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PassMed > Emergency medicine > Flashcards

Emergency medicine Flashcards

1
Q

What is epiglottitis?

A

Acute inflammation of the epiglottis

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2
Q

Causes of epiglottitis?

A

Bacterial infection is most common

Streptococcus, staphylococcus, Haemophilus influenzae B, pseudomonas, moraxella catarrhalis

Viral; HSV

Thermal injury

Inhaled foreign body

Chemotherapy reaction

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3
Q

Why is epiglottis less common in UK?

A

Hib vaccination

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4
Q

Symptoms of epiglottitis?

A

Sore throat
Odynophagia
Dysphagia
Fevers
Dyspnoea

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5
Q

Signs of epiglottis?

A

Drooling
Hot potato muffled speech
Cervical lymphadenopathy
Tenderness over hyoid bone
Tripod sign
Stridor
Respiratory distress

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6
Q

Differentials for epiglottitis?

A

Viral pharyngitis
Peritonsillar abscess
Bacterial tracheitis
Croup

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7
Q

Investigations for epiglottitis?

A

Clinical diagnosis, do not examine if suspected

Lateral neck X-ray; thumb sign

Throat swab

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8
Q

Management of epiglottitis?

A

A to E assessment
ENT/ Anaesthetic management of airway
Keep patient upright
High flow oxygen
Nebulised adrenaline
IV dexamethasone

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9
Q

Complications of epiglottitis?

A

Airway obsruction
Death
Abscess formation
Sepsis
Mediastinitis
Pneumonia

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10
Q

Triggers for sickle cell crises?

A

Infection
Hypoxia
Dehydration
Strenuous exercise
Cold exposure
Stress
Alcohol/ smokking
High altitudes

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11
Q

Presentations of sickle cell crises?

A

Acute painful crises (vaso-occlusive crises); severe bone pain, swelling of hands/ feet
Acute chest syndrome; cough, SOB, chest pain, fevers
Priapism
Acute anaemia; myalgia, fever, headache, arthralgia, SOB, palpitations, syncope
Acute stroke
Infection

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12
Q

Investigations to diagnose sickle cell crises?

A

ECG
Urinalysis
PSV swabs, sputum MC&S and viral PCR
ABG
FBC, U+E, LFT, Coagulation, bone profile, CRP, G+S, LDH
Blood cultures
Chest Xray
CT head

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13
Q

Management of acute painful crises?

A

Pain relief (paracetamol/ NSAIDs, SC morphine)
Keep warm and hydrated
Refer to haematology
Thromboprophylaxis

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14
Q

Management of acute chest syndrome?

A

Supplementary oxygen to maintain sats over 96%
IV broad spectrum antibiotics (co-amoxiclav, clarithromycin)
Top up/ exchange transfusion

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15
Q

Management of priapism?

A

Urology
Analgesia
Oral hydration
Encourage to pass urine and catheterise if necessary
Consider drainage

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16
Q

Management of acute anaemia?

A

Identify causes
Transfusion may be required

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17
Q

Management of acute splenic sequesteration?

A

Splenectomy

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18
Q

What infections are those on iron chelation more at risk of ?

A

Yersinia
Klebsiella

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19
Q

What is acute pancreatitis?

A

Inflammation affecting the pancreas with local/ distant tissue/ organ invovlement

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20
Q

Epidemiology of acute pancreatitis?

A

Most commonly caused by gallstones
1-3% mortality
80% have mild self limiting disease

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21
Q

Causes of acute pancreatitis?

A

Idiopathic
Ethanol
Trauma
Steroids
Mumps
Autoimmune disease
Scorpion stings
Hypercalcaemia, hypertriglycerideaemia, hypothermia
ERCP
Drugs; thiazide, azathioprine, sulphonamide

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22
Q

How is severity of acute pancreatitis assessed?

A

Glasgow score; each of the criteria scores 1 point, 3 or more predicts severe pancreatitis and should be calculated within 48 hours from admission

PaO2 <8kPa
Age >55 years
Neutrophils >15
Calcium <2
Urea >16
LDH >600 or AST >200
Albumin <32
Glucose >10

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23
Q

Signs and symptoms of acute pancreatitis?

A

Epigastric pain which radiates to the back
Nausea and vomiting
Diarrhoea
Abdominal tenderness
Peritonism, rebound tenderness
Abdominal distention
Fever, tachycardia, hypotension
Grey turner’s sign; bruising in flanks
Cullen’s sign; periumbilical bruising
Fox’s sign; bruising over inguinal ligament

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24
Q

Signs for haemorrhagic pancreatitis?

A

Grey turner’s sign; bruising in flanks
Cullen’s sign; periumbilical bruising
Fox’s sign; bruising over inguinal ligament

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25
Q

Differentials for acute pancreatits?

A

ACS
Perforated peptic ulcer
Ruptured abdominal aortic aneurysm
Bowel obstruction
Cholecystitis

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26
Q

Investigations for acute pancreatitis?

A

ABG, ECG, pregnancy test, capillary blood glucose

FBC, CRP, LFT, amylase, lipase, LDH, bone profile
Blood cultures
Coagulation
Lipid profile
Autoimmune markers

Abdominal USS, CXR, CT with contrast, MRCP

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27
Q

Management of pancreatitis?

A

Catheterise and monitor urine input/ output
Consider NG tube
IV fluid resuscitation , crystalloids
Analgesia
Antiemetics
Laparoscopic cholecystectomy, debridement of necrotic tissue

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28
Q

Complications of pancreatitis?

A

Pancreatic pseudocyst
Pancreatic necrosis
Peripancreatic fluid collections
Haemorrhage
Pancreatic fistulae
Acute respiratory distress syndrome
AKI
DIC
Multi organ failure
Hyperglycaemia

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29
Q

What is advanced life support?

A

Guideline based approach to treating patients who have had a cardiac arrest to improve chances of successful resuscitation and survival

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30
Q

Where can cardiac arrests occur?

A

Out of hospital
In hospital

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31
Q

Causes of cardiac arrest?

A

Hypoxia
Hypovolaemia
Hypokalaemia, Hyperkalaemia
Hypothermia, Hypothermia

Thromboembolism
Tamponade
Tension pneumothorax
Toxins

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32
Q

Classification of cardiac arrests?

