emergency and acute med

Question 1

alternative treatment to atropine/transcutaneous pacing for a symptomatic bradycardia

Answer 1

Isoprenaline/adrenaline infusion is an alternative treatment to atropine/transcutaneous pacing for a symptomatic bradycardia

Question 2

Dressler’s syndrome typical presentation

Answer 2

A man presents with central, pleuritic chest pain and fever 4 weeks following a myocardial infarction. The ESR is elevated - Dressler’s syndrome

Question 3

Acute coronary syndrome poor prognostic factors

Answer 3

Question 4

The following groups of patients are at an increased risk of developing hepatotoxicity following a paracetamol overdose:

Answer 4

• patients taking liver enzyme-inducing drugs (rifampicin, phenytoin, carbamazepine, chronic alcohol excess, St John’s Wort)
• malnourished patients (e.g. anorexia nervosa) or patients who have not eaten for a few days
• HIV
• P450 inducers

Question 5

Organisms causing post splenectomy sepsis:

Answer 5

Streptococcus pneumoniae
Haemophilus influenzae
Meningococci

Question 6

patient has an acidosis with a normal anion gap. There are several causes of this including:

Answer 6

Causes of a normal anion gap or hyperchloraemic metabolic acidosis
* gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
* renal tubular acidosis
* drugs: e.g. acetazolamide
* ammonium chloride injection
* Addison’s disease

Question 7

The anion gap is calculated by:

Answer 7

(sodium + potassium) - (bicarbonate + chloride)

A normal anion gap is 8-14 mmol/L

Question 8

Causes of a raised anion gap metabolic acidosis

Answer 8

lactate: shock, hypoxia
ketones: diabetic ketoacidosis, alcohol
urate: renal failure
acid poisoning: salicylates, methanol
5-oxoproline: chronic paracetamol use

Question 9

A patient is noted to have persistent ST elevation 4 weeks after sustaining a myocardial infarction. Examination reveals bibasal crackles and the presence of a third and fourth heart sound

Answer 9

left ventricular aneurysm

Question 10

The most common organism causing neutropenic sepsis

Answer 10

Coagulase-negative, Gram-positive bacteria such as Staphylococcus epidermidis are the most common cause of neutropenic sepsis

Question 11

investigation of choice for PE in renal impairment

Answer 11

Pulmonary embolism and renal impairment → V/Q scan is the investigation of choice

Question 12

treatment of choice for methotrexate toxicity

Answer 12

folinic acid

Question 13

If clopidogrel is contraindicated or not tolerated, give…for secondary prevention following stroke

Answer 13

If clopidogrel is contraindicated or not tolerated, give aspirin for secondary prevention following stroke

Question 14

when do you thrombolyse in PE

Answer 14

Massive PE + hypotension - thrombolyse

Question 15

Mesenteric ischaemia main points to remember

Answer 15

Mesenteric ischaemia: triad of CVD, high lactate and soft but tender abdomen

Question 16

after a tricyclic overdose which is the most important investigation?

Answer 16

Perform ECG if tricyclic overdose is suspected. Widening of QRS > 100ms is associated with an increased risk of seizures whilst QRS > 160ms is associated with ventricular arrhythmias

Question 17

tricyclic overdose features

Answer 17

Early features relate to anticholinergic properties: dry mouth, dilated pupils, agitation, sinus tachycardia, blurred vision.
Features of severe poisoning include:
* arrhythmias
* seizures
* metabolic acidosis
* coma

Question 18

ECG changes in tryciclic antidepressants

Answer 18

ECG changes include:
sinus tachycardia
widening of QRS
prolongation of QT interval

Widening of QRS > 100ms is associated with an increased risk of seizures whilst QRS > 160ms is associated with ventricular arrhythmias

Question 19

tricyclic overdose management

Answer 19

IV bicarbonate
* first-line therapy for hypotension or arrhythmias
indications include:
* widening of the QRS interval >100 msec or a ventricular arrhythmia

other drugs for arrhythmias

Question 20

compartment syndrome definition and pathophysiology

Answer 20

Question 21

compartment syndrome features

Answer 21

Question 22

diagnosis of compartment syndrome

Answer 22

• Is made by measurement of intracompartmental pressure measurements. Pressures in excess of 20mmHg are abnormal and >40mmHg is diagnostic
• Compartment syndrome will typically not show any pathology on an x-ray

Question 23

compartment syndrome management

Answer 23

• This is essentially prompt and extensive fasciotomies
• In the lower limb the deep muscles may be inadequately decompressed by the inexperienced operator when smaller incisions are performed
• Myoglobinuria may occur following fasciotomy and result in renal failure and for this reason these patients require aggressive IV fluids
• Where muscle groups are frankly necrotic at fasciotomy they should be debrided and amputation may have to be considered
• Death of muscle groups may occur within 4-6 hours