - impairs liver metabolism of lactate
A patient is brought into the emergency department following a road traffic accident.
He was the front seat passenger of a car in a head-on collision traveling at 60mph.
He is opening his eyes to speech, complaining loudly of pain in his right lower limb (which has sustained an open tibial fracture) and cannot concentrate on questions being asked.
He is asking for his friend and cannot identify where he is.
He intermittently follows your command to squeeze your fingers with his left hand but cannot do the same with his right.
What is his GCS score?
13
The patient scores as follows; E3 V4 M6.
The GCS score aims to objectively assess a patient’s level of consciousness.
The scale is composed of eye, voice and motor responses. The three values are considered separately as well as combined. Maximum score for eye responses is 4.
Maximum score for voice responses is 5.
Maximum score for motor responses is 6. The minimum score for each type of response is 1.
The lowest possible GCS is 3 (deep coma or death), while the highest is 15 (fully awake person).
A 67 year old male patient is brought into the emergency department after a fall.
He smells strongly of alcohol and appears unkempt.
On examination he does not open his eyes to pain, but groans and withdraws to a painful stimulus.
What is the most appropriate initial management of this patient?
Urgent CT head
This patient has risk factors for a subdural haematoma - decreased GCS, alcohol excess and history of a fall.
A CT head is needed to rule out a bleed.
What is goserelin
Goserelin, sold under the brand name Zoladex among others, is a medication which is used to suppress production of the sex hormones, particularly in the treatment of breast and prostate cancer.
It is an injectable gonadotropin releasing hormone agonist.
A 75 year old man with a diagnosis of metastatic prostate cancer presents to his GP complaining of increasing pain.
He is currently treated with goserelin injections.
His current pain relief regimen consists of;
- 25 mg MST Continus BD
- 10mg Oramorph for breakthrough pain
He is currently using four sachets of Oramorph per day but his pain is not controlled.
What is the single most appropriate regimen to prescribe for this patient to control his pain?
60 mg MST Continus BD and 20 mg Oramorph PRN
The patient is currently on 90mg total morphine sulphate and his pain is not controlled.
It is recommended to increase the dose by 1/3 which would take the total morphine required to 120mg.
- This is best split as two separate 60mg doses
- Breakthrough pain using Oramorph is 1/6 of the total morphine sulphate requirement 120/6 = 20mg.
A 72 year old lady is in recovery following a Hartmann’s procedure for a perforated sigmoid volvulus.
Physical examination shows no abnormalities.
She received a dose of cyclizine 50mg IV intra-operatively, however she is complaining of post-operative nausea and has vomited twice in the last 20 minutes.
What would be the most appropriate anti-emetic to prescribe for her?
Which receptor does it target?
Ondansetron 8mg IV
In order to prevent post-operative nausea and vomiting the recommended method is so called multi-modal analgesia, whereby anti-emetics of different mechanisms are used in combination for their synergistic effect.
Ondansetron is a centrally acting 5HT3-antagonist, but also acts upon chemoreceptors in the gut.
It is therefore ideal for post-operative nausea and vomiting which is often due to irritation of the gut by agents commonly used in anaesthesia.
A 29 year old female with a history of depression and hay fever is brought into the emergency department confused and drowsy.
Her drug history includes amitriptyline and loratadine.
She has a temperature of 37.9 degrees Centigrade, appears flushed, and on examination her pupils are dilated.
Her blood gas shows a pH of 7.25 (7.35-7.45).
What is the likely cause?
What is the most appropriate treatment for this patient?
Sodium bicarbonate
Patients with a suspected tricyclic antidepressant overdose, who are acidotic or have an arrhythmia should be managed according to the ABCDE algorithm and also with sodium bicarbonate.
A 28-year-old motorcyclist is brought into the emergency room after a road traffic accident.
Imaging shows a mid-tibial, displaced fracture, which is treated with open repair and intra-medullary nail insertion, then placed in a cast.