A

Depends on whether rhythm is shockable or non shockable

Shockable rhythm; pulseless ventricular tachycardia, ventricular tachycardia

Non shockable rhythm; pulseless electrical activity, asystole

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33
Q

What is PEA?

A

Organised cardiac electrical activity in the absence of of any palpable pulse
Survival is unlikely unless reversible cause and identified and treated effectively

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34
Q

When should defibrillation not be performed?

A

If doubt whether rhythm is shockable or non shockable

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35
Q

Management of shockable rhythm?

A

Attempt defibrillation if VT or VF is identified
Immediately resume CPR after first shock at 30:2
Continue CPR for 2 minutes and pause to check for pulse
If no pulse give a second shock
Continue CPR for 2 minutes and pause to check for pulse
Give a third shock
Continue CPR for 2 minutes and give 1mg adrenaline or 300mg amiodarone
Give repeat doses of adrenaline every 3-5 minutes
After 5 shocks give further dose of 150mg of amiodarone

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36
Q

Management of non shockable rhythm?

A

Start CPR at 30:2
Give 1mg IV adrenaline, repeat dose every 3-5 minutes

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37
Q

Causes of airway compramise?

A

Angioedema
Anaphylaxis
Thermal injury
Neck haematoma
Wheeze
Surgical emphysema
Reduced conciousness

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38
Q

Simple manoeuvres to secure airway?

A

Suction; if visible vomit, blood, secretions, foreign body
Turn patient onto side if actively vomiting
Head tilt/ chin lift
Place pillow under neck
Aim for sniffing position
Jaw thrust

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39
Q

What can be used as airway adjunct?

A

Oropharyngeal airway; Guedel,
Nasopharyngeal airway

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40
Q

What is a supraglottic airway?

A

Laryngeal mask airway, i- Gel that sits on top of larynx

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41
Q

What is an endotracheal tube?

A

Used for prolonged ventilation and acts as a protected airway

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42
Q

Examples of surgical airways?

A

Tracheostomy
Cricothyroidotomy

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43
Q

What is alcohol withdrawal?

A

When a patient who is dependant on alcohol suddenly stops or drastically reduces alcohol consumption

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44
Q

Epidemiology of alcohol misuse?

A

Affects 24% of the UK population

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45
Q

Pathophysiology of alcohol dependance?

A

Chronic exposure to alcohol causes tolerance to its effects, reduced GABA activity and increased glutamate activity

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46
Q

Signs and symptoms of alcohol withdrawal?

A

6-12 hours from last drink; Insomnia, tremor, anxiety, agitation, nausea, vomiting, sweating, palpitations

12-24 hours; visual hallucinations, auditory hallucinations, tactile disturbance (sensation of crawling bugs)

24-48 hours; alcohol withdrawal seizures

48-72 hours; delirium tremens
Delirium, agitation, hallucinations, delusions, tachycardia, hypertension, hyperthermia, diaphoresis, coarse tremor

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47
Q

Differentials for alcohol withdrawal?

A

Benzodiazepine withdrawal
Sepsis
Hepatic encephalopathy
Psychosis
Hypoglycaemia

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48
Q

Investigations to diagnose alcohol withdrawal?

A

ECG
Capillary blood glucose
FBC, CRP, LFT, Bone profile, blood culture
CXR, CT head

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49
Q

Management of alcohol withdrawal?

A

Use Clinical Institute Withdrawal Assessment of Alcohol scoring system to assess symptoms and guide prescription of benzodiazepines

Chlordiazepoxide (long acting) is first line
Oxazepam/ lorazepam are used in patients with liver disease

Treat seizures with short acting benzodiazepines, IV lorazepam

Pabrinex to prevent Wernicke’s encephalopathy

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50
Q

What is an anastomotic leak?

A

Post operative complication which occurs as a result of a defect in the joint between two hollow viscera that allows contents to leak into the abdomen

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51
Q

Epidemiology of anastomotic leak?

A

Occur 3-5 days post operatively
Frequency depends on location of surgery

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52
Q

Causes of anastomotic leak?

A

Emergency surgery
Prolonged operative time
Peritoneal contamination during surgery
Immunosuppressant medication
IBD
Smoking
Alcohol excess
Diabetes
Obese/ malnourished patients

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53
Q

Signs and symptoms of anastomotic leaks?

A

Progressive worsening of abdominal pain
Prolonged ileus
Tenderness on palpation of abdomen
Peritonism
Abdominal distention
Fevers
Tachycardia
Hypotension
Delirium
Nausea and Vomiting

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54
Q

Differentials for anastomotic leak?

A

Post operative ileus
Surgical site infection
Intra-abdominal abscess

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55
Q

Investigations to diagnose anastomotic leak?

A

Blood gas; raised lactate
Blood cultures
FBC, CRP, clotting, group and save
CT with contrast

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56
Q

Management of anastomotic leak?

A

Nil by mouth
IV fluids
Monitor input and output

IV antibiotics
TPN
Surgery/ emergency laparotomy

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57
Q

Complications of anastomotic leak?

A

Sepsis
Ileus
Abscess formation
Increased postoperative mortality

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58
Q

What is aortic dissection?

A

Tear in the tunica intima of the aorta creates a false lumen through which blood can flow between inner and outer layers of the aortic walls

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59
Q

Risk factors for aortic dissection?

A

Hypertension
Connective tissue disease
Valvular heart disease
Cocaine/ amphetamine use
Male over 50 years

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60
Q

Stanford classification of aortic dissection?

A

Type A; involves ascending aorta, arch of aorta
Type B; involves descending aorta

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61
Q

Clinical features of aortic dissection?

A

Sudden onset tearing chest pain/ intrascapular pain that radiates to the back
Bowel/ limb ischaemia
Renal failure
Syncope

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62
Q

Signs of aortic dissection?

A

Radio-femoral delay
Radio-radial delay
Blood pressure differential between arms

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63
Q

Investigations to diagnose aortic dissection?

A

CT angiogram
ECG
Echo; pericardial effusion
CXR; widened mediastinum
Troponin and D-dimer may be elevated

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64
Q

Prognosis of aortic dissection?

A

Prompt diagnosis and treatment as rupture carries 80% mortality

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65
Q

Management of aortic dissection?

