Emergency Medicine and Critical Care COPY Flashcards

Question

What are the contraindications to the use of Adenosine?

Answer 1

IV **adenosine** 3mg should not be administered to heart transplant patients, those with Central line access or medications that can potentiate **adenosine** such as **Dipyridamole** or **Carbamazepine** Asthma is a contraindicated to Adenosine so **Verapamil** should be used

Answer 2

* Syncope * DVT * Embolism * Cardiac Tamponade * Congestive Heart failure * Myocardial infarction * Death

Answer 3

Ethylene glycol poisoning occurs when anti-freeze and can be ingested on purpose or accidently

Answer 4

Early features are under 24 hours * Apparent intoxication (like alcohol drunk) * Nausea and vomiting * Haematemesis * Seizures * Ataxia * Opthalmoplegia * Papilloedema * Raised anion gap (metabolic acidosis) * Pulmonary Oedema

Answer 5

Late features are over 24 hours * Acute tubilar necrosis * Hypocalcaemia * Hyperkalaemia * Hypomagnesaemia

Answer 6

If under 1 hour since ingestion gastric lavage or NG aspiration Fomepizole (acts as a competitive inhibitor of alcohol dehydrogenase) - prevents metabolism of EG into toxic metabolites Alcohol (ethanol) can be used if fomepizole is unavailable Haemofiltration can be used in severe cases

Answer 7

Opioids are commonly administered subcutaneously If patient has other symptoms such as nausea, vomiting, colicky pain and increased secretions - can be treated with: * Hyoscine Butylbromide (muscarinic antagonist - first line) * Octreotide * Ondansetron (primarily used for nausea and vomiting in chemo patients - 5-HT3) * Atropine

Answer 8

* Peptic Ulcers * Portal Hypertension * Variceal Bleeding

Answer 9

Peptic ulcers encompass both gastic and duodenal ulcers

Answer 10

* NSAIDS * Smoking * Alcohol * H. Pylori infection * Steroids * Stress

Answer 11

Present with epigastric pain which occurs after food ingestion - will often have epigastric tenderness Can be prominent at night If on posterior wall, it may cause pain to radiate through to the back If there is significant acute bleeding, there may be tachycardia and hypotension suggesting hypovolaemic state Anecdotally, gastric ulcers can be differentiated from duodenal as in gastric, pain is worse right after eating but in duodenal pain worse several hours after eating - again VERY ANECDOTAL

Answer 12

Diagnosis is confirmed using oesophago-gastro-dudenoscopy (OGD)

Answer 13

Portal hypertension describes elevated pressure in the portal venous system

Answer 14

Can be divided into three broad causes: Pre-hepatic, hepatic, post-hepatic Pre-hepatic: obstructions of portal vein i.e portal vein thrombosis, extrinsic pressure from tumour Hepatic: Cirrhosis, chronic hepatitis, schistosomiasis (parasitic worms) Post-Hepatic: Due to obstructions of hepatic veins or venules i.e Budd-chiari syndrome (blood clot obstruction), right-heart failure Most common cause is Cirrhosis

Answer 15

the most common place is the gastro-oesophageal junction as those walls are the thinnest

Answer 16

Presents with features of upper GI bleed: * Haematemsis * abdominal pain * Malaena (black tarry stool * features of liver disease due to portal hypertension * if bleeding significant, tachychardia, hypotension suggesting a hypovolaemic state

Answer 17

Prior to endoscopy - Glasgow-blatchford scale - any score greater than 0 suggests high risk GI bleed Post endoscopy - Rockall Score - used to estimate risk of rebleeding and risk of mortality

Answer 18

* Glasgow-Blatchford score * Routine bloods * Clotting * Group and save * Cross-match

Answer 19

* ABCDE assessment * Insert 2 large bore IV cannulae and take bloods for FBC, U+E, LFT, clotting, cross match (check blood antibodies) * IV fluids - fluid challenge if hypotensive * Catheterise * Correct clotting if needed * Urgent endoscopy

Answer 20

Endoscopy is first line for bleeding from ulcer - i.e active bleeding lesions, non bleeding visible vessels or ulcers with adherent blood clot theraputic measures include, clipping, thermal coagulation, fibrin or thrombin - adrenaline injection can be given but adjunctively only Oozing ulcers should be left alone as they have good prognosis without intervention Interventional radiology should be considered for unstable patients who re-bleed after initial endoscopic treatment. Percutaneous angiography can be used to identify point of bleeding which can then be embolised Drugs for acid suppression should not be offered prior to endoscopy - proton pump inhibitors should be given when evidence of non-V Upper GI bleed and recent bleeding seen in endoscopy

Answer 21

Terlipressin is used in suspected variceal bleeding and acts as a vasopressin analogue - should be stopped after haemostasis or after 5 days Prophylactic antibiotics such as Tazocin should also be given in suspected variceal bleeding Oesophagogastroduodenoscopy can also isolate and treat the cause of the variceal bleeding Endoscopic haemostatic measures for bleeding varices include band ligation and injection of N-butyl-2-cyanoacrylate The formation of a transjugular intrahepatic portosystemic shunt (TIPS) should be considered if all else fails to control the bleeding

Answer 22

Horner's Syndrome is characterised by ptosis, meiosis with or without anhydrosis. It is due to an interruption of the sympathetic nerve supply to the eye and can be classified into pre-ganglion causes, post ganglionic causes and central causes

Answer 23

Pancoast tumour (affecting sympathetic nerve supply - presents as ipsilateral horner's syndrome with thoracic outlet syndrome) - an invasive apical lung cancer invading the sympathetic plexus and brachial plexus - can cause a hoarse voice and bovine cough if affecting laryngeal nerve Stroke Carotid artery dissection (Red flag: neck pain) Lateral Medullary syndrome - but would present with more symptoms such as ipsilateral vestibular nuclei deficits (nystagmus, vertigo, vomiting) and ipsilateral cerebellar signs (ataxia)

Answer 24

need to be assessed - ABCDE with focus on stabilising c-spine and airway, recognising haemorrhage and treating pain If decreased GCS, alcohol excess and a history of a fall - could be risk factors of subdural haematoma so get urgent CT head In paeds patients, take a note of the weight of the child

Answer 25

Pulmonary oedema is a condition caused by excess fluid in the lungs

Answer 26

Presents with extreme dyspnea, restlessness and anxiety Some patients may produce pink and frothy sputum They may have signs of fluid overload: * Bilateral reduced air entry and inspiratory crepitations * Raised JVP * S3 gallop - a third heart sound that occurs right after S2 * Peripheral Oedema