On his first post-operative day, he complains of severe pain in the leg.
He can move both his ankle and knee in all directions without worsening of the pain but screams when you passively plantar flex the foot.
Dorsalis pedis pulse is not felt.
What would be your first step in the management of this patient?
Immediate removal of cast
The cast is adding pressure to a closed compartment and exacerbating this gentleman’s compartment syndrome
removing it would be your first step.
A 59 year old gentleman presents feeling generally unwell.
An arterial blood gas shows a :
pH of 7.31 (7.35-7.45)
pO2 7.5 kPa (>12)
pCO2 of 7.1 kPa (4.3-6).
What type of respiratory failure does this demonstrate?
What are the causes of this type of respiratory failure?
Causes of Type II Respiratory Failure (5)
- COPD
- Brain stem disease/lesion
- Bronchitis
- Motor neuron disease
- Deformity e.g. ankylosing spondylitis, kyphoscoliosis
A 53 year old woman arrives in the anaesthetic room.
She is due to have a laparoscopic fundoplication.
Her past medical history includes polycystic ovarian syndrome and a severe hiatus hernia refractory to medical treatment.
Her current medications;
- atorvastatin 20mg ON
- omeprazole 20mg OD
Her pre-op assessment was normal.
What is the most appropriate method of anaesthetic induction in this patient?
Rapid sequence induction
We are told the patient has a history of a symptomatic hiatus hernia.
In such a patient the risk of aspiration during induction is high, and therefore rapid sequence induction is preferred.
Rapid Sequence Induction Definition
Rapid sequence induction (RSI) is the method of coordinating the administration of rapidly acting induction agents to produce anaesthesia and muscle relaxation
followed by prompt intubation
resulting in a secure airway with the minimal risk of aspiration.
Pre-defined roles for healthcare staff during RSI:
- Airway
- Drug preparation
- Monitoring of vital signs
- Drug administration
- Cricoid pressure
Steps forming the sequence of RSI.
(7)
These can be remembered by the ‘seven P’s’
Preparation
- Involves ensuring the environment is optimised, equipment is available and staff are ready
Preoxygenation
- Involves the administration of high flow oxygen for 5 minutes prior to the procedure
Pretreatment
- May involve administration of opiate analgesia or a fluid bolus to counteract the hypotensive effect of anaesthesia
Paralysis
- The administration of the induction agent (e.g. Propofol or Sodium Thiopentone) and paralysing agent (e.g. Suxamethonium or Rocuronium)
Protection and positioning
- Cricoid pressure should be applied to protect the airway following paralysis. In line stabilisation may be required in some cases.
Placement and proof
- Intubation is performed via laryngoscopy, with proof obtained (direct vision, end-tidal CO2, bilateral auscultation)
Post-intubation management
- Taping or tying the endotracheal tube, initiating mechanical ventilation and sedation agents
A 48 year old patient with a history of type I diabetes mellitus presents with chronic severe pain in both lower limbs.
She describes the pain as burning and shooting.
What is the most appropriate initial treatment for this patient?
Duloxetine
Duloxetine is a serotonin and noradrenaline re-uptake inhibitor considered as one of the first line treatments for diabetic neuropathy. Other first-line medications include amitriptyline, pregabalin and gabapentin for the treatment of chronic pain.
Management of neuropathic pain
(4)
NICE updated their guidance on the management of neuropathic pain in 2013:
first-line treatment*:
- amitriptyline
- duloxetine
- gabapentin
- pregabalin
if the first-line drug treatment does not work try one of the other 3 drugs
- in contrast to standard analgesics, drugs for neuropathic pain are typically used as monotherapy, i.e. if not working then drugs should be switched, not added*
- tramadol may be used as ‘rescue therapy’ for exacerbations of neuropathic pain
A 54-year old male presents to the Emergency Department.