A

Resuscitation
Cardiac monitoring
Strict blood pressure control
Type A; requires surgical managements
Type B; managed conservatively with BP control, endovascular/ open repair may be required

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66
Q

Complications of aortic dissection?

A

Death due to internal haemorrhage
Rupture
End organ damage
Cardiac tamponade
Stroke
Limb ischaemia
Mesenteric ischaemia

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67
Q

What is central abdominal pain?

A

Discomfort or pain in the mid section of the abdomen

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68
Q

What is a burn?

A

Injury to skin caused by heat, electricity, chemicals and radiation

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69
Q

Groups at high risk of burns?

A

Young children, under 5 years
Elderly patients
Reduced mobility/ sensory impairment
Patients with reduced sense of danger (Dementia, learning difficulty)

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70
Q

Causes of burns?

A

Thermal burns; flames, hot objects
Chemical burns; acids, alkalis, organic compounds
Electrical burns; high/ low voltage

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71
Q

Classification of burns?

A

Superficial epidermal burns; affects only epidermis, skin is erythematous and painful but not blistered, rapid CRT

Superficial dermal burns; affects epidermis and upper layer of dermis, erythematous, painful blistered skin with delayed CRT

Deep dermal burns; affects all layers of the dermis but not underlying subcutaneous tissue, dry, blotchy, blistered painful skin that does not blanch under pressure

Full thickness burns; extend to SC tissue and may involve muscle and bone, skin is white or black and may feel rubbery/ leathery/ waxy and is not painful

Complex; >15% of BSA or affect critical area (face, perineum, hands, feet, genitals) and all chemical and electrical burns

Non-complex; <15% BSA, partial thickness

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72
Q

Signs and symptoms of burns?

A

Pain
Erythema
Swelling
Blistering and peeling of skin
Respiratory distress
Hypotension
Tachycardia

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73
Q

Differentials of burns?

A

Cellulitis
Stevens- Johnson Syndrome
Toxic Epidermal Necrolysis
Pyoderma gangrenosum

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74
Q

What is Wallace rule of 9?

A

Divides areas of the body into multiples of 9 of the TBSA
Head- 9%
Whole arm-9%
Front of torso-18%
Back of torso-18%
Whole leg-18%

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75
Q

Methods of estimating TBSA?

A

Wallace tule of 9’s
Palmar method
Lund and Browder method

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76
Q

Complications of burns?

A

EARLY
Dehydration, hypovolaemic shock
Rhabdomyolysis
AKI
Electrolyte imbalance
Hypothermia
Respiratory distress due to smoke inhalation
Curling’s ulcer
Infection, sepsis
Arrhythmia
Loss of limbs if amputation necessary
Death

LATE
Scarring
Chronic pain
Contractures
Low mood
Anxiety, PTSD

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77
Q

Epidemiology of C-spine injury?

A

4% of trauma patients
Higher risk in those with decreased consciousness
C2 and C7 are most commonly fractured vertebrae

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78
Q

Causes of C-spine injury?

A

Road traffic accidents
Falls
Sports related injury
Assaults
Osteoporotic compression fractures

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79
Q

What makes a patient high risk following a C-spine injury as per Canadian C-spine rule?

A

Age over 65
Dangerous mechanism of injury
Paraesthesia in upper or lower limb

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80
Q

What makes patient low risk following C-spine injury as per Canadian C-spine rule?

A

Accident is a minor rear end motor vehicle collision
Comfortable in sitting position
No midline cervical spine tenderness
Delayed onset of neck pain
Unable to rotate neck 45 degrees to left and right

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81
Q

Signs and symptoms of C-spine injury?

A

Neck pain
Mid line cervical tenderness
Focal neurological deficit
Limited range of motion in neck movements
Haematoma/ oedema around cervical vertebrae
Sensory/ motor deficits- paralysis may affect trunk, upper and lower limb
Peripheral paraesthesia
Incontinence

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82
Q

Investigations to diagnose C-spine injury?

A

Assess high or low risk as per Canadian C-spine rule
CT of neck
If neurological abnormalities do MRI

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83
Q

Management of C-spine injury?

A

Imobilise and place in neck collar
IV morphine for pain control
Neurosurgical and spinal surgical review

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84
Q

What is choking?

A

Foreign object becomes lodged in a patients airway causing acute airway obstruction that is life threatening

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85
Q

Risk factors for choking?

A

Dysphagia
Poor dentition
Eating when not upright
Alcohol intoxication
Extremes of age
Risky foods

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86
Q

Signs and symptoms of choking?

A

Gagging, choking, distress
Unable to speak, breathe or cough
Clutching or pointing at neck
Stridor
Wheezing
Respiratory distress
Cyanosis
Attempts o cough a quiet or silent
Loss of consciousness

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87
Q

Differentials for choking?

A

Anaphylaxis
Asthma exacerbation
Syncope

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88
Q

Management of choking?

A

Encourage coughing
Give 5 back blows between shoulder blades with heel of hand and patient leaning forward
5 abdominal thrusts
Sequence until dislodged

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89
Q

Signs and symptoms of benzodiazepine overdose?

A

Slurred speech
Lethargy
Ataxia
Reduced levels of consciousness (may compromise airway)
Respiratory depression
Large overdoses may cause hypotension, bradycardia and hypothermia

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90
Q

Management of benzodiazepine overdose?

A

A to E assessment
Consider risk of aspiration pneumonia
Flumazenil

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5
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91
Q

What medication is used to counteract benzodiazepines?

A

Flumazenil- useful in iatrogenic overdose

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92
Q

Caution of use of Flumazenil?

A

Risk of seizures, used in ITU/ HDU
Avoid in epilepsy, chronic benzodiazepine use

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93
Q

Signs and symptoms of beta blocker overdose?

A

Small overdoses may be asymptomatic
Bradycardia
Hypotension
Drowsiness
Confusion
Seizures
Coma
Bronchospasm
Cardiac arrest

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94
Q

ECG changes in beta blocker overdose?

A

Prolonged PR interval
Bradycardia (most common)
Heart block
QRS widening (especially propranolol) which may progress to ventricular arrhythmias
QT prolongation (especially sotalol) with risk of torsades de pointes

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95
Q

Management of beta blocker overdose?

