Day 3 A&E Flashcards

Question

A 28-year-old man with a history of Type 1 Diabetes is found collapsed on the floor at a bus stop. A witness reports that preceding the blackout, the man appeared agitated and confused. On initial assessment, the patient has a GCS of 7 and his blood glucose level is 1.7 mmol/L (4-7 mmol/L). IV access is obtained. **Which of the following is the next best step in management?**

Answer 1

**100ml of 20% glucose IV** This patient is displaying **neuroglycopaenic** symptoms of hypoglycaemia which typically develops when the blood glucose level is * **less than 2.8 mmol/L.** These symptoms include confusion, drowsiness, seizures, slurred speech and loss of consciousness. As this patient has a severely reduced level of consciousness, it is important not to put any glucose replacement in his mouth as this carries the risk of choking and aspiration. Instead, glucose should be given IV at a concentration of either 20% or 10%.

Answer 2

**Aciclovir and Cefotaxime** This man is very ill with signs of an intracranial infection and a worrying drop in GCS. The signs of meningeal irritation with fever and behaviour change are highly suggestive of **meningoencephalitis**. Given the history of repeated seborrheic dermatitis during intercurrent illness and current oropharyngeal candidiasis, it is likely an opportunistic infection secondary to HIV. **Aciclovir covers for HSV-1 and HSV-2.** **Cefotaxime is a 3rd generation cephalosporin and covers for most causes of bacterial meningitis.**

Answer 3

Serotonin syndrome This patient has presented with features of serotonin syndrome, which can occur in patients taking therapeutic doses of serotonin reuptake inhibitors (SSRIs). This syndrome is often confused with neuroleptic malignant syndrome, but the clinical features are distinct. Clinical features of serotonin syndrome can be split into neurological and autonomic. Neurological features are of altered mental state, tremor, ataxia and hyperreflexia. **Autonomic features include** * tachycardia * hypertension * diarrhoea * hyperthermia

Answer 4

This is often confused with serotonin syndrome. It is caused by antipsychotic medications or sudden reduction in dopaminergic drugs (e.g. for Parkinson's disease). It can present with similar autonomic features, but the **predominant neuromuscular feature is of rigidity** (compared to tremor and hyperreflexia in serotonin syndrome).

Answer 5

**IV Magnesium Sulphate and stop any causative medication** The patient's ECG is consistent with Torsades de pointes a **polymorphic** **ventricular** **tachycardia** associated with **prolonged QT.** It must be treated urgently due to the risk of unstable VT or VF leading to sudden cardiac death. **If the patient is haemodynamically unstable, then cardioversion is indicated**

Answer 6

**PCI** The ECG shows ST elevation in leads **aVL**, **V2** to **V5** with reciprocal changes in **II**, **III**, **aVF**. This is diagnostic of a STEMI. The definitive treatment for this is a PCI, involving inserting a stent to reperfuse the affected myocardium.

Answer 7

**Endoscopic clipping** The history of an upper GI bleed in a patient who has NSAID exposure, especially without concurrent protection with acid suppression, is highly suggestive of a bleeding peptic ulcer. Endoscopy is the method of choice for managing bleeding from a peptic ulcer. Therapeutic measures include clipping, thermal coagulation, fibrin, or thrombin.

Answer 8

**Acute pancreatitis** Epigastric pain radiating to the back is characteristic of acute pancreatitis. Patients may also describe that the pain is relieved by leaning forwards. Gallstones and alcohol are the two biggest causes of pancreatitis, accounting for over 70% of cases. Serum amylase and lipase will aid diagnosis.

Answer 9

**Sit the patient upright** The underlying diagnosis is pulmonary oedema. This patient will likely need multiple investigations including ECG, chest X-ray and blood tests. However, the most immediate action that can be performed is to sit the patient upright and improve oxygenation. This patient may well end up receiving furosemide for management of pulmonary oedema. However, in the first instance sitting the patient up may provide immediate symptomatic benefit.

Answer 10

**Bisoprolol** As the patient is over the age of 65 and it is more than 48 hours after onset of symptoms, rate control is preferred over rhythm control. **Rate control options include beta-blocker (e.g. bisoprolol), a non-dihydropyridine calcium channel block (e.g. diltiazem or verapamil) or digoxin.** It is important to check for a history of asthma, as **brittle asthma is a contraindication for beta-blockers due to the potential for bronchospasm.**

Answer 11

**1L of 0.9% NaCl IV STAT** This patient appears severely dehydrated. He has * vomiting * appears lethargic * has a capillary refill time of 4 seconds * a dropping BP * raised sodium level He would need intravenous fluids as soon as possible, hence this is the right answer.