He has had previous overdose attempts and had a background of severe depression for which he takes amitriptyline.
His observations include a
- heart rate of 142bpm
- blood pressure 142/74
- respiratory rate 16 and Sp02 96%
An ECG is performed which shows widened QRS complexes.
What is the most appropriate first-line management?
How does it work?
IV bicarbonate
In this particular case the overdose is likely caused by amitriptyline.
Overdose of amitriptyline and other tricyclic antidepressants is characterised by anticholinergic effects e.g. coma, respiratory depression and tachycardia, alongside sodium channel blockade which causes prolongation of the QRS complex.
Intravenous sodium bicarbonate is the correct management.
IV bicarbonate is the first-line therapy if there is evidence of hypotension, arrhythmias or widening of the QRS interval.
Bicarbonate increases the serum pH and the extracellular sodium. Alkalisation favours the neutral form of the drug thus reducing the amount of active cyclic antidepressants.
How would you treat an amitriptyline overdose?
(2)
IV bicarbonate is the first-line therapy if there is evidence of hypotension, arrhythmias or widening of the QRS interval
Bicarbonate increases the serum pH and the extracellular sodium. Alkalisation favours the neutral form of the drug thus reducing the amount of active cyclic antidepressants.
What is the function of Atropine? (1)
How does Atropine work? (1)
- Atropine is used for symptomatic bradycardia in the absence of reversible causes.
- It inhibits vagal activation on the heart and can therefore temporarily revert tachycardia to a normal sinus rhythm.
Side effects include:
- tachycardia
- pupil dilation
- dry mouth
- urinary retention
- inhibition of sweating (anhidrosis)
- blurred vision
- constipation
What is the function of Adenosine? (1)
How does Adenosine work? (2)
What is a common contra-indication to adenosine? (1)
Adenosine is used to treat patients with supraventricular tachycardias,
They are used if vagal manoeuvres are unsuccessful and work by temporarily blocking the conduction through the atrioventricular node (AV node).
In patients with asthma verapamil should be used in place of adenosine.
A 62 year old lady is undergoing a carpal tunnel release under a right sided brachial plexus nerve block.
Her past medical history includes rheumatoid arthritis and benign paroxysmal positional vertigo.
She has previously undergone nerve block anaesthesia with no complications.
Ten minutes into the procedure she begins to complain of tinnitus and dizziness as well as a tremor and tingling sensation in her upper right arm.
What is the single most likely diagnosis?
Local anaesthetic toxicity
Signs of local anaesthetic toxicity occur following raised plasma concentration which then leads to stimulation of the central nervous system
Symptoms include:
- tinnitus
- tremor
- dizziness
- paraesthesia
Symptoms and signs of local anesthetic poisoning
(7)
- Numbness or tingling around the mouth
- Restlessness/agitation
- Tinnitus
- Shivering
- Vertigo/dizziness
- Subtle tremors of the face and extremities
- Hypertension
A 79 year old female presents with severe, spasmodic back pain.
She has a diagnosis of breast cancer with metastases to the liver and spine.
What is the most appropriate treatment for her pain?
Diazepam
This patient has a diagnosis of metastatic cancer, and control of pain in these patients is important yet very challenging.
According to the NICE guidelines, diazepam is the first line treatment for spasmodic pain in palliative care patients.
A 36 year old female with a history of depression presents with a three month history of headaches.
She takes TDS co-codamol and PRN ibuprofen, and gets headaches almost every day.
She has a history of anxiety, and is otherwise fit and well.
Neurological examination findings are normal.
What is the most appropriate management of this patient?
Stop co-codamol and ibuprofen
This patient is likely to have medication overuse headaches, which is caused by excessive use of analgesia leading to down-regulation of pain receptors.
The most appropriate treatment is to withdraw the analgesia she is currently taking.
A 22 year old lady undergoes epidural anaesthesia for a caesarean section.
The procedure and anaesthetic process were uncomplicated.