A

Resuscitation
Correct glucose
Activated charcoal if within 1 hour
Symptomatic bradycardia; atropine
Glucagon
High dose insulin

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96
Q

Signs and symptoms of NMDA toxicity?

A

Nausea and vomiting
Hallucinations, agitation and psychosis
Delirium
Hyperreflexia
Tremor
Hyperthermia
Diaphoresis
Flushing
Mydriasis
Tachycardia
Hypertension

97
Q

Complications of NMDA toxicity?

A

Arrhythmias
Rhabdomyolysis
Seizures
Cardiovascular collapse
Hyponatraemia
Serotonin syndrome
Acute renal failure
Disseminated intravascular coagulation
Coma

98
Q

Management of NMDA toxicity?

A

Resuscitation
Benzodiazepines
Cooling if hyperthermic
If hyponatraemic fluid restriction and hypertonic saline
Labetolol
Dantrolene

99
Q

Management of organophosphate poisoning?

A

Remove clothing
Protect airway
Intubation and ventilation
Gastric lavage
Give IV atropine
Pralidoxine

100
Q

Signs and symptoms of cyanide poisoning?

A

Nausea and vomiting
Headache
Tachycardia
Hypertension
Tachypnoea
Loss of consciousness
Seizures
Respiratory depression

101
Q

Management of cyanide poisoning?

A

Decontamination
Intubation and ventilation
High flow oxygen
Dicobalt edetate

102
Q

Antidote for cyanide?

A

Dicobalt edetate

103
Q

Sensitive indicator for cyanide poisoning?

A

Lactate over 10

104
Q

What is compartment syndrome?

A

Inflammation of injured muscle causes an increase in pressure within fascial compartment
As pressure rises circulation is cut off leading to tissue damage and necrosis

105
Q

Cause of compartment syndrome?

A

Fractures; commonly tibial, forearm, wrist
Crush injuries
Constrictive dressings/ plaster casts
Prolonged immobilisation
Reperfusion of ischaemic limb

106
Q

Signs and symptoms of compartment syndrome?

A

Severe pain out of proportion of initial injury
Passive stretching of affected muscles exacerbates pain
Paraesthesia
Pallor
Pulselessness
Paralysis
Coolness of the affected limb
The area may feel tense on palpation

107
Q

Differentials for compartment syndrome?

A

DVT
Cellulitis
Acute limb ischaemia

108
Q

Investigations to diagnose compartment syndrome?

A

Measure intracompartmental pressures- typically around 40mmHg
Creatinine kinase
U+E, FBC, LFT, clotting, group and save
ECG

109
Q

Management of compartment syndrome?

A

Surgical management; fasciotomies
Analgesia
Monitor neurovascular status
Monitor other limbs

110
Q

Complications of compartment syndrome?

A

Rhabdomyolysis
Limb amputation
Volkmann contracture

111
Q

Triggers of asthma exacerbation?

A

Cold air and exercise
Pollution and cigarette smoke
Allergens
Chemical irritants
Medications; NSAIDs, beta blockers

112
Q

What type of reaction is an acute asthma exacerbation?

A

Type 1 hypersensitivity reaction

113
Q

Symptoms of acute asthma attack?

A

Wheeze
Difficulty breathing
Struggling to eat, speak or sleep due to breathlessness
Cough
Chest tightness
Dizziness

114
Q

Signs of acute asthma attack?

A

Tachypnoea
Increased work of breathing
Hyperinflated chest
Expiratory polyphonic wheeze throughout the lung fields
Decreased air entry
Cyanosis
Tachycardia
Altered mental state, e.g. drowsiness or confusion
Exhaustion
Hypotension

115
Q

Differentials for acute asthma?

A

Pulmonary embolism
Vocal cord dysfunction
Acute exacerbation of COPD
GORD
Anaphylaxis

116
Q

Investigations for acute asthma?

A

PEFR
ABG
ECG
FBC, CRPU+E, LFT
Blood cultures
CXR

117
Q

Complications of acute asthma?

A

Respiratory failure
Pneumothorax
Status asthmaticus
Death

118
Q

Management of acute asthma asthma?

A

ABCDE
Maintain O2 sats 94-98%
Nebulised salbutamol 5mg
Ipratropium bromide 500mcg 4-6 hours
Prednisolone 40-50mg and continue for atleast 5 days
IV magnesium sulphate; 1.2-2g over 20 minutes
Aminophylline

119
Q

Signs and symptoms of ACS?

A

Chest pain - typically central and crushing in nature. May radiate to left arm/neck/jaw
Shortness of breath
Nausea +/- vomiting
Sweating and clamminess
Syncope
Atypical presentations are more likely in some groups (e.g. the elderly or patients with diabetes who may not experience chest pain)
Pain may be epigastric rather than in the chest, or there may be no pain
Acute confusion or hyperglycaemic crises are examples of atypical ACS presentations

120
Q

Differentials for ACS?

A

Myocarditis
Pericarditis
PE
Costochondritis
Aortic dissection

121
Q

Investigations to diagnose ACS?

A

ECG
Troponin, repeat after 4-6 hours
U+E, HbA1c, lipid, FBC, CRP, coagulation
CXR
Echo

122
Q

Management of STEMI?

A

Loading dose of aspirin 300mg
Second antiplatelet agent; prasugrel, clopidogrel
Sublingual GTN
Morphine
PCI; primary if presented within 12 hours and can be offered in 2 hours

123
Q

Management of NSTEMI and UA?

A

Loading dose of aspirin
Antithrombin; fondaparinux
Risk stratification; GRACE score
Low risk patients managed medically; aspirin + ticagrelor
Intermediate/ high risk managed with PCI and DAPT

124
Q

Complications of ACS?

A

Ventricular arrhythmia
Acute mitral regurgitation
Acute heart failure
Heart block
Cardiogenic shock
Cardiac tamponade
Ventricular septal defect
Dressler’s syndrome

125
Q

What is an acute exacerbation of COPD?

A

Acute worsening of patients baseline symptoms beyond expected day to day variation

126
Q

Causes of exacerbation of COPD?

A

Viral; rhinovirus, influenza, parainfluenza, coronavirus, adenovirus, RSV

Bacterial; haemophilus influenza, streptococcus pneumonia, moraxella catarrhalis, staphylococcus aureus, pseudomonas aeurginosa

Nitrogen dioxide, particulates, sulphurdioxide

Pneumothorax, PE, intra-abdominal pathology, heart failure, metabolic disturbance

127
Q

Signs of exacerbation of COPD?

