Deck2

Question 1

Functions of bile

Answer 1

Emulsification of fat -> ADEK absorption

Elimination of cholestero

Question 2

Where is bile reabsorbed

Answer 2

terminal ileum

Question 3

How is billirubin formed

Answer 3

RBCs broken down to Haem and globin
Haem converted to biliverdin
Biliverdin = unconjugated bilirubin and iron

Question 4

How is unconjugated bilirubin transported to liver

Answer 4

insoluble

Binds to albumin

Question 5

How is bilirubin conjugated

Answer 5

In liver

Becomes water soluble excreted in bile

Question 6

Relationship between preload and cardiac output

Answer 6

Frank-Starling Law

Increase end diastolic volume, stretches the cardiac muscle, allowing it to contract more forcefully

Question 7

What causes Frank Starling curve to become flatter and shift to right

Answer 7

Reduced contractiliy:
Acidosis
B blockers
Heart failure

Question 8

What makes the Frank Starling curve to shift to left

Answer 8

Increased contractility or reduction in afterload:

- adrenaline

Question 9

Indications for a central line

Answer 9

1. Monitoring
   - CVP
   - CO (Swann-Ganz catheter)
2. Intervention
   - TPN
   - Adenosine rich solution
   - high K content
   - Haemodialysis

Question 10

CVP trace

Answer 10

Question 11

Incision landmarks for fasciotomy for compartment syndrome of leg

Answer 11

Anterolateral: just above ankle to tibial tuberosity
Posteromedial: 5 cm above medial mal to tibial tuberosity

Question 12

Closure of fasciotomy

Answer 12

Should not be closed

Loose subcuticular suture could be place to later reduce the size of the defect

Question 13

Blood test for rhabdomyolysis

Answer 13

CK elevated 5 times normal range

Also AKI

Question 14

Most common cervical fracture

Answer 14

C5

Question 15

What further investigation should be considered when the is a cervical fracture

Answer 15

CT angio of neck damage to carotids

Question 16

Spinal shock fx

Answer 16

Flaccid paralysis
Areflexia
Lack of sensation to spinal cord

Question 17

Neurogenic shock

Answer 17

Lack of sympathetic outflow (unopposed parasympathetic innervation)

Bradycardia
Hypotension

Question 18

Cause of neurogenic or spinal shock

Answer 18

Spinal cord injury/trauma

Question 19

How to test improvement from spinal shock

Answer 19

Bulbocavernous reflex returns:

Tugging on Foley catheter or pressing on clitoris or glans causes contraction of anal sphincter (S2-4)

Question 20

What is autonomic dysreflexia

Answer 20

Autonomic dysfunction to an insult (eg infection or urinary retention) in spinal injury above T6

1. Sympathetic response below level of insult: hypertension and peripheral vasoconstriction
2. Parasympathetic response above the level of insult: bradycardia and vasodilation: headache/blurred vision/CVE

Question 21

Why right IJV preferred over left IJV for central line insertion

Answer 21

Right has a straighter more direct route into SVC and right ventricle

Question 22

Why right IJV preferred over left IJV for central line insertion

Answer 22

Right has a straighter more direct route into SVC and right ventricle

Question 23

Where should the tip of central line be placed

Answer 23

In SVC just before right atrium

Question 24

How to troubleshoot a central line that is not flushing

Answer 24

Make sure no kinks
Slowly move the line whilst pt coughing/deep breathing and flush simultaneously
Anti-thrombolytics such as urokinase could be used

Question 25

Tissues producing ALP

Answer 25

Bile duct epithelial cells Bone Placenta

Question 26

Which of ALT and AST more specific for liver

Answer 26

ALT (L for liver) AST found in heart kidney brain intestine

Question 27

Complications of central line insertion

Answer 27

Immediate: bleeding/ haematoma, pneumothorax Early: pseudoaneurysm, Chylothorax Late: infection, thrombosis

Question 28

Complications of central line insertion

Answer 28

Immediate: bleeding/ haematoma, pneumothorax Early: pseudoaneurysm, Chylothorax Late: infection, thrombosis