She is now recovering on the ward.
Following offset of the epidural she is able to walk again.
Thirty minutes later she complains of back pain, shooting sensations down both legs and one episode of bladder incontinence.
On examination she has loss of sensation at multiple lower limb dermatomes as well as hyperreflexia and increased tone bilaterally in both legs.
What is the single most likely diagnosis?
Epidural haematoma
Epidural haematomas are a rare but serious complication of epidural anaesthesia.
Symptoms and signs are classically consistent with those of cord compression, involving compression of upper motor neurons of both sensory and motor tracts.
A 37 year old banker presents to the emergency department with a severe headache on the right side of his face, worse around his right eye.
On examination, the eye is bloodshot.
What is the best management for this patient?
What is the diagnosis?
Subcutaneous sumatriptan
The history of this patient suggests a diagnosis of a cluster headache, first-line treatment for which is a triptan and 100% oxygen.
What is Sumatriptan?
Sumatriptan, sold under the brand name Imitrex among others, is a medication used to treat migraine headaches and cluster headaches
Sumatriptan’s primary therapeutic effect is in its inhibition of the release of Calcitonin gene-related peptide (CGRP)
A 76 year old patient with a history of chronic obstructive pulmonary disorder is admitted to the acute medical ward with a pneumonia. An arterial blood gas shows a
pH = 7.27 (7.35-7.45)
pCO2 = 7.6 kPa (4.5-6)
pO2 = 8.1 kPa (>12).
What type of respiratory failure does he have?
What is the most appropriate method of delivering oxygen to this patient?
Bi-level positive airway pressure
BiPAP is used to treat type II respiratory failure, which presents with hypoxia and hypercapnia.
A higher inspiratory pressure is used compared to the expiratory pressure, and BiPAP is commonly used in patients with COPD.
A 75 year old woman is brought into the emergency department following a fall down 2 flights of stairs. She is opening her eyes to voice. She fails to answer your questions but is calling out random words and is unable to form a sentence. She moans and withdraws from painful stimuli.
What is her GCS score?
E4V3M4
A 70 year old lady has undergone a total hip replacement.
She is now three days post-op and recovering on the ward.
She has a past medical history of hypertension, chronic liver disease secondary to alcohol excess and gastritis.
Her surgery was uncomplicated from an anaesthetic perspective, however she was noted to need twice the normal weight dependent dose of propofol for anaesthetic induction.
On examination she is noted to be confused and agitated with a marked tremor.
Ten minutes later she begins having a tonic-clonic seizure.
What is the most appropriate next step in management?
Lorazepam 4mg intravenous
This patient is having a seizure secondary to alcohol withdrawal.
This is a common scenario post-anaesthesia, and patients classically require larger doses of an induction agent.
The appropriate treatment of an active seizure is IV lorazepam.
A 72 year old lady is currently undergoing a hysterectomy for uterine cancer. She has a history of hypertension and heart failure.
She is induced with propofol and given fentanyl as an adjunct.
During the first hour of surgery she is given two further doses of fentanyl for ongoing analgesia.
Following the most recent fentanyl dose her blood pressure decreases from 110/79 to 90/65. After a 500ml bolus of 0.9% saline she is still hypotensive.
What is the most appropriate next step in management?
Metaraminol
This patient has been given several doses of fentanyl, a potent opioid which can lead to sympathetic inhibition and significant hypotension.
Metaraminol is an alpha agonist which can counteract this effect and rapidly correct hypotension.
What is Metaraminol used for?
Metaraminol is an alpha agonist which can counteract this effect and rapidly correct hypotension.
Used in surgery, if a patient has received an fentanyl overdose which can leading sympathetic inhibition and significant hypotension,
A 51 year old female is brought into the emergency department after sustaining a fall from a ladder.
She has been secured in a collar and blocks and is awaiting review from the trauma team.
The patient is snoring and not opening her eyes to pain.