A

Worsening shortness of breath
Reduced exercise tolerance/not coping at home
Worsening cough (especially if increased sputum production/change in colour)
Worsening wheeze and chest tightness
Infective symptoms (e.g. sore throat, coryza, fevers)
Lethargy
Confusion
Ankle swelling

128
Q

Signs of exacerbation of COPD?

A

Tachypnoea and respiratory distress
Tripod positioning (where patient leans slightly forward with arms propped up in front - reduces work of breathing and allows greater use of accessory muscles)
Pursed lip breathing
Reduced oxygen saturations from baseline
Tachycardia
Cyanosis
Asterixis
On auscultation: wheeze, reduced air entry, prolonged expiratory phase, crackles

129
Q

Investigations to diagnose exacerbation of COPD?

A

ABG
Sputum culture
ECG
FBC, CRP, U+E
Blood culture
CXR

130
Q

Differentials for exacerbation of COPD?

A

Pneumonia
Pneumothorax
Pulmonary embolism
Acute exacerbation of asthma
Exacerbation of bronchiectasis
Acute heart failure
Exacerbation of interstitial lung disease
Lung cancer
Tuberculosis

131
Q

Management of exacerbation of COPD?

A

Oxygen saturations between 88-92%
Salbutamol 2.5-5mg
Ipratropium 0.5mg QDS
Steroids; prednisolone 30mg for 5 days, if unable to swallow IV hydrocortisone
IV aminophylline
Consider antibiotics if infectious

132
Q

What is acute angle closure glaucoma?

A

Blockage of the angle formed by the cornea and the iris which prevents the humour from draining resulting in progressive increase in intra-ocular pressure

133
Q

Risk factors for acute angle closure glaucoma?

A

Anatomical variations
Older age
Female sex
East Asian ethnicity
Medications e.g. oxybutynin, amitriptyline, tropicamide
Hypermetropia (farsightedness)
Family history of AACG
Pupillary dilation e.g. being in a dark room

134
Q

Symptoms of acute angle closure glaucoma?

A

Rapid onset of severe eye pain
Blurred vision which may progress to visual loss
Nausea and vomiting
Headache
Coloured haloes around lights

135
Q

Signs of acute angle closure glaucoma?

A

Conjunctival injection in the affected eye
Haziness of the cornea
Mid-dilated or fixed pupil that is not reactive
Globe feels hard and is tender on palpation

136
Q

Differentials of acute angle closure glaucoma?

A

Open angle glaucoma
Acute anterior uveitis
Anterior scleritis

137
Q

Investigations to diagnose acute angle closure glaucoma?

A

Slit lamp examination
Ophthalmoscopy
Gonioscopy; allows assessment of the angle between the iris and cornea
Tonometry; >30mmHg

138
Q

What is the gold standard for for acute angle closure glaucoma?

A

Goldmann applanation tonometry

139
Q

Management of acute angle closure glaucoma?

A

Conservative management;
Lie patient flat with their face up without pillows to relieve pressure on the angle
Referral to ophthalmology
Monitor symptoms and ensure analgesia and antiemetics

Medical management;
Dorzolaminde (carbonic anhydrase inhibitor) and timolol (beta blocker)
Apraclonidine; alpha-2 agonist
Polocapine; cholinergic agonist
Acetazolamide

Surgical management;
Peripheral iridotomy
Treat both eyes

140
Q

What is anaphylaxis?

A

Rapid onset of life threatening airway, breathing or circulatory dysfunction as a result of an immunological reaction when patient is exposed to allergen

141
Q

Epidemiology of anaphylaxis?

A

20-30 deaths per year, about half are iatrogenic due to penicillin

142
Q

Causes of anaphylaxis?

A

Insect stings
Nuts
Other foods such as eggs or milk
Latex
Antibiotics (e.g. penicillins)
Intravenous contrast agents
Other medications (such as NSAIDs)

143
Q

Signs and symptoms of anaphylaxis?

A

Airway; difficulty swallowing, breathing, stridor, hoarse voice, swelling of tongue and lips

Breathing; difficulty breathing, wheeze, cough, respiratory distress, respiratory arrest

Circulation; dizziness, pallor, clamminess, tachycardia, hypotension, arrhythmias, anaphylaxis, cardiac arrest

Disability; sense of impending doom, confusion, agitation, loss of consciousness

Exposure; erythematous patches, urtrcaria, angioedema

GI manifestation; abdominal pain, incontinence, vomiting

144
Q

Differentials for anaphylaxis?

A

Life threatening asthma exacerbation
Other causes of angioedema; ACE inhibitors, histamine, bradykinin mediation
Panic attack
Vasovagal episode

145
Q

Investigations for anaphylaxis?

A

ECG, ABG, mast cell tryptase

146
Q

Management of anaphylaxis?

A

Remove triggers
Lie patient flat and elevate legs
IM adrenaline into anterolateral aspect of thigh
Secure airway
High flow oxygen
Inhaled salbutamol/ ipratropium
IV fluid bolus
Repeat IM adrenaline after 5 minutes if no response

Once stabilised;
Oral non sedating antihistamine
Observe for biphasic reaction

147
Q

What should patients who have had anaphylaxis be given upon discharge?

A

2 adrenaline auto injectors
Advice on trigger avoidance
Refer for follow up in specialist allergy service

148
Q

What is a biphasic reaction?

A

When symptoms of anaphylaxis reoccur without further exposure to trigger

149
Q

Causes of atrial fibrillation?

A

Cardiac causes;
Ischaemic heart disease
Hypertension
Valvular heart disease (including rheumatic heart disease, typically affecting the mitral valve)
Heart failure
Cardiomyopathies
Myocarditis and pericarditis
Recent cardiothoracic surgery

Non-cardiac causes;
Electrolyte disturbances (e.g. hypokalaemia, hypomagnesaemia)
Acute infections e.g. pneumonia, sepsis
Pulmonary embolism
Hyperthyroidism
Alcohol excess
Smoking
Medications (e.g. lithium)

150
Q

Classification of AF?