Answer 12

vomiting appears lethargic has a capillary refill time of 4 seconds a dropping BP raised sodium level

Answer 13

**Recommence CPR** This patient has pulseless electrical activity (PEA). **This falls under the 'non-shockable rhythm' branch of the adult advanced life support algorithm.** It is important to minimise interruptions to CPR, which provides vital organ perfusion.

Answer 14

**Haemophilus influenzae B** This patient has acute **epiglottitis**, which is most frequently caused by bacterial infection of the soft tissue structures that are anatomically superior to the glottis. Haemophilus influenzae B (Hib) is the most common cause of epiglottitis in non-vaccinated children.

Answer 15

**Raised anion gap metabolic acidosis** The anion gap is the difference between measured cations and measured anions in the serum. It is calculated by the following equation: * ([Na+] + [K+]) – ([Cl-] + [HCO3]) The normal range is approximately between 10-20 mmol/L. In a raised anion gap metabolic acidosis, there is either endogenous or exogenous acid that leads to a decrease in the bicarbonate (in order to buffer the acid) thereby increasing the anion gap. In DKA, the ketones are the source of the acidosis. Other important causes of a raised anion gap metabolic acidosis include uraemia (in renal failure), lactic acidosis (e.g in sepsis) and ingestion of drugs such as aspirin, methanol and ethylene glycol.

Answer 16

**Intravenous magnesium sulfate** The patient presents with torsades de pointes (TdP), a polymorphic ventricular tachycardia that has occurs due to **QT prolongation** (in this case most likely **secondary to co-prescription of a tricyclic antidepressant** with a macrolide). Treatment is with intravenous **magnesium** **sulphate**, withdrawal of offending drugs, and correction of electrolyte abnormalities.

Answer 17

**Digoxin overdose** **First line is atropine** **Intravenous digoxin-specific antibody (Digibind)** **The ECG reveals reserve tick ST depression with first degree heart block** which is the classic effect seen in digoxin overdose. This patient is experiencing severe digoxin toxicity (the presence of arrhythmia and xanthopsia - yellow vision, haemodynamically unstable) following an overdose of digoxin tablets with suicidal intention. Digoxin-specific antibody (Digibind) is reserved for the reversal of life-threatening overdoses. Digibind binds to molecules of digoxin, making them unavailable for binding at their site of action on cells in the body. The fragment-digoxin complex accumulates in the blood, from which it is excreted by the kidney.

Answer 18

**IV Atropine** The Resuscitation Council (UK) guidelines emphasise that the management of bradycardia depends on haemodynamic compromise and identifying the potential risk of asystole. The factors indicating haemodynamic compromise (and therefore the need for treatment) are shock, syncope, myocardial ischaemia and heart failure. **IV Atropine 500 micrograms is given, and can be repeated every 3–5 min to a total of 3 mg.**

Answer 19

The most important therapeutic action of atropine is the **inhibition of smooth muscle** and glands innervated by **postganglionic cholinergic nerves** It also dilates the pupils

Answer 20

20-40% Carbon monoxide poisoning is a significant complication of exposure to fires, particularly if the fire is within a closed space (e.g. rooms of a house). It can present in non-specific ways and its signs and symptoms depend on the level of carboxylation of the patient's haemoglobin. At this level of COHb lethargy, nausea and disorientation are common presentation. There is reduced oxygen available for cytochrome function which results in abnormal cellular functioning and occasional encephalopathy. Patients can therefore seem disoriented, confused and nauseated and to their detriment be dismissed as intoxicated.

Answer 21

**Computed tomographic pulmonary angiography (CTPA)** This patient has recently had surgery and is presenting with shortness of breath and tachycardia. The most likely diagnosis is a pulmonary embolism (PE). The ECG most commonly demonstrates a sinus tachycardia, although the S1Q3T3 pattern is characteristic (S-wave in lead I, Q-wave and inverted T-wave in lead III). A CTPA will produce images of the pulmonary arteries, which are the blood vessels from the heart to the lungs. This is used to identify any blockages in these vessels.