She is making incomprehensible sounds and is withdrawing to pain.
She has dark bruising around her eyes and her partner, who has come in with her, says that her face looks like it is ‘caved in’.
She is maintaining saturations of 98% on 15L through a non-rebreathe mask.
What is the most appropriate initial management for this patient?
What does the bruising around her eyes indicate?
Jaw thrust - the airway is not secure
This patient has the classical ‘panda eyes’ sign of a base of skull fracture, and she may has sustained an intracranial bleed, C-spine fracture and other injuries.
Her C-spine has been secured and the focus should now be on ensuring that her airway is maintained.
The best treatment for this patient is intubation and ventilation and transfer to a neurosurgical unit, however since she is currently maintaining her saturations, the most appropriate initial management for this patient is a jaw thrust to open up the airway and try to relieve the snoring.
What are “panda eyes”?
(2)
Classical ‘panda eyes’ are a sign of a base of skull fracture
It may also indicate an intracranial bleed, C-spine fracture and other injuries.
A 72 year old gentleman has been listed for a carotid endarterectomy following a doppler ultrasound of the carotids revealing significant stenosis.
He has a past medical history of hypertension, recurrent TIAs and a metallic mitral valve.
His current medications include amlodipine, warfarin, clopidogrel and atorvastatin.
His target INR range is 3-4.
His latest INR reading a week ago was 3.4.
What is the most appropriate peri-operative management with regards to his warfarin dose?
Stop warfarin and bridge with treatment dose low molecular weight heparin (LMWH) 5 days prior to surgery
Warfarin is typically stopped in the peri-operative period due to the bleeding risk it poses.
However, with a history of recurrent TIAs and a metallic valve this patient is at high risk of further thromboembolic events, and therefore bridging with a LMWH is recommended.
A 25 year old female patient is on the wards recovering from a thyroidectomy for thyroid carcinoma.
The post-operative period has been complicated by nausea, vomiting, and pain around the wound site so she has been prescribed post-operative medication accordingly.
24 hours after surgery she becomes increasingly restless and is noted to have forced extension of the neck, rigid opening of the jaw, and sustained upward deviation of the eyes.
Which drug was most likely cause of this presentation?
What can be done to reverse this?
Treatment with a dopamine antagonist
Metoclopramide appears to bind to dopamine D2 receptors
This describes an acute dystonic reaction most likely secondary to metoclopramide.
Reactions to metoclopramide, an antidopaminergic anti-emetic, can cause acute dystonic reaction, clasically in patients younger than 30 years old and when doses of greater than 30 mg per day are administered.
Metoclopramide should be discontinued.
An anticholinergic agent, such as procyclidine or biperiden, can be administered to alleviate the acute dystonic reaction.
How can dystonia associated with metoclopramide be reversed?
(2)
An anticholinergic agent, such as procyclidine or biperiden, can be administered to alleviate the acute dystonic reaction.
How does ondansetron work?
Serotonin antagonists, such as ondansetron, may be used in the management of post-operative nausea.
Ondansetron is in a class of medications called serotonin 5-HT3 receptor antagonists.
A 28-year-old man is brought into A&E with a reduced level of consciousness.
His friends believe he has ingested large quantities of an unknown substance.
He opens his eyes briefly on pressure on the fingertips, but not in response to voice.
He is making moaning sounds but no words or sentences.
On assessment of his motor response, there is abnormal flexion in response to pain, with no localisation.
What does this patient score on the Glasgow Coma Scale (GCS)?
7
This is the correct answer.
Eye-opening to pain and incomprehensible sounds (moans and groans) each score two points.
Flexion response to pain scores three points.
Remember that when a patient’s GCS is less than 8, intubation must be considered to secure the airway.
A 61 year old lady is brought into the emergency department having been found lying on the pavement with a bleeding head wound.
She opens her eyes and pulls her hand away when a nurse attempts to cannulate her.