A

Paroxysmal; episodes last < 7 days and are intermittent
Persistent; episodes last > 7days
Permanent; lasts > days, no further attempts to get sinus rhythm are attempted

151
Q

Symptoms of AF?

A

Palpitations
Chest pain or tightness
Shortness of breath
Reduced exercise tolerance
Light-headedness
Syncope
Fatigue
A complication of AF e.g. a stroke or transient ischaemic attack

152
Q

Signs of AF?

A

Irregularly irregular pulse
Radial- apical deficit
Variable intensity of first heart sound on auscultation
Haemodynamic instability; tachycardia, hypotension, loss of conciousness, acute pulmonary oedema

153
Q

Differentials for AF?

A

Sinus tachycardia
Atrial flutter
Supraventricular tachycardia
Multifocal atrial tachycardia

154
Q

Investigations to diagnose AF?

A

ECG; absence of p waves irregularly irregular QRS
Bloods; FBC, CRP, U+E, bone profile, TFT, HbA1c, LFT, Lipids, clotting screen, blood cultures
CXR
Echocardiogram
CTPA

155
Q

Management of AF?

A

AF with adverse signs;
A to E approach
DC cardioversion
If 3 attempts are unsuccessful give 300kg IV amiodarone followed by another shock and 900mg amiodarone infusion over 24 hours

Stable patients
Synchronised DC cardioversion with sedation or general anaesthetic
Pharmacological cardioversion with flecainide
Rate control

Ongoing management;
Anticoagulation; DOAC

156
Q

Complications of AF?

A

Embolic event
Hear failure
Myocardial ischaemia
Tachycardia induced cardiomyopathy
Increased risk of vascular dementia

157
Q

Which groups of patients are more sensitive to CO poisoning

A

The elderly
Young children
Pregnant women
People with anaemia
People with cardiovascular disease

158
Q

Signs and symptoms of carbon monoxide poisoning?

A

Headache
Dizziness
Lethargy
Flushing
Myalgia and weakness
Confusion
Nausea and vomiting
Cherry red skin (rare)
Tachycardia and hypotension
Seizures

159
Q

Differentials for carbon monoxide poisoning?

A

Migraine
Viral infections
Diabetic ketoacidosis

160
Q

Investigations to diagnose carbon monoxide poisoning?

A

Pulse oximetry
Blood gas
ECG
Capillary blood glucose
Bloods; FBC, U+E, CK, Troponin, lactate

161
Q

Management of carbon monoxide poisoning?

A

A to E assessment
100% oxygen
IV fluids

162
Q

Complications of CO poisoning?

A

Emotional lability and personality change
Difficulty concentrating
Insomnia
Lethargy
Movement disorders such as chorea and Parkinsonism
Memory impairment and dementia
Psychosis
Neuropathy

163
Q

What is cardiac tamponade?

A

Compression of heart by fluid accumulation in the pericardial sac which impairs cardiac filling during diastole compromising cardiac output leading to cardiac arrest

164
Q

Causes of cardiac tamponade?

A

Trauma; especially penetrating injuries
Iatrogenic causes; cardiothoracic surgery
Pericarditis which can be secondary to malignancy, myocardial infarction, HIB, TB, connective tissue disease, radiation, CKD
Aortic dissection
Medication; minoxidil, hydralazine
Cardiac perforation
Pneumopericardium

165
Q

Symptoms of cardiac tamponade?

A

Fatigue
Dyspnoea
Cold and clammy peripheries
Confusion

166
Q

Signs of cardiac tamponade?

A

Beck’s triad (raised jugular venous pressure, hypotension and muffled heart sounds)
Pulsus paradoxus (a decrease in systolic blood pressure by more than 10 mmHg during inspiration)
Tachycardia
Tachypnoea
Altered mental state
Hepatomegaly
Pericardial friction rub
Cyanosis
JVP shows an absent Y descent (due to reduced diastolic filling of the ventricles)

167
Q

What is Beck’s triad?

A

Raised JVP
Hypotension
Muffled heart sounds

168
Q

Differentials for cardiac tamponade?

A

Acute heart failure
Constrictive pericarditis
Pulmonary embolism
Tension pneumothorax

169
Q

Investigations to diagnose cardiac tamponade?

A

ECG; electrical alternans where height of QRS complexes alternate due to movement of heart in pericardial space
FBC, CRP, U+E, coagulation, HIV testing, group and save, troponin
Imaging; echocardiogram, CXR, CT
Pericardiocentesis fluid for cytology

170
Q

Management of cardiac tamponade?

A

Supportive therapy; oxygen, IV fluids, inotropes
Pericardiocentesis
Open surgical drainage
Percutaneous balloon pericardiotomy, pericardiectomy
Treat underlying cause

171
Q

What is the triad for diabetic ketoacidosis?

A

Hyperglycaemia; >11mmol/L
Ketosis; >3 mmol/L
Acidosis; pH <7.3

172
Q

Causes of DKA?

A

Insulin deficiency leads to hyperglycaemia which are converted to ketones which leads to ketosis

173
Q

What proportion of T1DM first presentation is DKA?

A

10-20%

174
Q

Triggers for diabetic ketoacidosis?

A

Infections
Dehydration and fasting
Missing doses of insulin
Medications e.g. steroid treatment or diuretics
Surgery
Stroke or myocardial infarction
Alcohol excess or illicit drug use
Pancreatitis

175
Q

When should patients with DKA be considered to higher dependency care?

A

Blood ketones > 6mmol/L
Bicarbonate < 5mmol/L
Blood pH < 7
Anion gap above 16
Hypokalaemia on admission
GCS less than 12
Oxygen saturations < 92% in air
Systolic BP < 90mmHg
Brady or tachycardia (heart rate < 60 or > 100bpm)

176
Q

Symptoms of DKA?

A

Nausea and vomiting
Abdominal pain
Polyuria
Polydipsia
Weakness

177
Q

Signs of DKA?

A

Dry mucous membranes
Hypotension
Tachycardia
Altered mental state (drowsiness, confusion, coma)
Kussmaul’s breathing (deep, sighing breathing to compensate for metabolic acidosis by blowing off carbon dioxide)
Fruit-like smelling breath (due to ketosis)

178
Q

Investigations to diagnose DKA?