Answer 27

* Cardiac Ischaemia * Arrhythmias * Non-compliance with regular heart failure medication

Answer 28

* ABG * ECG * Troponin if concerned about a new cardiac event * Serum BNP * Chest X-ray * Bedside observations

Answer 29

* ABCDE * Sit the patient up * Adminster Oxygen * Ensure IV access * IV Furosemide (40mg IV) * Consider non-invasive ventilation such as CPAP if medical therapy failed * In ICU/ITU setting consider invasive ventilation and inotropic support (IV dobutamine or Milrinone - especially if patient has severly reduced LV systolic function i.e low ejection fraction) if all of above fails Morphine can be given to patients who are very anxious and in severe respiratory distress - give with metoclopramide (an antiemetic) to offset the nausea and vomiting side effects of morphine

Answer 30

AKI is normally pre-renal due to under-perfusion and can be managed by replacing fluid as patients are normally hypovolaemic In cases of heart failure + AKI, the underperfusion is however due to poor output from the heart and patients have fluid overload (the left ventricle end diastolic volume is too high so stroke volume falls) So in these patients off-loading fluid with diuresis results in improved stroke volume and so greater output from heart and improved kidney perfusion - so diuresis can also recover renal function

Answer 31

Difficult to manage as diuretic can further lower BP and impact perfusion of vital organs - if patients has low LV ejection fraction and systolic below \<85mmHg or patient is shocked (cool extremities, confusion) - then addition of inotrope may be indicated but discuss with senior - In interim give 250ml boluses over 15-20 mins to keep blood pressure above 90mmHg but need careful titration Vasopressors like noradrenaline can also be added when there is persistent hypotension + end-organ hypoperfusion - but only after insufficient response to inotropes All these measures are temporary tho and just used to maintain until the acute trigger for the deterioration has been reversed

Answer 32

* Nausea and vomiting * Tinnitus * Fever * Confusion * Tachycardia * Initial Respiratory Alkalosis (caused by activation of respiratory centres in the brain) * Later Metabolic acidosis (due to wasting of bicarbonate ions due to ingested acid load) - can be mixed with resp alkalosis

Answer 33

* VBG - looking for acid-base imbalance * Measure Salicylate levels

Answer 34

If ingestion \<1 hour ago - then use activated charcoal Otherwise IV fluid, sodium bicarbonate and potassium chloride - this alkalises the urine in order to increase salicylate excretion and should be monitored with VBGs Dialysis may be necessary if blood levels are extremely high Monitor for complications by checking Renal function - get chest x-ray for pulmonary oedema and CT head if signs of cerebral oedema

Answer 35

DKA is a life-threatening complication of diabetes characterised by hyperglycaemia, hyperketonaemia and metabolic acidosis - there is partial respiratory compensation

Answer 36

* Capillary blood glucose (\>11mmol/L) * Capillary blood ketones (\>3mmol/L) * Venous blood gas - for bicarbonate (\<15mmol/L) and pH(\<7.3) * Urine dip (Ketones 2+ or more) You will expect to find low or normal sodium in DKA

Answer 37

* U+Es - looking for electrolyte abnormalities * FBC - looking for raised infective markers * Blood cultures * Urine MSU * Chest X-ray - looking for focus of infection * ECG - complications of potassium disturbance The common precipitants of DKA include infection, trauma and myocardial infarction

Answer 38

* Abdominal pain * Vomiting * Lethargy * Dehydration - may lead to hypotensive (also from acidosis effects) → coma and death

Answer 39

* Pre-renal kidney failure - secondary to dehydration * Hyperkalaemia - may be secondary to pre-renal failure (so not reccommended to give potassium in the first bag of fluids) * Hypokalaemia - secondary to kidney loss during diuresis and shifts into cells following insulin infusion * Hypoglycaemia - As a consequence of rapid correction of ketosis * Cerebral oedema - rare in adults - may be caused by rapid fluid shifts during rehydration * Pulmonary Oedema - secondary to rapid rehydration * Rhabdomyolysis * Thrombosis * Stroke

Answer 40

Initial treatment of DKA involves fluid resuscitation and maintenance as patients can be severely dehydrated Hyperglycaemia and acidosis can be corrected with insulin treatment When plasma glucose drops below 11.1mmol/L, 5% dextrose should be added to IV fluids - Electrolyte abnormalities like hypokalaemia should be corrected

Answer 41

Management of DKA is time dependent and in paeds, fluids resus more cautious due to risk of Cerebral Oedema but in adults the following: In hour 1: * 1L 0.9% Saline over 1 hour * Give STAT fluid challenge if systolic under 90 * Fixed rate insulin infusion (0.1 units/kg/hr i.e 50 units Actrapid in 50mL 09% saline) AFTER commencing fluids * Continue any long acting insulin patient is on * check blood glucose, ketones and GCS every hour * Continuous ECG monitoring In hours 2-12: * Continue fluid resuscitation (with potassium if serum K\<5.5mmol/L - check before every bag * 1L 0.9% saline + 40mmol KCl over 2 hours, then 2 hours again then over 4 hours then over 4 hours again then over 6 hours * Make sure ketones are falling at least 0.5mmol/L/Hour if not then increase insulin rate * Consider catheter to measure urine output at for at least 0.5ml/kg/hour * if cap glucose drops below 14mmol/L start 125ml/hour 10% glucose alongside the saline * continue fixed rate insulin until Blood ketones \<0.3mmol/L and ph\>7.3 and bicarbonate \>18mmol/L In hours 12-24: * Aim for normal biochemical parameters * if patient unable to eat and drink then start sliding scale insulin * if able to eat and drink then restart subcutaneous insulin regimen - will need some crossover with IV insulin

Answer 42

A.K.A Infectious mononucleosis is a viral infection caused by EBV and transmitted through saliva

Answer 43

Mild infection in small children but a severe infection in teenagers - with fatigue persisting for a few weeks

Answer 44

Usually made clinically - but heterophile antibody ‘Paul Bunnell’ test will be positive if performed

Answer 45

Management is supportive - acute EBV can cause hepatomegaly and splenomegaly - splenomegaly can be so large and high risk of rupture that patients are recommended to avoid heavy lifting or contact sports for 1 month

Answer 46

Should never prescribe amoxicillin for bacterial pharyngitis if glandular fever is suspected as it can cause a widespread rash until amoxicillin is stopped and supportive management initated