Answer 22

**Damage to middle meningeal vessels** Damage to the middle meningeal vessels would result in an Extradural haemorrhage (**EDH**). Patients with an EDH usually experience a lucid interval after a recent traumatic incident. This refers to a period where there is temporary improvement in a patient’s condition following injury, after which the condition deteriorates. This patient has a history of a lucid interval following his ski accident. A few days later, he has started to deteriorate, showing signs of raised intracranial pressure (ICP), probably resulting from an extension and worsening of the bleed in his brain.

Answer 23

**Pulmonary embolism** Pulmonary embolism (PE) must always be considered in patients with unexplained hypoxia and/or breathlessness. The swollen and tender right calf is most likely to be deep vein thrombosis, which makes a diagnosis of PE much more likely. The major risk factor in this patient is the recent hip surgery. Sinus tachycardia is the most common ECG finding in PE.

Answer 24

## Footnote generally unwell, lethargy, nausea & vomiting, anorexia, confusion, yellow-green vision arrhythmias (e.g. AV block, bradycardia) gynaecomastia yellow vision

Answer 25

Disseminated intravascular coagulation This is the correct answer. Disseminated intravascular coagulation (DIC) is a syndrome characterised by widespread activation of coagulation pathways, and subsequent depletion of platelets and coagulation factors. Causes include sepsis, haematological malignancies, and major organ dysfunction. Oozing from a cannula size is a classic sign of DIC. The low platelet count and fibrinogen are due to consumption, and prolonged PT due to the consumption of coagulation factors. APTT can be normal or prolonged.

Answer 26

**IV fluid resuscitation** This patient likely has an acute kidney injury secondary to hypovolaemia (i.e. a pre-renal cause), considering he has been nil by mouth, not on any maintenance IV fluids and has a poor urine output. His regular medications can also be nephrotoxic. In this case, IV fluid resuscitation is essential to achieve euvolaemia and improve urine output. If the patient remains nil by mouth he should subsequently be started on maintenance IV fluids.

Answer 27

* **A diagnosis of diabetic ketoacidosis (DKA) is made.** * **0.9% Sodium Chloride 1L over 1 hour** Although there are some controversial areas in DKA management, it is widely accepted that the most important initial management in DKA is fluid replacement. Fluid replacement aims to restore circulatory volume, clear ketones, and correct electrolyte imbalance. A typical adult with DKA has 100ml/kg of water deficit. If the patient is haemodynamically unstable, e.g. systolic blood pressure \< 90, then more aggressive fluid resuscitation would be indicated (e.g. 0.9% sodium chloride 500 mL over 15 minutes).

Answer 28

**IV fluid resuscitation, followed by maintenance, with 0.9% saline** This patient likely has as-yet undiagnosed type one diabetes and this is their first presentation. **The patient is suffering from diabetic ketoacidosis** (DKA), diagnosed by the triad of: * hyperglycaemia (\>11 mmol/L) * ketonaemia (blood ketones \>3.0 mmol/L * or urine dip \>2+ ketones) * and acidosis (blood pH \<7.30) * serum bicarbonate \<15 mmol/L As a result of the uncontrolled hyperglycaemia these patients start to become dehydrated due to the associated polyuria. As the blood becomes hyperosmolar due to the high glucose levels, more and more water is drawn into the circulation from the intra/extracellular space. As the condition progresses and ketonaemia/acidaemia develops, patients may start to vomit and oral intake often decreases. As a result, patients are often profoundly dehydrated on presentation in DKA. Considering the level of dehydration IV fluid resuscitation followed by maintenance is key, as this will not only support tissue perfusion, but will also help to improve the acidosis and ketonaemia. **There are often associated electrolyte abnormalities in DKA;** * potassium, chloride, and sodium are often low. * As such, giving IV fluid is the most important priority in treating DKA.

Answer 29

hyperglycaemia (\>11 mmol/L) ketonaemia (blood ketones \>3.0 mmol/L urine dip \>2+ ketones) and acidosis (blood pH \<7.30) serum bicarbonate \<15 mmol/L

Answer 30

IV thyroxine Timely (but careful) administration of T3 or T4 (thyroxine) is critical for reversal of the patient's symptoms in **myxoedema** **coma**.

Answer 31

**Morphine, Metoclopramide, Aspirin 300mg, Clopidogrel 300mg, GTN spray, PCI** The ECG shows ST elevation in leads aVL, V2 to V5 with reciprocal changes in II, III, aVF. This is diagnostic of a STEMI. As this patient is saturating at 97%, she does not require oxygen. The 2008 BTS guidelines recommend that oxygen therapy should only be administered in patients who are saturating less than 94% as there is an increased mortality risk. These are the most appropriate options for managing a STEMI in the initial setting. The mnemonic MMONAC can be used to remember this. It stands for Morphine, Metoclopramide, (Oxygen if sats \<94%), Nitrates (GTN spray), Aspirin 300 and Clopidogrel 300.