A

Capillary blood glucose
Blood or urinary ketones
Urine dip and MSU
ECG
Venous blood gas
U+E, FBC, CRP
Blood cultures
HbA1c

179
Q

Management of DKA?

A

A to E assessment
Ensure IV access
Consider urinary catheterisation and monitor fluid balance
IV fluids
Potassium replacement
Insulin 0.1 units/ kg/ hour

180
Q

What is ethylene glycol poisoning?

A

Chemical in antifreeze or radiator coolant

181
Q

Signs and symptoms of ethylene glycol poisoning?

A

Early;
Apparent intoxication (similar to that of alcohol)
Nausea and vomiting
Haematemesis
Seizures
Ataxia
Ophthalmoplegia
Papilloedema
Raised anion gap metabolic acidosis
Pulmonary oedema

Late;
Acute tubular necrosis
Flank pain
Oligouria
Hypocalcaemia
Hyperkalaemia
Hypomagnesaemia

182
Q

Differentials for ethylene glycol poisoning?

A

Alcohol intoxication
Poisoning with other substances
Acute renal failure

183
Q

Investigations to diagnose ethylene glycol poisoning?

A

Urine sample
ECG
Blood gas; metabolic acidosis with raised anion gap
U+E, LFT
Bone profile, hypocalcaemia
Magnesium, hypomagnesaemia
CT head

184
Q

Management of ethylene glycol poisoning?

A

A to E assessment
Monitor urine output
Gastric lavage, NG aspiration
Fomepizole
Ethanol
Haemofiltration
Treat any electrolyte imbalance

185
Q

Mechanism of action of fomepizole?

A

Competitive inhibitor of alcohol dehydrogenase

186
Q

What is hyperosmolar hyperglycaemic state?

A

Complication of T2DM commonly seen in older patients with known diabetes

187
Q

Key features of hyperosmolar hyperglycaemic state?

A

Blood glucose ≥ 30 mmol/L
Serum osmolality ≥ 320 mOsm/kg
Significant hypovolaemia
Blood ketones ≤ 3 mmol/L
pH ≥ 7.3 and bicarbonate ≥15.0 mmol/L

188
Q

Factors that can cause hyperosmolar hyperglycaemic state?

A

Infection
Recent trauma or surgery
Acute events like stroke or MI
Medications; steroids

189
Q

Symptoms of hyperosmolar hyperglycaemic state?

A

Polyuria
Polydipsia
Nausea
Lethargy
Weakness
Confusion
Drowsiness
Loss of consciousness

190
Q

Signs of hyperosmolar hyperglycaemic state?

A

Tachycardia
Hypotension
Altered mental state
Sunken eyes
Dry mucous membranes

191
Q

Investigations to diagnose hyperosmolar hyperglycaemic state?

A

Capillary glucose; over 30
VBG
Capillary blood ketones
ECG
Urine dip
Serum osmolality, glucose, U+E, FBC, CRP, LFT
Bone profile
Blood cultures
CXR

192
Q

Management of hyperosmolar hyperglycaemic state?

A

Fluid resuscitation; 1L of 0.9% saline over 1 hour
Potassium replacement
Monitor glucose, ketones, U+Es hourly and calculate serum osmolality every hour
VTE prophylaxis
Refer to diabetes specialist

193
Q

Complications of hyperosmolar hyperglycaemic state?

A

Hypovolemic shock
Cerebral oedema
Thromboembolic events
Acute kidney injury
Cardiac arrhythmias
Respiratory failure
Long-term neurological sequelae

194
Q

What is pericarditis?

A

Inflammation of the pericardium

195
Q

Causes of pericarditis?

A

Idiopathic
Viral; echovirus, enterovirus, cocksackievirus, adenovirus
Bacterial; pneumococcus, staphylococcus, mycoplasma
TB
Dresslers syndrome
Autoimmune; rheumatoid arthritis, SLE, scleroderma
Uraemic pericarditis
Malignancy
Drugs; isoniazide, hydralazine
Trauma

196
Q

Signs and symptoms of pericarditis?

A

Acute onset pleuritic chest pain; relieved by leaning forward, retrosternal may radiate down left arm/ shoulder
Pericardial friction rub
Fever
Cough
Arthralgia

197
Q

Investigations to diagnose pericarditis?

A

ECG; acute phase PR depression, global saddle shaped ST elevation
FBC, CRP, Troponin, U+E,
Echo
CXR

198
Q

Management of pericarditis?

A

NSAIDs
Low dose colchicine
Steroids in uraemic pericarditis, connective tissue disorders
Aspirin is used in pericarditis post MI

199
Q

High risk features of pericarditis?

A

Large pericardial effusion or tamponade
Myopericarditis (elevated troponin)
Immunosuppression
High fevers (>38 degrees)
Trauma
On oral anticoagulants
Subacute cause
Not responding to initial treatment (after 1-2 weeks)

200
Q

What is a pneuothorax?

A

Collection of air in the pleural cavity which may cause collapse of underlying lung parenchyma

201
Q

How is pneumothorax classified?

A

Spontaneous
Traumatic
Tension

202
Q

Symptoms of pneumothorax?

A

Sudden onset shortness of breath
Pleuritic chest pain
Dry cough
Tachypnoea and increased work of breathing

203
Q

Signs of pneumothorax?

A

Unilateral reduced expansion
Unilateral hyper-resonance to percussion
Reduced or absent breath sounds
Reduced vocal resonance or tactile vocal fremitus

Tracheal deviation to the contralateral side
Tachycardia
Hypotension
Distended neck veins

204
Q

Investigations to diagnose pneumothorax?

A

CXR
ABG
CT chest
Needle aspiration

205
Q

Management of tension pneumothorax?

A

Insertion of large bore cannula into second intercostal space, mid clavicular line
Thoracostomy
Chest drain

206
Q

Follow up requirements for pneumothorax?

A

OPD in 2-4 weeks
Smoking cessation
No flying until 7 days post pneumothorax resolution
No underwater diving

207
Q
A
208
Q

Triad of PE?

A

Sudden onset shortness of breath
Pleuritic chest pain
Haemoptysis

209
Q

Symptoms of PE?

A

Sudden onset Shortness of breath
Pleuritic chest pain
Haemoptysis
Cough
Syncope
RV ischaemia -> retrosternal chest pain

210
Q

Signs of PE?