Answer 47

Umbrella term covering STEMI, NSTEMI and unstable angina

Answer 48

Unstable angina is a critical narrowing of coronary artery causing ischaemia * Characterised by chest pain at rest or minimal exertion lasting \>15 minutes * ECG changes (new ST depression or T wave inversion * NO rise in troponin; no myocardial necrosis

Answer 49

NSTEMI is a partially occluded coronary artery * Characterised by chest pain at rest or minimal exertion lasting \>15 minutes * ECG changes (new ST depression or T wave inversion * Rise in troponin; myocardial necrosis Can differentiate between NSTEMI and unstable angina by a rise of troponin in NSTEMI

Answer 50

A STEMI is a completely occluded coronary artery * Characterised by chest pain at rest or minimal exertion lasting \>15 minutes * ECG changes (New ST-elevation or left bundle branch block) * Rise in troponin; no myocardial necrosis NSTEMI and STEMI are differentiated by the ECG findings

Answer 51

To diagnose STEMI, there needs to be new ST elevation in 2 or more contiguous leads. must be larger than or equal to 2mm in precordial leads or more than or equal to 1mm in the limb leads

Answer 52

Remember the Mnemonic MMONAC * M - Morphine * M - Metoclopramide * O - Oxygen (if Sats \<94%) * N - Nitrates (GTN spray) - if patient has systolic below 90mmHg then the use of GTN spray is contraindicated as GTN can cause a decrease in blood pressure - this cut off should be used in the clinical context * Asprin 300mg PO * Clopidogrel 300mg

Answer 53

* PCI can be considered if patient presents within 12 hours of symptom onset and within 2 hours of medical contact - they should be haemodynamically stable * if patient within 12 hours of onset but after 2 hours of medical contact, offer thrombolysis - provided they are stable and have no contraindications - if contraindicated to thrombolysis PCI can be done * if patient presents more than 12 hours of symptom onset, pharmacotherapy should be management of choice if they are asymptomatic and stable - otherwise revascularization can be considered

Answer 54

AGAINST * A - Aortic Dissection * G - GI Bleed * A - Allergic Reaction * I - Iatrogenic: recent surgery * N - Neurological disease: recent stroke (within 3 months), malignancy * S - Severe hypertension (\>200/120) * T - Trauma, including CPR

Answer 55

start MMONAC then stratify the patients according to either the TIMI score or GRACE model depending on the hospital patients at high risk of death and further ischaemic events should be offered re-vascularisation within 12-24 hours - patients found to be at low risk can be managed conservatively with medications They can be discharged after having stabilised and should have further cardiac investigations in the future

Answer 56

Status Epilepticus describes any seizure activity that lasts more than 5 mins or if the patients experiences more than one seizure + does not fully regain consciousness between the two

Answer 57

* ABCDE * Oxygen * Ensure IV access * Arterial blood gas * take bloods for glucose, FBC, UE, CRIP, Calcium, Phosphate, Magnesium, drug levels if patient on anti-epileptic medications * Need anaesthetic review to ensure the airway is managed * Give IV Lorazepam 4mg - followed by second dose if no response - If IV access not gained, first line is then administration of PR Diazepam or Buccal Midazolam * If initial benzodiazepines fail, further anticonvulsants can be used (**Leviteracetam, Phenytoin, Valproate**) * If seizures carry on then persist, intubate and general anesthesia is necessary

Answer 58

Rapid Sequence Induction is a method of coordinating the administration of rapidly acting induction agents to produce anaesthesia and muscle relaxation followed by prompt intubation resulting in a secure airway with minimal risk of aspiration

Answer 59

* Airway * Drug Preparation * Monitoring of Vital signs * Drug administration * Cricoid pressure

Answer 60

Think the 7 Ps: * P - Preparation - make sure environment is optimised * P - Pre-oxygenation - administer high flow oxygen for 5 minutes prior to procedure * P - Pretreatment - may involve administration of opiate analgesia or fluid bolus to counteract the hypotensive effect of anaesthesia * P - Paralysis - administration of the induction agent e.g propofol or Sodium Thiopentone and a paralysing agent e.g Suxamethonium or Rocuronium * P - Protection and positioning - cricoid pressure should be applied to protect the airway following paralysis - in line stabilisation may be required in some cases * P - Placement and proof - Intubation is performed via laryngoscopy with proof obtained (direct vision, end tidal CO2, bilateral auscultation) * P - Post-Intubation management - taping or tying the endotracheal tube, initiating mechanical ventilation and sedation agents

Answer 61

* Dizziness * Nausea and vomiting * Palpitations (due to arrhythmias) * Bardycardia typically without hypotension * Yellow-green colour disturbance * Visual halos * Confusion * Hyperkalemia (hypokalemia is a risk factor for toxicity)

Answer 62

* Immediate Digoxin level * IV fluids * Correct electrolyte abnormalities * Continuous cardiac monitoring * Give digiband if level \>15ng/mol after 6 hours of last dose OR level \>10ng/ml within 6 hours of last dose OR symptomatic

Answer 63

McBurney's Sign can be located one-third of the distance from the anterior superior Iliac spine to the umbilicus on the right side and tenderness there indicates acute appendicitis - other signs of appendicitis are Rovsing's sign (palpatiation of left lower quadrant elicits pain in the right lower quadrant) and Psoas sign (right lower quadrant pain elicited on stretching of the iliopsoas muscle)

Answer 64

Epistaxes are nosebleeds and can vary from minor bleeds to life-threatening haemorrhages requiring hospitalisation and surgical treatment

Answer 65

They can be primary or secondary the majority of primary where there is no clear or obvious cause Secondary epistaxis causes can be: * Alcohol * Antiplatlet agents (e.g clopidogrel) * Asprin and NSAIDS * Anticoagulants (e.g warfarin) * Coagulopathy (e.g haemophilia, Von Willebrand's Disease) * Trauma (e.g Nasal Fracture) * Tumours * Surgery * Septal perforation

Answer 66

* ABCDE * Take brief history * First line is direct compression for 10-15 minutes → if it doesn't work and the epistaxis is an anterior position then move onto cauterisation (done through 75% silver nitrate sticks applied to the bleeding site for 3-10 seconds + anaesthesia through lidocaine with phenylephrine) - if posterior or bleeding point not identified, severe bleeding move straight to nasal packing → nasal packing through nasal tampons inflateable packs or ribbon gauze impregnated with vaseline can be used * More aggresive therapies include nasal balloon catheres and transnasal endoscopy with direct cautery/arterial ligation are for posterior bleeds and patients unamenable to nasal packing