She is mumbling a few words but is unable to give her personal details or a history of what has happened to her.
What is her Glasgow Coma Scale?
9
This patient is withdrawing to pain (motor), has inappropriate speech (verbal) and is opening her eyes to pain.
The Glasgow Coma Scale is calculated based on these three aspects, giving a total of 15.
A 52 year old lady has been listed for an elective right hemicolectomy.
She has a past medical history of hypertension, hypothyroidism bladder cancer and Addison’s disease.
Her current medications include;
- hydrocortisone 20mg PO in the morning, 10mg PO in the evening
- fludrocortisone 50mcg PO OD
- amlodipine 5mg PO OD
- levothyroxine 100mcg PO OD
What is the most appropriate management of her steroids prior to surgery?
Switch to an increased dose of IV hydrocortisone peri-operatively and temporarily stop fludrocortisone
Patients on long term steroids must be covered during surgery due to the risk of adrenocortical insufficiency.
IV hydrocortisone alone is sufficient for this during surgery, and oral steroids may be started again 48-72 hours post-op provided the patient is eating and drinking again.
An increased dose of steroid is required to account for the stress response to surgery
A 24 year old gentleman involved in a road traffic collision has been listed for an emergency laparotomy due to a suspected splenic rupture.
He has no medical history of note.
On examination he has guarding, rebound tenderness and left upper quadrant pain.
Following anaesthetic induction his observations are as follows blood pressure 87/42mHg, pulse rate 110bpm, respiratory rate 12 breaths per minute, oxygen saturation 99% on high flow oxygen and capillary refill time 5 seconds peripherally.
What is the most appropriate next step in management?
Blood transfusion
This patient has a suspected splenic rupture and therefore requires a blood transfusion as per the major haemorrhage protocol.
Although crystalloid fluid can be given, in a bleeding patient it is inferior to blood because it has no oxygen carrying potential and may exacerbate bleeding.
An 78 year old female is being managed palliatively for small bowel obstruction secondary to metastatic bowel cancer.
She is currently being treated with subcutaneous morphine, but is complaining of crampy abdominal pain, nausea and increased secretions.
What is the most appropriate pharmacological agent to treat her symptoms?
Hyoscine butylbromide is a muscarinic antagonist that will act to decrease her pain, nausea and secretions by acting to block muscarinic receptors that cause increased gastric secretions and motility.
A 32 year old lady is undergoing anaesthetic induction for a trans-sphenoidal resection of a pituitary macroadenoma.
She receives IV propofol and bag mask ventilation is attempted, however no chest rise and fall is observed and there is no fluctuation in end tidal carbon dioxide.
What is the most appropriate next step in management?
Insert oropharyngeal airway
Following general anaesthesia loss of airway smooth muscle tone is common.
Therefore ventilation without an airway adjunct is unlikely to be successful in isolation.
In these situations it is best to start with a simple airway adjunct such as an oropharyngeal airway.
A 29-year-old man presents to A&E following an assault.
He was hit across the head with an open hand.
There is no suspicion of skull base fracture.
On examination there is a small laceration to the pinna in addition to a ragged, fresh tympanic membrane perforation.
What percentage of traumatic tympanic membrane perforations heal within 8 weeks?
90%
A 56 year old gentleman is undergoing anaesthetic induction for a nasoendoscopy and septoplasty.
He has no medical history of note.
He is induced with IV propofol and fentanyl.
Ventilation is attempted following insertion of a laryngeal mask airway, however no respiratory effort is noted.
Following re-insertion of a laryngeal mask airway ventilation is still not possible.
He has a family history of difficulty ventilating during anaesthesia.
The decision is made to intubate the patient.
Which of the following should be given to aid intubation?
(2)
Rocuronium is a rapid acting muscle relaxant, which relaxes airway smooth muscle to assist intubation
First-line would be suxamethonium except this patient has a history of suxamethonium apnoea.