Answer 32

* PEF \<33% * SO2 \<92% or PO2 \<8 * Cyanosis * Hypotension * Exhaustion, altered consciousness * Silent chest * Tachyarrhythmias

Answer 33

## Footnote **Discharge, with follow up in 2 to 4 weeks at the outpatient department** The findings on chest examination and signs on the CXR point to a diagnosis of spontaneous pneumothorax. As this patient does not have any underlying lung disease, this can be considered a primary pneumothorax. Patients with a primary pneumothorax who are asymptomatic and have a pneumothorax measuring \<1cm from the chest rim, as in this case, can be discharged and followed up in 2 to 4 weeks in the outpatient department.

Answer 34

Carbon monoxide poisoning This is a difficult clinical diagnosis to make. Confusion and pink mucosae are typical features of carbon monoxide poisoning. Most patients also present with a headache, and nausea and vomiting. In severe toxicity there may be hyperpyrexia, arrhythmias, extrapyramidal features and coma. Pulse oximetry may be falsely high due to similarities between oxyhaemoglobin and carboxyhaemoglobin. Treatment is with 100% high-flow oxygen via a non-rebreather mask.

Answer 35

**Continue CPR for 2 minutes** After the first shock, CPR should be commenced immediately for a further 2 minutes after which the rhythm can be checked again. The pause in chest compressions in order to check the rhythm and administer the shock should be no longer than 5 seconds.

Answer 36

**Treatment dose of apixaban.** The patient has an acute massive pulmonary embolism (PE) and is in shock. In this instance thrombolysis would be indicated. **However**, the patient has a high risk of haemorrhage due to his recent stroke (an absolute contraindication) and therefore anticoagulation is the next preferred step in management. Current guidance would suggest a DOAC (such as apixaban) in the first instance. **Being over 75 years of age is also a relative contraindication to thrombolysis.**

Answer 37

**Defibrillation** (continuing CPR while defibrillator charges) This is the correct answer according to the UK Resuscitation Council Advanced Life Support Guidelines (2016). **Ventricular fibrillation** and **pulseless** **ventricular** **tachycardia** are shockable rhythms. Therefore, once identified, one shock should be delivered (at least 150 J of energy). **After this, CPR is resumed for two minutes, and rhythm reassessed.**

Answer 38

**Aortic dissection** Aortic dissections commonly present with severe chest pain that is often described as tearing in nature with radiation to the inter-scapular region. In addition, there are many other possible features that can arise due to blood in the artery wall (false lumen) compressing branches of the aorta. These include **paraparesis** (e.g carotid or spinal artery involvement); anuria and loin pain (e.g renal artery involvement); abdominal pain (e.g mesenteric artery involvement) and acute limb ischaemia (e.g subclavian or femoral artery involvement). Aortic regurgitation is also a recognised complication of aortic dissection and results from a proximal dissection that involves the aortic valve leaflets. This would be the likely cause of the patient's murmur. Aortic dissections commonly present with severe chest pain that is often described as tearing in nature with radiation to the inter-scapular region. In addition, there are many other possible features that can arise due to blood in the artery wall (false lumen) compressing branches of the aorta. These include paraparesis (e.g carotid or spinal artery involvement); anuria and loin pain (e.g renal artery involvement); abdominal pain (e.g mesenteric artery involvement) and acute limb ischaemia (e.g subclavian or femoral artery involvement). Aortic regurgitation is also a recognised complication of aortic dissection and results from a proximal dissection that involves the aortic valve leaflets. This would be the likely cause of the patient's murmur.

Answer 39

**Aspirin** * Aspirin overdose initially presents with a respiratory alkalosis due to hyperventilation * This progresses to a metabolic acidosis. * Patients may also experience tinnitus, vomiting and dehydration.

Answer 40

**Give aspirin 300mg PO** This patient has acute coronary syndrome. The history of increasing frequency of chest pain brought on by activity and alleviated by rest is strongly suggestive of crescendo angina. **Without troponin results, it is not yet possible to determine whether this is unstable angina or an NSTEMI.** ECG can initially be normal in both unstable angina and NSTEMI, and serial ECGs should be performed to look for dynamic changes.