Answer 67

Increase current dose by ⅓ i.e 90mg to 120mg and control breakthrough pain with oramorph with 1/6 mg of total MST dose PRN i.e if total dose is 120mg then give 20mg prn of oramorph to control breakthrough pain

Answer 68

* Can be classified as either spontaneous and traumatic * Spontaneous can be due to either primary causes or secondary causes - primary causes mean that there is no underlying pathology and secondary causes means there are * Traumatic can either be due to iatrogenic causes e.g insertion of central line or positive pressure ventilation or non-iatrogenic causes e.g penetrating trauma or blunt trauma with rib fracture

Answer 69

* Connective tissue disorders e.g marfan's syndrome and Ehlers-Danlos syndrome * Obstructive lung disease e.g asthma and COPD * Infective lung disease e.g TB and Pneumonia * Fibrotic lung disease e.g cystic fibrosis and idiopathic pulmonary fibrosis * Neoplastic lung disease e.g Bronchial carcinoma

Answer 70

* If patient is NOT short of breath AND the pneumothorax is \<2cm on x-ray -conservative management is enough and patient should be discharged and reviewed in 2-4 weeks * if patient is short of breath OR pneumothorax is \>2cm, patient should be aspirated with 16-18G cannula under local anaesthetic - if this fails patient an intercostal drain is necessary

Answer 71

* if patient is NOT short of breath AND pneumothorax is \<1cm, does not require any further invasive intervention but should be admitted for observation for 24 hours and administer oxygen as required * If patient is NOT short of breath and the pneumothorax is 1-2cm on x-ray, aspiration is required, if successful the patient can be admitted for 24 hours of observation - if unsuccessful, the intercostal drain is necessary * if patient IS short of breath OR pneumothorax is \>2cm on x-ray, an intercostal drain is necessary

Answer 72

Management is dependent both on how paracetamol was taken and when - treatment based on nomogram i.e if paracetamol levels above treatment line then start NAC 1. If ingestion under an hour + dose \>150mg/kg - give activated charcoal 2. If staggered dose or ingestion \>15 hours ago: Start N-acetylcysteine immediately 3. if ingestion \<4 hours ago: Wait until 4 hours to take a level and then treat N-acetylcysteine based on level 4. If ingestion 4-15 hours ago: Take immediate level and treat based on level 5. **If patient presents after 16 hours/uncertainty about timing/has staggered overdose then give NAC immediately** **Obtain following bloods:** * FBC * Urea and Electrolytes * INR * Venous gas If bloods worsening then transfer to liver unit

Answer 73

* Lethargy * Ataxia * Slurred speech * Coma * Respiratory Distress

Answer 74

* Bradycardia * Hypotension * Mild Hypoglycaemia * Mild Hyperkalemia

Answer 75

* Confusion * Pinpoint pupils * Respiratory distress * Cyanosis if severe

Answer 76

* Dystonia * Sedation * Dry mouth * Hyperthermia * Dysrhythmias

Answer 77

* **S**alivation * **L**acrimation * **U**rination * **D**iarrhoea * Small pupils * Fasciculations * Bradycardia

Answer 78

* Agitation * Tachycardia * Hyperthermia * Acute Renal Failure * Hypo/hypertension * Mydriasis (dilated pupils)

Answer 79

* Anxiety * Agitation * Aggression * Paranoid Psychosis * Hyperthermia * Seizures * Arrythmias are also possible and if untreated will lead to cardiac arrest

Answer 80

These are non-shockable rhythms - so CPR should be commenced immediately Adrenaline 1mg IV should be given in first cycle of CPR and should it still be non shockable then should be administered every other cycle

Answer 81

VT is a regular broad complex tachycardia VF presents as chaotic irregular deflections of varying amplitude They are both shockable rhythms

Answer 82

Defib + CPR is mainstay Non-synchronised DC cardio version should be used in patient with VT/VF - after the first shock CPR should carry on for a further 2 minutes if still persistent then amiodrone 300mg IV and adrenaline 1mg IV (1:10,000) should be given after third shock is delivered - adrenaline should be repeated every other cycle

Answer 83

Acute pancreatitis causes hypocalcaemia which prolongs the QT interval and therefore can lead to TdP

Answer 84

When mild (i.e still conscious): * Eat/drink 15-20g fast acting carbohydrates such as glucose tablets, small can of cocacola, sweets or fruit juice * Avoid chocolate * Eat some slower acting carbohydrates afterwards (e.g toast) If severe (e.g unconsious, seizing): * 200ml 10% dextrose IV (can also be given as 100ml 20% glucose IV) * 1mg/kg glucagon IM if no IV access (will not work if caused by acute alcohol because of its action in blocking gluconeogenesis) * Treat siezure if prolonged or repeated

Answer 85

Oesophagitis is an inflammation of the lining of the gullet commonly caused by the reflux of gastric contents into oesophagus Can also be caused by drugs (e.g Doxycycline - due to its direct chemical irritant effect on the mucosa), infection and allergens (e.g eosinophilic oesophagitis)

Answer 86

* Heartburn (retrosternal burning pain) * Nausea +/- vomiting * Odynophagia (painful swallowing)

Answer 87

Endoscopy allows direct visualisation of oesophagus and can be used to grade the degree of Oesophagitis (Savary-miller grading system or Los Angeles grading system) - biopsy can be taken at the same time as endoscopy If reflux is suspected then oesophageal pH monitoring to identify the timing of symptoms and reflux correlate

Answer 88

managed conservatively through lifestyle changes i.e weight loss, stop smoking, reduced alcohol intake Pharmacological treatements include trial of full dose proton pump inhibitors for one month

Answer 89

Atrial fibrillation occurs when abnormal electircal impuselses suddenly start firing in the atria - overriding the AVN causing a highly irregular pulse rate - if heart rate is \>100bmp it is defined as FAst On ECG you would see irregular QRS complex with absent P waves

Answer 90

Depends on a number of factors: * Presence of adverse sings * Duration * Likelihood of successful cardioversion (e.g age, previous attempts, known reversible precipitatnt) Adverse signs are: * Shock * Syncope * Heart failure * Myocardial Ischaemia The presence of any of these signs in the context of tachycardia is an indication for DC cardioversion If these signs are absent - an AF with a duration \<48 hours can be safetly cardioverted - those with unkown duration or duration \>48 hours require anticoagulation for a minimum of 3 weeks before and 4 weeks after cardioversion due to risk of stroke from left atrial appendage thrombus. Patients who are not cardioverted require life long anti-coag based on their CHA2DS2 VaScscore