A 17 year old female is brought into the emergency department after being involved in a fire in her first floor flat.
She is otherwise fit and well.
On admission she is anxious and tearful, and on examination is noted to have soot in her nostrils.
She is currently saturating 93% on 15L via face mask and has a respiratory rate of 21.
On taking a history from her, her voice is hoarse and croaky.
What is the most appropriate management for this patient?
Urgent intubation and ventilation
This patient is displayed signs of smoke inhalation and impending upper airway obstruction - soot in the nasal cavity and a hoarse voice.
Early intubation should always be considered in these patients as the rapidly developing swelling and oedema may quickly lead to total airway obstruction and a difficult or failed intubation.
A 71 year old gentleman has just undergone a left hemicolectomy for malignancy.
He has a history of hypertension and type II diabetes mellitus, but is otherwise fit and well.
He is complaining of severe pain in his abdomen.
- His heart rate is 111
- His blood pressure is 84/56
- saturating 98% on 2L via a nasal cannula.
Which of the following is the next best step in the management of this patient?
500ml bolus of intravenous crystalloid
A fluid bolus would treat the hypotension and tachycardia, as this is likely hypovolemic in origin.
This will not treat the underlying cause of shock, which in this patient is most likely to be a post-operative bleed, requiring surgical intervention.
However, the next best treatment for this patient is to restore blood pressure.
A 30-year-old nulliparous woman is very anxious about labour and delivery and has presented to birth options clinic to discuss the possibility of having a Caesarean section and epidural anaesthesia during labour.
She has conducted some online research and found the following.
What is the site for epidural anaesthesia?
Which of the following statements is correct?
Maternal and foetal distress secondary to hypotension are a recognised complication
Maternal hypotension can be a distressing complication from epidural anaesthesia.
It can be treated with 1L Hartmann’s solution over 20 minutes
The correct site for epidural anaesthesia is L2-3 or L3-4
A 21 year old lady is due to have an elective laparoscopic cholecystectomy in 6 weeks time.
She has no past medical history of note.
Her current medications include:
- microgynon OD
- salbutamol inhaler 2 puffs PRN
What is the most appropriate advice to give regarding her ongoing contraception prior to surgery?
Stop microgynon 4 weeks before surgery
Combined contraceptive preparations increase a patient’s thromboembolic risk which is significant at the time of surgery.
Therefore, it is recommended to stop combined preparations 4 weeks before surgery and use barrier contraception in this period.
A 67 year old gentleman has just undergone an emergency Hartmann’s procedure for a perforated rectal cancer.
He is now waiting in recovery.
He has had a 1 litre bag of 0.9% saline IV over the last 24 hours with no oral intake.
His catheter has drained 1500mL over the last 24 hours.
His weight is 70kg.
Which of the following would be the most appropriate fluid volume to prescribe him over the next 24 hours?
2.5 litres
The NICE guidelines for prescribing maintenance fluids recommend a total volume of 25-30ml/kg/day.
This patient also has a 500mL fluid deficit.
Therefore, a total volume in the range of 2250-2600mL would be most appropriate.
Difference between crystalloid and colloid fluids
(2)
Crystalloid = solution containing small molecules e.g. sodium, chloride
Colloid = solution containing larger molecules e.g. albumin
Normal daily fluid requirements
- Water
- Sodium
- Potassium
- Chloride
- Glucose
25-30mL/kg/day water
1mmol/kg/day sodium
1mmol/kg/day potassium
1mmol/kg/day chloride
50–100g/day glucose to limit ketosis
A 19 year old male is brought into the emergency department after a collapse.
He was involved in a fight 6 hours previously, but his friend reports he was fine afterwards.
He is not opening his eyes, but moans and flexes in response to a painful stimulus.
What is the most likely cause of his collapse?
Extradural haematoma
This patient has the history and symptoms of a patient with an extradural bleed, typically arising due to trauma to the face, and often with a lucid interval prior to collapse.