Answer 41

IV Ceftriaxone and IV Acyclovir In addition to fever, headache and vomiting, this patient also shows features of altered mental status, personality change and possibly focal neurological deficits. Encephalitis must be suspected and empirical treatment should include an anti-bacterial and anti-viral agent, therefore this is the right answer.

Answer 42

**Give crystalloid IV fluid and assess response** This is the recommended course of action according to the **Advanced** **Trauma** **Life** **Support** **algorithm** **warmed** **crystalloids** should be used for initial resuscitation. Further decisions about whether the patient requires **blood are then made based on the patient’s response to initial fluid.**

Answer 43

**1L IV normal saline over 1 hour** The most important part of diabetic ketoacidosis is not the blood sugar but instead the dehydration (as this is what is most life-threatening). It is therefore important to give IV fluids quickly to restored body fluid volume. The patient's hypernatraemia is a consequence of his dehydration and is only a relative hypernatraemia (i.e. more water has been lost than sodium) therefore there is no problem giving normal saline in this situation.

Answer 44

**Rupture of the interventricular septum** Patients with occlusion of the left anterior descending artery are particularly at risk of rupture of the interventricular septum due to infarction of the septal area. The rupture usually leads to haemodynamic instability, with hypotension and biventricular failure (often largely right-sided). An auscultation a harsh and holosystolic murmur may be heard.

Answer 45

Urgent needle decompression followed by chest drain insertion This patient has a left sided apical pneumothorax, but worryingly the mediastinum is shifted towards the right. This is highly concerning for a tension pneumothorax and needs to be urgently decompressed using a wide bore needle/cannula in the **2nd intercostal space**, **midclavicular line** and followed up with a chest drain.

Answer 46

**Pulmonary embolism (PE)** The patient is at higher risk of developing a PE due to the immobility following his operation. He is describing pleuritic chest pain, is tachycardic and tachypnoeic. Patients may also present with cough and haemoptysis. In severe cases, right heart failure causes dizziness or syncope.

Answer 47

Dexamethasone This patient presents with symptoms of spinal cord compression, and needs urgent neurosurgical review. A loading dose of dexamethasone should be given whilst awaiting specialist advice.

Answer 48

**Stridor** is the term used to describe an **inspiratory wheeze** which occurs when the airway swells, such as in anaphylaxis or in infections such a croup (a viral infection common in young children) or epiglottitis (a bacterial infection which is rarely seen since the introduction of the H. influenzae vaccine into the childhood vaccination regime).

Answer 49

BP 88/58 GTN is notoriously known to cause a decrease in the blood pressure, and is contraindicated in patients whose systolic pressure is less than 90 mmHg. This could potentially cause the patient to have a cardiac arrest. Note that the systolic pressure cut-off should be used in the clinical context appropriately - there is no guarantee the blood pressure will not drop precipitously if it were, for example, 91 mmHg to start with. Other treatments for pulmonary oedema such as morphine and furosemide all cause a fall in the blood pressure, hence it is an important parameter to observe in this context.

Answer 50

**Orthostatic syncope** Also known as orthostatic hypotension or **postural** **hypotension**, this is a diagnosis that is more common in elderly patients and/or those who are taking medications that can cause low blood pressure. This patient is both elderly (so likely has a degree of autonomic dysfunction) and takes medications that may lower his blood pressure (bisoprolol and amlodipine). Factors that support this diagnosis are that the patient had been lying in bed overnight and rapidly stood up in the morning, the episode was preceded by a brief period of dizziness, and the patient rapidly regained consciousness and was behaving normally within a few minutes after the episode.

Answer 51

Aspirin Tinnitus is a characteristic feature of an aspirin overdose. Other symptoms include vertigo, nausea, sweating, hyperventilation and confusion. The ABG shows a **respiratory** **alkalosis** that is secondary to **hyperventilation** induced by the drug stimulating respiratory centres in the brain-stem. A follow-up ABG at a later point may show a **raised anion-gap metabolic** **acidosis**. This is due to aspirin being a salicylate and therefore intrinsically acidic. Management consists of measuring serum salicylate levels and acting accordingly. Options include increasing fluid intake, alkalinising the urine (to facilitate excretion of the drug) and dialysis.