Answer 91

* Infection * Hypovolaemia * Pain * Paralytic ileus * Drugs

Answer 92

in order to prevent post-operative nausea and vomiting, multi-modal alagesia model reccommended where anti-emetics of different mechanisms are used in combination for their synergistic effects there are non-pharmological managements: * Minimise patient movement * Analgesia * IV fluids if dehydrated Pharmalogical management: * 5HT3 receptor antagonists e.g ondansetron - which is first line but has risk of QT prolongation and constipation * Histamine (H1) receptor antagonist e.g. Cyclizine. avoid in severe heart failure * Dopamine (D2) receptor antagonist e.g. prochlorperazine. risk of extrapyramidal side effects (dystonic reaction) * Corticosteroids or Metoclopramide (avoid in bowel surgery as can percipitate bowel obstruction) reserved for specific cases of post operative nausea and vomiting for example if patient recieved cyclazine intraoperatively, prescribe ondansteron 8mg IV (give IV if patient vomiting as PO won't work) post op for synergistic effect

Answer 93

Think AEIOU BLAST * A - Acidosis (ph \<7.2 or bicarbonate \<10mmol/L) * E - Electrolyte (persistent hyperkalemia i.e \>7mmol/L) * I - Intoxication - overdose of **B**arbiturates Lithium Alcohol Salicylates Theophylline * Oedema (pulmonary that is refratory) * Uraemia (urea \>40 or symptomatic/complications e.g encephalitis, pericarditis)

Answer 94

AKi is defined as increase in serum creatinine of 26 micromol/L within 48 hours or an increase in serum creatinine \>1.5 times above baseline value within 1 week or urine output of \<0.5 ml/kg/hr for \> 6 consecutive hours

Answer 95

1. Find and treat causes (e.g Sepsis, drugs, obstruction) * Bloods - FBC, U+Es, CRP, antibody screen if autoimmune causes suspected * Urine Dip and Microscopy * Bladder scan - if retention suspected * Ultrasound renal tract - if obstruction suspected * ECG - looking for hyperkalemia/pericarditis 1. Stop renotoxic drugs * ACE-I/ARBs * Spironolactone * Diuretics * Gentamicin - may need dose adjustments if necessary for treatment * NSAIDs 1. Give IV fluid - aggresiveness depends on severity of AKI and comorbities 2. Treat complications (e.g hyperkalaemia, acidosis) 3. Give dialysis if: * Persistently high potassium that is refractory to medical treatment * Severe acidosis (pH\<7.2) * Refractory pulmonary oedema (does not respond to dietry sodium restriction and combined diuretic treatment) * Symptomatic uraemia (pericaditis, encephalopathy) * Drug Overdose (e.g aspirin)

Answer 96

* Hyperkalaemia * Pulmonary Oedema * Metabolic acidosis leading to nausea, vomiting and drowsiness * Chronic kidney disease * Death

Answer 97

In Posterior STEMI, you would see reciprocal changes in leads V1-3 (ST depression, Broad R waves and upright T waves In leads V7-9 you would see the opposite as it shows the posterior aspect of the heart

Answer 98

* Sinus Tachycardia * T wave inversion in leads V1-4

Answer 99

* Global Saddle shaped ST elevation (concave shaped) seen in all leads * PR depression * T wave changes Get an ESR and CRP test to confirm pericarditis

Answer 100

* Tachycardia and hypotension * FBC, U+Es, CRP and culture should be sent off immediately * Fluid bolus of crystalloid should be given in any patient showing hypovolemic shock

Answer 101

* Insomnia * Tremor * Anxiety * Agitation * Nausea and Vomiting * Sweating * Palpitations

Answer 102

* Hallucinations of visual, tactile or auditory origin

Answer 103

* Delusions * Confusion * Seizures * Tachycardia * Hypertension * Hyperthermia

Answer 104

* Patient drinking \>30units a day * Scoring over 30 on the SADQ score * High risk of alcohol withdrawal seizures * Concurrent withdrawal from benzos * Signficant medical or psychiatric comorbidity * Vulnerable patients * Patients under 18

Answer 105

Assisted alcohol withdrawal required in patients who drink over 15 units per day or score over 20 in AUDIT questionnaire * Chlordiazepoxide prescribed in a reducing regimen in accordance with the CIWA-Ar score and local protocol * For alcohol-withdrawal seizures, patient should be prescribed a rapid-acting benzodiazepine (e.g IV lorazepam) - if agitated should also prescribe benzo * Pabrinex (1 pair of ampoules once daily to prevent Wernicke's encephalopathy) - if there are signs of Wernicks (confusion, ataxia, ophthalmoplegia or nystagmus) patients should be prescribed 2 pairs of ampoules TDS * In delirium tremens offer oral lorazepam as first line, if symptoms persist or declines offer parenteral lorazepam

Answer 106

In an anaphylactoid reaction, immune mediators are released as a direct consequence of the drug itself - the appropraite management is to stop the infusion and to give 10mg IV chlorphenamine and restart the infusion at a slower rate once the symptoms settle If patient is also wheezy due to reaction then salbutamol nebulisers can be considered

Answer 107

* Seborrheic dermatitis during intercurrent illness * Oropharyngeal candidiasis

Answer 108

* Most common cause of infectious encephalitis is Herpes Simplex Virus * Cytomegalovirus (CMV) * Adenovirus, Influenzavirus * Tuberculosis * Listeria * Fungal: cryptococcosis, coccidiomycosis, histoplasmosis * Tick borne encephalitis

Answer 109

* Fever * Headache * Altered mental status * Personality change * Focal neurological defecits * Convulsions * HSV1 encephalitis is associated with temporal lobe involvement → olfactory seizures e.g foul smell of rotten eggs

Answer 110

* CT may show medial temporal and inferior frontal lobe involvement with the presence of petechial haemorrhages in HSV encephalitis * Lumbar puncture with CSF analysis - microscopy, serology, cultures

Answer 111

Empirical treatment for suspected encephalitis includes IV aciclovir and IV ceftriaxone/cefotaxime

Answer 112

Lorazepam 4mg IV

Answer 113

If patient over 65 and more than 48 hours after onset of symptoms - rate control is preferred to rhythm control - rate control options include beta-blockers, non dihydropyridine calcium channel block (rate limiting CA blockers like e.g diltiazem or verapamil) or digoxin - check for brittle asthma as betablockers are contraindiated in those patients Rhythm control drugs like Flecainide, amiodarone (reserved for older more sedentary patients) and sotalol preferred in younger patients - but not in those with sturctural heart diseases

