Day 1 Flashcards

Question

**Causes of type B lactic acidosis** **(5)**

Answer 1

**Abnormalities in metabolism of lactate** (Type B) * Diabetic ketoacidosis * Cancer * Liver disease * Inborn errors in metabolism * Drugs:Aspirin, Metformin - impairs liver metabolism of lactate

Answer 2

**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).

Answer 3

**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.

Answer 4

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.

Answer 5

**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.

Answer 6

**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.

Answer 7

**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**.

Answer 8

**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.

Answer 9

**Causes of Type II Respiratory Failure (5)** * **COPD** * **Brain stem disease/lesion** * **Bronchitis** * **Motor neuron disease** * **Deformity** e.g. ankylosing spondylitis, kyphoscoliosis

Answer 10

**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.

Answer 11

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.

Answer 12

* Airway * Drug preparation * Monitoring of vital signs * Drug administration * Cricoid pressure

Answer 13

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

Answer 14

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.

Answer 15

**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**

Answer 16

**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.**

Answer 17

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.

Answer 18

* 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

Answer 19

**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.

Answer 20

**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

Answer 21

* Numbness or tingling around the mouth * Restlessness/agitation * Tinnitus * Shivering * Vertigo/dizziness * Subtle tremors of the face and extremities * Hypertension

Answer 22

**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.**

Answer 23

**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.

Answer 24

**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.

Answer 25

**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.

Answer 26

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)**

Answer 27

**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.**

Answer 28

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.

Answer 29

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.

Answer 30

**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**,

Answer 31

**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.

Answer 32

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.

Answer 33

**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.

Answer 34

**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.

Answer 35

An anticholinergic agent, such as **procyclidine** or **biperiden**, can be administered to alleviate the acute dystonic reaction.

Answer 36

**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.

Answer 37

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.

Answer 38

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.

Answer 39

**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

Answer 40

**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.

Answer 41

**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.

Answer 42

**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.

Answer 43

**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.

Answer 44

**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.

Answer 45

**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.

Answer 46

**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**

Answer 47

**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.

Answer 48

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.

Answer 49

Crystalloid = solution containing small molecules e.g. sodium, chloride Colloid = solution containing larger molecules e.g. albumin

Answer 50

25-30mL/kg/day **water** 1mmol/kg/day **sodium** 1mmol/kg/day **potassium** 1mmol/kg/day **chloride** 50–100g/day **glucose** to limit ketosis

Answer 51

**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.

Answer 52

A patient with an extradural bleed will typically present with a ## Footnote **lucid interval prior to collapse**

Answer 53

**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.

Answer 54

Malignant hyperthermia is managed by: * stopping the triggering agent * administrering intravenous **Dantrolene 200mg IV** (a ryanodine receptor antagonist) and restoring normothermia.

Answer 55

The most common cause is * **autosomal** **dominant** **mutation** * in the **ryanodine** **receptor** 1, * increasing **calcium** **levels** in the **sarcoplasmic** **reticulum** * **increasing** **metabolic** rate.

Answer 56

**Presentation of malignant hyperthermia** * increased body temperature * muscle rigidity * metabolic acidosis * tachycardia * increased exhaled carbon dioxide.

Answer 57

**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.

Answer 58

**CT head** The patient has presented with possible f**racture 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).

Answer 59

**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.

Answer 60

Naloxone 400mcg IV This patient has signs and a history consistent with an opioid overdose. The immediate treatment of this is with naloxone.