Question 29

National guidance for standards of central line insertion

Answer 29

1. USS guided | 2. Post insertion CXR to check position and r/o pneumothorax

Question 30

Where to approach a IJV central line

Answer 30

The apex of triangle between two heads of sternocleidomastoid inserting on to the clavicle and sternum and clavicle itself

Question 31

Step by step of central line insertion through IJV

Answer 31

1. USS to identify IJV and carotid 2. either medial border of SCM at upper border of thyroid cartilage (C4) or apex of the clavicular triangle 3. aim the needle at 30 degrees towards to ipsilateral nipple 4. incision made -> guidewire inserted through dilator -> line inserted of guidewire -> sutured in place

Question 32

Anatomical landmark for central line insertion through subclavian

Answer 32

Inferior surface of midpoint of clavicle, towards jugular notch

Question 33

Anatomical landmark for central line insertion through subclavian

Answer 33

Inferior surface of midpoint of clavicle, towards jugular notch

Question 34

Which layers do you go through when inserting a subclavian line

Answer 34

``` Skin Subcut fascia Pec major Subclavius Subclavian vein ```

Question 35

Blood results for DIC

Answer 35

High PT, APTT, d-dimmer | Low fibrinogen

Question 36

Causes of DIC

Answer 36

Infection Malignancy Trauma Transfusion

Question 37

Define core temp

Answer 37

Temp of blood and internal organs

Question 38

Measurement of core temp

Answer 38

Axilla Rectum Sublingual

Question 39

Consequences of hypothermia

Answer 39

Increased Hb affinity for oxygen ->hypoxia Platelet dysfunction Enzyme dysfunction Cardiac arrhythmia

Question 40

Diverticular abscess mx

Answer 40

<3cm -> conservative with abx ``` Hinchey 1 (>3cm) or 2 -> IR drainage Hinchey 3 and 4 -> Surgery ```

Question 41

Factors determining the area/level of analgaesia achieved with an epidural

Answer 41

Patient position Initial bolus Level that is placed Rate of infusion

Question 42

Clinical sx of hypovolaemic shock

Answer 42

``` Pale, anxious and SHOCKS Sinus tachy Hypotension Oliguria CK cool Klammy peripheries S slow capillary refill ```

Question 43

Difference between spinal and epidural anasthaesia in terms of area of blockade

Answer 43

Spinal: blocks everything below the level of insertion Epidural: segmental blockade (if inserted at T3/4, blocks T2-T6, sparing legs)

Question 44

Consequence of high thoracic spinal block

Answer 44

Paralysis Numbness Respiratory compromise (intercostal nerves) Cardiovascular compromise (loss of sympathetic)

Question 45

Consequence of high thoracic spinal block

Answer 45

Paralysis Numbness Respiratory compromise (intercostal nerves) Cardiovascular compromise (loss of sympathetic)

Question 46

Indications for CT head within 1 hr post trauma

Answer 46

``` GCS >13 or >15 after 2 hrs Seizure >1 vomiting Skull # Base of skull signs Focal neurology ```

Question 47

Indications for CT head post trauma within 8 hrs

Answer 47

>65 Coagulopathy Dangerous mech of injury > 30 min retrograde amnesia before the head injury

Question 48

Indications for ET intubation

Answer 48

``` GCS < = 8 Failure to ventilate/oxygenate Inhalational injuries from burns Maxillofacial fractures Neck injury ```

Question 49

Indications for extradural haematoma conservative (series CTs and neurological obs) mx

Answer 49

1. Extradural haematoma <30cm3 2. <15mm thickness 3. <5mm midline shift 4. GCS>8 and no neurological deficit

Question 50

Cerebral perfusion pressure

Answer 50

``` CPP = MAP - ICP MAP = diastolic + 1/3 pulse pressure ```

Question 51

Causes of raised ICP

Answer 51

Hydrocephalus (infection) Space occupying lesion Bleeding

Question 52

Cushings reflux

Answer 52

Result of raised ICP: Low HR High BP Irregular breathing (Cheyne-Stokes)