Answer 52

**Insert a needle just left to her xiphoid process, aiming towards her left shoulder** This describes how pericardiocentesis can be done. Pericardiocentesis involves the insertion of a needle into the pericardial sac to relieve over-accumulation of fluid. This can be done to treat cardiac tamponade, which is what this lady has. SLE is a risk factor for the development of cardiac tamponade. This lady also displays Beck’s triad - the combination of raised JVP, hypotension and muffled heart sounds, a feature of cardiac tamponade. She has **Kussmaul’s** sign (rise in JVP with inspiration) and **pulsus** **paradoxus** (drop in systolic blood pressure of about 15 mmHg with inspiration), which are also features of cardiac tamponade.

Answer 53

**Aspirin** The arterial blood gas (ABG) shows a respiratory alkalosis. In salicylate poisoning, for example in aspirin overdose, respiratory alkalosis occurs early due to stimulation of the brainstem medullary respiration centre. **This is later followed by metabolic acidosis. This early respiratory alkalosis may present with shortness of breath alone.** Aspirin is the most common salicylate in regular use and poisoning is common. Management includes possible gastric lavage, activated charcoal, hydration and consideration for dialysis in severe cases.

Answer 54

**Ascending cholangitis** Charcot's triad of ascending cholangitis: * right upper quadrant (RUQ) pain * fever/raised white cell count * jaundice This is an infection of the bile duct which must be treated with systemic antibiotics. **This is NOT Acute cholecystitis** Right upper quadrant pain and fever are features of acute cholecystitis; however, **jaundice indicates obstruction at the level of the common bile duct leading to cholangitis.**

Answer 55

**Reynolds' pentad** describes two further features in addition to Charcot's triad: * shock (low blood pressure) * altered mental state * RUQ pain * Jaundice * fever/raised white cell count **Used to diagnosis ascending cholangitis**

Answer 56

**0.5ml 1 in 1000 adrenaline IM** Angioedema, urticaria, stridor and respiratory distress are important symptoms of anaphylaxis. In this case, the trigger is likely to be a substance in food that this man has consumed. 1 in 1000 adrenaline means 1g (or 1000mg) in 1000mls. This simplifies to 1mg per 1ml of solution. Therefore 0.5mls of 1 in 1000 adrenaline gives a dose of 500 micrograms (0.5mg) of adrenaline. This is the recommended dose for anaphylaxis in patients aged over 12. Further doses can be given at 5-minute intervals if necessary. The preferred route is IM as treatment can be started without gaining IV access. IV administration is also extremely dangerous and should not be performed by anyone other than a trained specialist (e.g. anaesthetist).

Answer 57

**CT abdomen and pelvis with rectal contrast** This patient has developed a colonic anastamotic leak, which is one of the most serious complications of intestinal surgery. This is indicated by his fever, tachycardia, rigid abdomen, and purulent abdominal drain. A CT abdomen and pelvis with rectal contrast can the detect presence and location and degree of a leak which will guide further management. A complimentary or alternative test is a fluoroscopic water-soluble enema.

Answer 58

Hydrocortisone 100mg IM This patient has an iatrogenic Addisonian crisis due to repeated prescriptions of steroids with poor compliance to medications, and no consideration by his prescribers for the effect of previous prescriptions. It is an example of a medical cause of the ‘acute abdomen’. Patients with an Addisonian crisis can present variably such as with shock, abdominal pain or hypoglycaemia. It can be accompanied by mild **hyponatraemia** and **hyperkalaemia**.

Answer 59

**Jaw thrust** According to the UK Resuscitation Council, in a patient with a suspected cervical spine injury, there is a theoretical risk of further damage to the cervical-spine when performing head tilt. Therefore, a jaw thrust should be performed alone. It should be noted, that if there is life-threatening airway obstruction, head tilt should be performed incrementally until the airway opens (patent airway takes priority over potential cervical spine injury).

Answer 60

**Vagal maneuvers** This patient has a narrow complex tachycardia with no adverse features (myocardial ischaemia, syncope, shock, heart failure). Therefore, the most appropriate first step is to attempt vagal maneuvers such as carotid massage or valsalva maneuver (asking the patient to blow into a syringe) which is an attempt to transiently block the atrioventricular node. If this is unsuccessful, IV Adenosine can be given.

Answer 61

**Hypokalaemia** Potassium disturbance is the most common complication of DKA. The presence of small T waves and prolonged PR interval shows that the patient has hypokalaemia.

Answer 62

**Repeat rectal Diazepam 10mg PR** Rectal Diazepam can be repeated once after 10-15 minutes if the first dose is ineffective and IV access has not been established.