Answer 114

* Increasing symptoms * PEF \>50-75% * No features of severe asthma

Answer 115

* PEF 33-50% * RR more than equals to 25 * HR more than equals to 110 * Inability to complete sentences in one breath

Answer 116

Remember 33,92,CHEST * PEF \<33% * SO2 \<92% or PO2\<8 * Cyanosis * Hypotension * Exhaustion, altered counsiousness * Silent Chest (feeble respiratory effort) * Tachyarrhythmias Patients with life threatening asthma can have a normal PCO2 between 4.6-6.0 - raised PCO2 is indication of near fatal asthma

Answer 117

* Requiring ventilatory support * with acute severe or life threatening asthma who is failing to respond to therapy as evidenced by 1. Deteriorating peak flow reading 2. Persisting or worsening hypoxia 3. Hypercapnia 4. Exhaustion, feeble respiration 5. Respiratory arrest

Answer 118

Immediate: * Sit-up * 100% O2 via non-rebreathe mask (aim for 94-98%) * Nebulised Salbutamol (5mg) and ipratropium (0.5mg) * Hydrocortisone 100mg IV or prednisolone 50mg PO If life threatening: * Inform intensive care team * Mangesium sulphate 2g IV over 20 minutes * Nebulised salbutamol every 15 minutes If no improvement: * Nebulised salbutamol every 15min * Continue ipratropium 0.5mg 4-6hrly * Consider aminophylline unless already on theophylline (this is no longer routinely done) * ITU transfer for invasive ventilation Monitor through * Peak flow measurements every 15-30 min pre and post salbutamol * SpO2 keep \>92% * Consecutive aterial blood gas measurements

Answer 119

* Sharp pleuritic chest pain that is relieved by leaning forward - may have had flu like prodrome recently * Examination unremarkable except pericardial friction rub * ECG may show PR depression and global saddle shaped ST elevation * Troponin mildly elevated

Answer 120

* NSAIDS such as aspirin, ibuprofen, and naproxen * Bed rest * Colchicine and steroid may also be used

Answer 121

A clinical syndrome presenting with complications of the body's response to infection Sepsis is when SIRS + presumed/confirmed infection

Answer 122

2 or more of the following: * \>38C or \<36C * Heart rate \>90 * Respiratory rate \>20 * WBC \>12000/mm3 or \<4000/mm3

Answer 123

Sepsis + evidence of organ dysfucntion: confusion, hypoxia, oliguria, metabolic acidosis

Answer 124

Severe sepsis + hypotension, despite adequate fluid resus or lactic acidosis (lactate \>4mmol/L)

Answer 125

* Fever, sweats or chills * Breathlessness * Headache * Nausea and Vomiting * Diarrhoea Observations: * Tachycardia * Hypotension * Pyrexia * Peripherally vasodilated * Hypoxia * Tachypnoea

Answer 126

* ABC Firstly * Sepsis 6 1. Take Bloods (FBC, U&E, LFT, CRP, Lactate, clotting) 2. Take Blood Cultures 3. Administer Oxygen if required (should be for all sepsis patients regardless of saturation - or below 94%) 4. Administer broad specturm IV antibiotics 5. Administer IV fluid resuscitation (crystalloid) - if systolic BP \<90mmHg or lactate \>4mmol/L 6. Monitor Urine output - catheterise Ongoing managment is IV antibiotic therapy, surgical removal of infection source, critical care involvement

Answer 127

* Imaging e.g chest x-ray, echocardiogram, abdominal ultrasound * Viral PCR * Urinalysis +/- culture * Lumbar puncture

Answer 128

Repeat endoscopy with therapeutic intervention - but attempt a different treatment than the first as long as patient haemodynamically stable

Answer 129

Essentially serotonin toxicity - associated with increased seretoninergic activity in CNS

Answer 130

Triad of: * Mental Status changes * Autonomic hyperactivity * Neuromuscular abnormalities

Answer 131

NMS caused by antipsychotics firstly Also NMS develops over days to weeks whereas serotonin syndrome develops over 24 hours NMS is also more characterised by rigidity and bradyreflexia

Answer 132

* Hyperkalaemia (tented T-waves on ECG, best seen in precordial leads) * Acute pulmonary oedema (bi-basal crepitations and type I respiratory failure on an ABG) * Uraemia (confusion and uremic pericarditis

Answer 133

* Tented T-waves

Answer 134

IV Calcium Gluconate

Answer 135

* Infection * MEdications that cause fluid loss or lower glucose tolerance * Surgery * Impaired renal function

Answer 136

* Nausea and Vomiting * Lethargy * Weakness * Confusion * Dehydration * Coma * Seizures Patients can show evidence of hypovolaemia, tachycardia hypotension and exhaustion

Answer 137

* Sever hyperglycaemia (≥30mmol/L) * Hypotension * Hyperosmolality (Usually \>320mosmol/Kg) Unlike in DKA no signifcant acidosis (pH\>7.3 Bicard \>15mmol/L) or ketosis (ketones \> 3mmol/L)

Answer 138

The presence of endogenous insulin production in T2 DM is sufficient to switch off ketone production

Answer 139

Mainstays are rehydration to correct hypotension and electrolyte abnormalities - as patients are at risk of thrombosis due to hyperviscocity (think Virchow's triad: blood stasis, endothelial injury, hypercoagulablilty) , VTE prophylaxis (anticoags e.g heparin or LMWH) is also essential to management Management is: * Fluid resucitation: 0.9% saline, first 1L over 1-2 hours, 1L over 2-4 hours, 1L over 4-6, 1L over 6-8, 1L over 8-10 - change to 0.45% saline only if failing to reduce osmolality by 5mOsm/kg/hr * Insulin at 0.05 units/kg/hour - only if ketones \>1mmol/L or glucose fails to fall - continue any long acting insulin * VTE prophylaxis *

Answer 140

* Drowsiness * Confusion * Arrhythmias * Seizures * Vomiting * Headache * Flushing * Dilated pupils

Answer 141

* Bloods * ECG - evidence of QRS prolongation and PR and QT prolongation which can percipitate cardiac arrythmias e.g heart block or ventricular arrythmias

Answer 142

First line therapy is IV bicarbonate if there is evidence of hypotension, arrhythmias or widening of the QRS interval Activated charcoal can be considered within 2-4 hours of the overdose

Answer 143

* Normal saline (0.9% NaCl) * Hatmann's solution * 4-5% human albumin solution - if severe sepsis * Blood - if severe haemorrhage (i.e splenic rupture) Should not use Dextrose (does not stay in intravascular compartment) or Gelofusine (risks anaphylaxsis) for fluid resus