A

Tachypnoea
Crackles o auscultation
Tachycardia
Hypoxia
Low grade pyrexia

211
Q

How to interpret wells score?

A

Less than 4; PE unlikely, perform D dimer

More than 4; PE likely, CTPA or V/Q scan

212
Q

Investigations for PE?

A

ECG; sinus tachycardia
ABG
D-dimer
FBC
CRP
U+E
LFT
Coagulation
Troponin
CXR
CTPA
V/Q scan
TTE

213
Q

What is seen on CXR in PE?

A

Fleischner sign; enlarged pulmonary artery
Hampton’s sign; peripheral wedge shaped opacity
Westermark sign; regional oligaemia

214
Q

Management of PE?

A

Anticoagulation
Embolectomy
Catheter directed thrombolysis

215
Q

Cause of status epilepticus?

A

Withdrawal/ interruption or change in anti-epileptic medication
Non compliance with medication
Seizure threshold lowering medications
Intercurrent illness
Metabolic abnormalities
Infection
Brain injury; trauma, stroke, subarachnoid haemorrhage
Withdrawal from benzodiazepines, alcohol

216
Q

Signs and symptoms of convulsive status epilepticus?

A

Abrupt generalised muscle stiffening (tonic phase) followed by rhythmic jerking of the muscles (clonic phase)
Loss of consciousness
Tongue biting - typically lateral tongue
Urinary or faecal incontinence
Clenched jaw
Erratic eye movements
Drooling
Cyanosis

217
Q

Signs and symptoms of non convulsive status epilepticus?

A

Reduced levels of consciousness
Catatonia
Behavioural changes/psychosis
Subtle motor signs e.g. myoclonus, eye deviation or twitching
Autonomic dysfunction
Speech disturbance e.g. aphasia or perseveration

218
Q

Features of non epileptic seizures?

A

Last longer
Eyes closed
Emotional vocalisation; crying, screaming
Limbs moving in phase with each other
Head and trunk moving side to side
React to external stimuli
Incontinence and tongue biting

219
Q

Causes of non convulsive status epilepticus?

A

Encephalitis
Hypoglycaemia
Psychogenic pseudocoma
Alcohol/ benzodiazepine withdrawal
Transient global amnesia
Stroke

220
Q

Investigations to diagnose status epilepticus?

A

Capillary glucose
Blood gas; electrolytes, lactate
Urine toxicology
Pregnancy test
ECG

FBC, CRP, U+E, bone profile, magnesium LFT, clotting, serum anticonvulsant levels, blood cultures

CT head, chest x ray
Lumbar puncture

221
Q

Management of status epilepticus

A

Ensure patient safety
Airway adjunct
High flow oxygen via non-rebreather
Check glucose and give pabrinex is concern around alcohol excess
At 5 minutes give 4mg of IV lorazepam (rectal diazepam or buccal midazolam)
At 10 minutes repeat benzodiazepine
At 15 minutes IV infusion of levetiracetam, phenytoin, sodium valproate
If 30 minutes GA and intubate

222
Q

What is supraventricular tachycardia?

A

Tachycardia originating above the level of bundle of his with narrow complex QRS

223
Q

Management of SVT?

A

Unstable;
DC cardioversion if signs of shock, syncope, heart failure, myocardial ischaemia

Stable
Vagal manoeuvre; carotid sinus massage, valsalva manoeuvre
IV 6mg adenosine, 12mg then 18mg if unsuccessful
Continuous ECG
If adenosine fails, beta blocker or CCB with DC cardioversion

224
Q

Short term effects of adenosine?

A

Difficulty breathing
Chest tightness
Flushing

225
Q

What is torsades de pointes?

A

Polymorphic ventricular tachycardia characterised by twisting and gradually changing amplitude QRS complexes around isoelectric line on ECG as a result of QT prolongation

226
Q

Causes of torsades of pointes?

A

Congenital long QT syndrome
Stress, fear, exercise
Toxins; heavy metals, insecticides
Ischaemia
Medications; erythromycin, ketoconazole, TCA, methadone, antipsychotics
Electrolyte abnormalities; hypokalaemia, hypocalcaemia, hypomagnesaemia
Subarachnoid haemorrhage

227
Q

Symptoms of torsades de pointes?

A

Upto 50% are asymptomatic
Palpitations
Lightheadedness
Syncope
Chest pain
Nausea
Cold sweats
Dyspnoea
Sudden cardiac death

228
Q

Investigations to diagnose torsades the points?

A

ECG
VBG
Troponin
Echo
Genetic testing

229
Q

Management of torsades de pointes?

A

IV fluids
Correct any electrolyte imbalance
IV magnesium 2g
DC cardioversion
Defibrillation

230
Q

What is an upper GI bleed?

A

Haemorrhage in the GI tract anywhere between oesophagus and duodenum at the ligament of treitz

231
Q

What is the most common cause of upper GI bleed?

A

Peptic ulcer disease

232
Q

Causes of upper GI bleed?

A

Oesophageal causes;
Oesophageal varices
Oesophagitis
Mallory- Weiss tear
Oesophageal cancer

Stomach causes;
Peptic ulcer
Gastric varices
Gastritis
Gastric cancer
Vascular malformation

Duodenal causes;
Peptic ulceration
Aortoenteric fistula

233
Q

Scoring systems to classify upper GI bleed?

A

Glasgow blatchford score
Rockall score

234
Q

Symptoms of upper GI bleed?

A

Haematemesis
Coffee ground vomit
Melena
Lightheadedness
Syncope
Abdominal pain
Fatigue
Shortness of breath
Decreased exercise tolerance
Palpitations

235
Q

Signs of upper GI bleed?

A

Tachycardia
Hypotension
Prolonged capillary refill time
Altered mental state
Abdominal tenderness
Melaena or haematochezia (fresh red blood) on rectal examination
Stigmata of chronic liver disease; spider naevi, gynaecomastia, palmar erythema, caput medusae

236
Q

Investigations to diagnose upper GI bleed?

A

VBG
ECG
FBC
U+E
LFT
Coagulation
Group and save
Cross match
OGD
CXR

237
Q

Which blood thinner can be continued in upper GI bleed?

A

Aspirin

All other anticoagulation is discontinued

238
Q
A

PassMed (2 decks)

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