Answer 63

**1L 0.9% saline over 1-2 hours** The most important initial step in HHS (Hyperosmolar Hyperglycaemic State) management is reducing serum osmolality by treating the dehydration. The best way to do this is to start by giving normal saline over 1-2 hours. Note that initial resuscitation is slightly slower than in DKA (Diabetic Ketoacidosis). This because the dehydration in HHS develops over a long time period and is more pronounced so should be corrected slightly more cautiously to avoid rapid fluid shifts.

Answer 64

**IV thrombolysis** This patient has a 'massive (high-risk) pulmonary embolus' as he has evidence of haemodynamic instability (systolic blood pressure \< 90 mmHg or a drop of 40 mmHg for 15 minutes or more). The recommended management for a massive PE is thrombolysis, however it should be noted that it carries a significant risk of intracerebral bleeding.

Answer 65

**Reduce oxygen supply to 20%** This patient has started to become drowsier, confused and developed a headache about half an hour after being started on 60% oxygen. In the context of a COPD patient, this must be treated as hypercapnia. The oxygen supply should be reduced immediately. You may also need to do an ABG to assess his arterial pH and pCO2, which will allow you to consider further management options such as NIV.

Answer 66

**Apply 15L/min oxygen via non-rebreathe facemask** The history is consistent with sepsis. The patient is alert and responsive, so there is no suggestion that the airway is compromised. 'Critically ill' patients, including those with sepsis, should receive high-flow oxygen irrespective of their saturations, as per British Thoracic Society guidelines. This is on the basis that there is likely a degree of underlying tissue hypoperfusion and associated hypoxia, even in the presence of normal saturations.

Answer 67

**Prepare and administer 500 micrograms of IM adrenaline (1:1000 concentration)** This patient is showing signs of anaphylactic shock, this is the correct dose/route/concentration of adrenaline to administer in anaphylaxis. This treatment will both help to reduce the airway angioedema, which may cause rapid airway compromise, as well as supporting the circulation by increasing the blood pressure (by increasing peripheral vascular resistance and its intotropic/chronotropic effects).

Answer 68

Whole spine MRI This is the correct answer. Spinal cord compression is a medical emergency and once suspected, must be investigated radiologically. MRI whole spine is the modality of choice which will confirm the diagnosis and assess the likely cause of the compression.

Answer 69

**ABG with co-oximetry** The most likely diagnosis here is carbon monoxide poisoning. Carbon monoxide can be produced by faulty boilers and results in confusion and drowsiness. Pulse oximetry gives a falsely high reading as is it unable to distinguish between carboxyhaemoglobin and oxyhaemoglobin. An ABG should be performed and analysed using a co-oximeter to differentiate between carboxyhaemoglobin and oxyhaemoglobin.

Answer 70

Repeat the troponin and review the patient again As an elderly male this patient has an increased risk of a cardiovascular event. The chest tightness and sweating suggest this could be an ischaemic event. Troponin does not rise until 2 to 3 hours after myocardial infarction and so the troponin needs to be repeated to identify any changes.

Answer 71

Damage to middle meningeal vessels Damage to the middle meningeal vessels would result in an Extradural haemorrhage (EDH). Patients with an EDH usually experience a lucid interval after a recent traumatic incident. This refers to a period where there is temporary improvement in a patient’s condition following injury, after which the condition deteriorates. This patient has a history of a lucid interval following his ski accident. A few days later, he has started to deteriorate, showing signs of raised intracranial pressure (ICP), probably resulting from an extension and worsening of the bleed in his brain.

Answer 72

IV Magnesium Sulphate IV Magnesium Sulphate is the most appropriate treatment for TDPs, which is what this patient has on ECG. Anti-psychotics can cause a prolonged QT interval, which can develop into TDP.

Answer 73

**Start IV crystalloids** Fluid replacement is the most important initial treatment in DKA as there can be severe fluid deficits. Fluid replacement will also help lower blood sugar.

Answer 74

**Pharmacological management only** This patient has clinical features and evidence of a STEMI. ST elevation can last many hours after the episode, and troponin levels reach a peak at about 12 to 24 hours after the episode of chest pain. However, he does not meet the time window for PCI. PCI should only be offered within 12 hours of symptom onset. Beyond 12 hours, PCI can still be offered if the patient has persistent symptoms. In this case, the patient is currently well and asymptomatic. **He has certain contraindications to thrombolysis which include recent stroke (within 3 months) and being currently on anticoagulation.** This patient should only receive pharmacotherapy for his ACS. This usually includes **aspirin**, **Ticagrelor** or **Clopidogrel**, **Fondaparinux** in the acute stages followed by **bisoprolol** and a **statin**.