Answer 144

* initially 500ml of fluid of choice or 250ml if cardiac or disease or elderly due to risk of secondary pulmonary oedema * given over \<15 minutes * repeat if needs be * if patient fails to respond to 2L of fluid = fluid non-responsive and immedaite help should be sought

Answer 145

* GCS less than 13 on initial assessment * GCS less than 15 2 hours after the injury * Suspected open or depressed skull fracture * Any sign of basal skull fracture (haemotympanum, panda eyes, cerebrospinal fluid leakage from ear or nose, battle's sign) * Post traumatic seizure * Focal neurological deficit * More than 1 episode of vomiting

Answer 146

if they have experienced loss of consiousness or amnesia since injury + one of the following risk factors: * age 65 or older * any history of bleeding or clotting disorders * dangerous mechanism of injury ( hit by car, thrown out of car, fall from a height greater than 1 metre or 5 stairs * More than 30 minutes retrograde amnesia of events immediatly before head injury

Answer 147

Open fracture occurs when the bone breaches the skin and communicates directly with the external environment - Tibia and Phalanges are most likely to be open fractures They have an increased risk of infection and require prompt adminstration of antibiotics along with debrinemnet and irrgation prior to reduction and fixation (if loss of pulse urgent reduction required)

Answer 148

* Bowel obstruction * early appendicitis * acute gastritis * acute pancreatitis * ruptured AAA * Ischaemic bowel disease * Examine genitalia as illiac fossa pain could be caused by urological cause i.e testicular torsion

Answer 149

Anaemia = Hb \<130g/L for men and \<120g/L for women Causes are: * Iron deficiency * B12 or folate deficiency * Renal Failure * Malignancy * Menorrhagia * Anaemia of chronic disease * Drugs e.g chemotherapy agents Pre-op Management depends on cause and may include: * Oral Iron if \>6 weeks until surgery * IV iron if \<6 weeks to surgery * B12/folate replacement * ESA therapy * Transfusion if profound anaemia and surgery cannot be delayed Post op management may include: * Transfusion * IV Iron * Oral Iron

Answer 150

* Develops after limb trauma - muscle swelling and inflammation leads to increase in pressure in the muscle compartment - limb threatening condition as the increase in pressure can cause a loss of the blood supply to that limb and subsequent ischaemia

Answer 151

* Severe Pain, particularly on passive flexion of toes * Pallor * Paralysis of the limb * Pulselessness * Paraesthesia

Answer 152

* If patient is in cast - split open the cast and call for ortho review * Urgent fasciotomy, analgesia and fluids

Answer 153

Rare tumour of adrenal gland tissue - results in the release of adrenaline and noradrenaline, hormones that control heart rate, metabolism and blood pressure

Answer 154

Management involves controlling the side-effects of excess adrenaline production: 1. Phentolamine IV (short acting alpha blocker) - to intially control BP 2. Phenoxybenzamine (longer acting alpha blocker) - to control BP before surgery can be arranged 3. Labetolol (beta blocker) - can be used if patient has tachyarrhythmia but only after alpha blockade Definitive management is adrenalectomy 4-6 weeks after blood pressure is controlled

Answer 155

* Heart Damage * Kidney Damage * Pulmonary Oedema * Cerebral Haemorrhage

Answer 156

If patient had a recent stroke thrombolysis is absolutely contraindicated - therefore anticoag should be used - current guidelines is a DOAC such as apixaban

Answer 157

Acute Angle Closure Glaucoma is a medical emergency that occurs when high intra-ocular pressure causes damage to the optic nerve. This occurs due to closure of the iridio-corneal angle in the eye

Answer 158

* Female * Asian * Antimuscarinic medications such as amitriptyline

Answer 159

* Sudden Headache * Nausea * Red eye and visual disturbance * Haloes around bright lights * Symptoms worsen at night as pupils dilate closing iridio-corneal angle even more * on examination, patients have red eye, cloudy cornea and mid-dilated pupil

Answer 160

Initial managment is IV acetazolamide and a topic beta blocker such a Timolol - Muscarinic agonist such as pilocarpine eye drops may be given - Urgent opthalmology referral should be made Definitive management is peripheral iridotomy to relieve the intraocular pressure

Answer 161

* Temporary loss of vision * malignant glaucoma * Iris sphincter atrophy * permanently dilated pupils * Permanent blindness

Answer 162

Inadequate perfusion of key organs

Answer 163

* Hypovolaemic (blood loss) * Septic (severe systemic infections) * Anaphylactic * Cardiogenic (poor cardiac output) * Neurogenic * Obstructive ( caused by physical obstruction to vessels or the heart)

Answer 164

Stage 1 - Anxiety from patient Stage 2 - Agitation and tachyardia Stage 3 - Confusion, Tachycardia, Hypotension, Tachypnoea and reduced pulse pressure Stage 4 - Heart rate \>140 and unconsious

Answer 165

Management of Hypovolaemic (traumatic as this shock is caused by blood loss): * 1.5-2L warmed IV crystalloid * Assess for response * If inadequate response to fluid then arrange O-negative Blood * Give fully cross-matched blood as soon as possible * If patient is severely shocked initiate the massive haemorrhage protocol

Answer 166

* Type of broad complex tachycardia characterised by \>100bpm and a QRS width of more than 120ms Can be caused by: * Electrolyte imbalances i.e hypokalaemia and hypomagnesaemia * Structural heart disease i.e MI and HOCM * QT prolonging drugs i.e clarithromycin erthromycin * Inherited channelopathies i.e romano-ward syndrome, brugada syndrome

Answer 167

Patients with HISS (heart failure, ischaemia, shock, syncope or Heart rate \>150) adverse effects should be offered synchronised DC shock If patient stable with regular broad complex tachy - IV 300mg amiodarone

Answer 168

Injected into the epidural space around the L2-3 or L3-4 vertebral level

Answer 169

Epidural can cause maternal hypotension resulting in fetal and maternal distress There is also a risk of dural puncture, resulting in severe postural headache other risks are epidural haematoma Epidural given for any surgery can cause hypotension due to local anasthesia of the sympathetic nerves thus leading to unopposed parasympathetic activity - if this occurs then epidural should be removed to counteract the hypotension

Answer 170

Once epidural has taken effect, continuous monitoring of the foetus is recommended

Answer 171

Rapid onset of type 1 IgE-mediated hypersensitivity reaction that develops when patient is exposed to a certain precipitant - patients are often hypotensive and this is a life threatening emergency