Characteristics of Extradural haematoma
A patient with an extradural bleed will typically present with a
lucid interval prior to collapse
A 20 year old man is undergoing an emergency appendicectomy.
He has no relevant history of note.
He undergoes rapid sequence induction. 30 minutes into surgery his observations are:
- blood pressure 120/79mmHg
- pulse rate 80bpm
- respiratory rate 18 breaths per minute
- oxygen saturations 98%
- temperature 38.5 degrees
His catheter bag is noted to be draining brown coloured urine.
Given the likely diagnosis, what is the most appropriate management?
Dantrolene 200mg IV
The patient has developed malignant hyperthermia secondary to suxamethonium use during rapid sequence induction.
Initial treatment should be an immediate 2mg/kg bolus of dantrolene.
Management of malignant hyperthermia
(2)
Malignant hyperthermia is managed by:
- stopping the triggering agent
- administrering intravenous Dantrolene 200mg IV (a ryanodine receptor antagonist)
and restoring normothermia.
Mechanism of malignant hyperthermia.
(4)
The most common cause is
- autosomal dominant mutation
- in the ryanodine receptor 1,
- increasing calcium levels in the sarcoplasmic reticulum
- increasing metabolic rate.
Presentation of malignant hyperthermia (5)
Presentation of malignant hyperthermia
- increased body temperature
- muscle rigidity
- metabolic acidosis
- tachycardia
- increased exhaled carbon dioxide.
A 62 year old female is brought into the emergency department with a three day history of a productive cough and fatigue.
She is drowsy but rousable and is able to tell the paramedics her name and date of birth.
She has;
- respiratory rate of 29
- saturations of 95% on high flow oxygen
- blood pressure is 89/65
- pulse is 121
- capillary refill time is prolonged.
- She is pyrexial.
She has no past medical history.
Which of the following is the most appropriate management of this patient?
Intravenous antibiotics
This patient is displaying signs of septic shock.
Intravenous antibiotics should be given within an hour, preferably after blood cultures have been taken, but this should not delay the start of treatment.
Supportive treatment should also be provided, but the most important treatment for sepsis is antibiotics.
A 26-year-old diver has presented to the Emergency Department complaining of blurry vision and watery rhinorrhoea that increases on bending forwards.
He has recently returned from a diving expedition and reports blunt trauma to the head.
Which is the most appropriate next step in the management of this patient?
CT head
The patient has presented with possible fracture of the anterior skull base due to blunt trauma during diving.
Watery nasal discharge should arouse suspicion of CSF rhinorrhoea, especially if discharge is increased on bending forwards.
The current standard in diagnosis of suspected fracture of the anterior skull base is CT (axial and coronal planes).
A 32 year old patient with a history of depression presents with four episodes of severe shooting pain on her right cheek.
Cranial nerve examination is normal, but the patient complains of worsening pain on light touch in the same area.
What is the most appropriate first line treatment for this patient?
Carbamazepine
This patient has symptoms of trigeminal neuralgia, which causes severe pain in the distribution of the trigeminal nerve, particularly in response to light touch.
A 23 year old lady has undergone an elective myomectomy for uterine fibroids. She is currently in recovery.
Her past medical history includes fibroids and asthma.
The patient has never previously undergone general anaesthesia.
Her surgery was uncomplicated from an anaesthetic perspective, however episodes of tachycardia were noted and treated with IV fentanyl.
On examination her breathing is notably shallow, she appears drowsy and confused and her pupils are notably constricted.
Her observations are as follows;
- blood pressure 100/70mmHg
- pulse rate 81 bpm
- respiratory rate 8 breaths per minute
- oxygen saturation 98%
What is the most appropriate next step in management?
Naloxone 400mcg IV
This patient has signs and a history consistent with an opioid overdose. The immediate treatment of this is with naloxone.