Answer 75

**Fast Atrial Fibrillation** **Synchronised DC cardioversion** This patient is showing signs of haemodynamic instability: * tachycardia \> 200 * heart failure (pulmonary oedema) * shock The treatment for any tachycardia with adverse features is DC cardioversion, after ABCDE measures have been taken.

Answer 76

**History of anorexia nervosa** There is increased risk of paracetamol toxicity in patients that are in glutathione deplete states. This includes eating disorders, HIV and malnutrition. A history of anorexia nervosa would warrant immediate administration of NAC.

Answer 77

**CT head \<1 hour** Given the history of initial unconsciousness following the head injury, followed by a lucid interval, a diagnosis of an extradural bleed should be considered. This patient has vomited twice since his head injury and has failed to return to GCS 15. NICE recommends a CT head within one hour. Even without knowledge of the specific NICE criteria, this clinical picture should be recognised as an emergency.

Answer 78

**0.9% saline IVI** This patient is severely dehydrated due to **hyperosmolar** **hyperglycaemic** state (**HHS**), as evidenced by: * hypotension * tachycardia * confusion The history of Type 2 diabetes, severe hyperglycaemia, and the lack of other significant examination findings points to the aetiology. He requires resuscitation with IV fluids. Even without knowing the aetiology, this patients' need for fluids and risk of VTE should be recognised.

Answer 79

**Pharmacological management only** This patient has clinical features and evidence of a STEMI. ST elevation can last many hours after the episode, and troponin levels reach a peak at about 12 to 24 hours after the episode of chest pain. However, he does not meet the time window for PCI. **PCI should only be offered within 12 hours of symptom onset.** Beyond 12 hours, PCI can still be offered if the patient has persistent symptoms. In this case, the patient is currently well and asymptomatic. **He has certain contraindications to thrombolysis which include recent stroke (within 3 months) and being currently on anticoagulation.** This patient should only receive pharmacotherapy for his ACS, including **anti-platelet therapy and beta-blockers**

Answer 80

* Tracheal deviation to the left * reduced chest expansion * hyper-resonant percussion on the right * decreased vocal resonance on the right This option describes the typical examination findings in a patient with a tension pneumothorax. A tension pneumothorax may be large enough to shift the trachea to the opposite side. Due to the collection of air in the pleural space, percussion will appear hyperresonant and vocal resonance will be decreased on the same side as the pneumothorax. Other findings may include signs of haemodynamic instability and crepitus over the skin from surgical emphysema.

Answer 81

* **Insert a 16G cannula** * **into 2nd intercostal space** * **mid-clavicular line** * **right side** This patient has a right-sided tension pneumothorax secondary to blunt trauma. A 14-16G cannula (i.e. orange or grey) should be inserted on the ipsilateral side without delay to relieve the tension.

Answer 82

**Venous blood gas** * **pH** and the **bicarbonate** **levels**, * either of which if low will confirm a diagnosis of diabetic ketoacidosis.

Answer 83

**Discharge, with follow up in 2 to 4 weeks at the outpatient department** The findings on chest examination and signs on the CXR point to a diagnosis of spontaneous pneumothorax. As this patient does not have any underlying lung disease, this can be considered a primary pneumothorax. Patients with a primary pneumothorax who are asymptomatic and have a pneumothorax measuring \<1cm from the chest rim, as in this case, can be discharged and followed up in 2 to 4 weeks in the outpatient department.

Answer 84

**Rapid infusion of IV 0.9% Sodium Chloride 1 L** Specific protocol for acute upper gastrointestinal bleed may differ between hospitals; however, this patient is haemodynamically unstable and so must be resuscitated with rapid infusion of crystalloid.

Answer 85

**Addisonian crisis** Addisonian crises (also called acute adrenal insufficiency) is a life-threatening condition resulting from insufficient circulating cortisol levels. Symptoms can be non-specific: lethargy, fever, hypotension, vomiting and diarrhoea. Biochemical features include **hyponatraemia** (most classically), **hyperkalaemia**, **hypoglycaemia** and **hypercalcaemia**. This can occur in patients with existing Addison's disease (which is associated with other autoimmune conditions), or those who have suddenly stopped long-term steroids. Triggers include increased physiological stress during infections, trauma and surgery, or simply due to missed medications. A rarer cause is meningococcal septicaemia causing bilateral adrenal haemorrhage (Waterhouse-Friderichsen syndrome).