Answer 172

* Skin reactions: widespread urticaria, itching, flushed skin * Respiratory symptoms: swollen tongue/lips, sneezing, wheeze (inspiratory wheeze a.k.a stridor) * Gastrointestinal symptoms: abdominal pain, nausea, vomiting, diarrhoea * Tachycardia * Hypotension Serum levels of mast cell tryptase to confirm anaphylaxis diagnosis

Answer 173

1. Remove trigger if possible 2. Call for early help 3. ABCDE assessment 4. Administer Oxygen and Lie patient flat and raise legs 5. Administer adrenaline (adult dose is 500 micrograms IM 1:1000) 6. Adminster chlorphenamine and hydrocortisone (should be given after ABCDE assessment when patient has been stabilised 7. IV fluid challenge if hypotensive

Answer 174

Jaw thrust

Answer 175

Rupture of the interventricular septum - harsh and holosystolic murmur may be heard

Answer 176

Beck's Triad: * Hypotension * Raised JVP * Muffled heart sounds

Answer 177

As loop diuretic works on the thick ascending loop of henle targeting naKCl cotransporters on the apical membrane therefore it must be first filtered into the tubules by the glomerulus - if eGFR low, the dose must be increased from the normal 40mg IV so that an increased conc reaches the glomerulus and tubules to achieve the desired effect

Answer 178

Manage conservatively by prescribing 250ml IV saline over 15 minutes as it may reverse the cause of the Fast AF

Answer 179

Also any slight temperature should be a cause for concern as neonates and infants may not be able to generate true pyrexia

Answer 180

Repeat Troponin level in a few hours as in MI troponin does not rise until 2 to 3 hours after so needs to be repeated to identify any changes

Answer 181

* Systolic BP \<100mmHg * Heart rate \>90bpm * Capillary refill \>2s * Cool peripheries * Respiratory rate \>20bpm * NEWS ≥5 * Dry mucous membranes

Answer 182

* Identify cause of fluid deficit and respond appropriately * Fluid bolus of 500mL crystalloid over \<15 minutes * Reassess ABCDE approach * Further fluid boluses (up to 200mL) may be required

Answer 183

Assess ability to meet fluid needs enterally Assess fluid deficits, excess losses, abnormal fluid distribution Normal daily fluid requirement: * 25-30mL/kg/day water * 1mmol/kg/day Sodium * 1mmol/kg/day Potassium * 1mmol/kg/day chloride * 50-100g/day glucose to limit ketosis

Answer 184

Pancreatitis is inflammation of the pancreas

Answer 185

Remember GET SMASHED: * G - Gallstones (most common cause worldwide) * E - Ethanol (most common cause in Europe) * T - Trauma * S - Steroids * M - Mumps * A - Autoimmune disease (Polyarteritis Nodosa/SLE) * S - Scorpion Bite * H - Hypercalcaemia, hypertriglycerideaemia, hypothermia * E - ERCP * D - Drugs

Answer 186

Remember FATSHEEP * F - Furesomide * A - Asathioprine/Asparaginase * T - Thiazides/Tetracycline * S - Statins/Sulfonamides/Sodium Valproate * H - Hydrochlorothiazide * E - Estrogens * E - Ethanol * P - Protease inhibitors and NRTIs Some of the drugs listed above are sulphonamides (thiazides, furesomide, HIV drugs - protease inhibitors and NRTIs) Sulfazalazine and gliclizide

Answer 187

* Stabbing-like, epigastric pain which radiates to the back that is relieved by sitting forward or lying in the fetal position * Vomiting is highly associated with this * History of recent alcoholic binge or a history of gallstones are highly suggestive

Answer 188

Signs are variable: * Hypovolaemia (tachycardia, dry mucous membranes due to third space loss of fluids) * fever - only if pancreatitis has been complicated with infection * Guarding in the epigastric region - admittedly not a very specific sign * Haemorrhagic pancreatitis patients show a rare sign called Grey-Turner's sign - bruising along the flanks and indicates retroperitoneal bleeding which is highly associated with acute pancreatitis * Cullen's sign - bruising around the peri-umbilical area - highly associated * Third space fluid sequestration in pancreatitis results due to a combo of inflammatory mediators, vasoactive mediators and tissues which lead to vascular injury, vasoconstrictin and increased capillary permeability - can lead to ARDS, pleural effusions and hypovoleamie which can leading to AKI

Answer 189

* Leukocytes can indicate the presence of necrotising pancreatitis * LFTs may be abnormal if there is gallstone disease * Lipase level is more sensitive than amylase but not found in all hospitals - amylase 3x the upper limit extremly suggestive of acute pancreatitis 1. other causes such as duodenal ulcer, cholecystitis and mesenteric infacrtion may elevate amylase but to a lesser extent

Answer 190

Imaging is useful for finding underlying cause * Ultrasound - gallstones * MRCP looks for obstructive pancreatitis - ERCP is preferred and can be theraputic in those cases * CT scan - checks for later stage complications such as pseudocysts or necrotising pancreatisis

Answer 191

Using the modified glasgow scale - if 3 or more of the following factors then indication for transfer to ITU/HDU Remember PANCREAS: * P - PaO2 \< 8kPa (60mmHg) * A - Age \>55 years * N - Neutrophils WBC \> 15x109/L * C - Calcium \<2mmol/L * R - Renal function - Urea \>16mmol/L * E - AST/ALT \>200iu/L or LDH \>600 iI/L * A - Albumin \<32g/L * S - Sugar - Glucose \>10mmol/L

Answer 192

* Aggresive fluid resuscitation with crytalloids - aim to keep urine output \>30mL/Hour - start with a 1 litre bolus and try to maintain adequate urine output - basically fluid requirement of 3-5ml/kg/hr * Catheriseation * Analgesia - strong analgesia in the form of opioids needed * Anti-emetics * IV antibiotics - only for necrotising pancreatitis (a complication due to inadequate fluid resus during initial management) * Calcium can be given if hypocalcaemia is present * Insulin may be given in the presence of hyperglycaemia due to damaged pancreas reducing the release of the hormone

Answer 193

* Type A - dissections involving the ascending aorta and aortic arch * Type B dissection - dissection involving the descending part of aorta and may extend into the abdomen

Answer 194

* Central chest pain (coronary Ostia → MI) * Dyspnoea (ascending aorta → aortic regurgitation → CCF) * Neck/Jaw pain (aortic arch) * Horner's (cervical sympathetic ganglia) * Symptoms of stroke (carotid arteries) i.e paraparesis (partially unable to move legs)

Answer 195

* Interscapular pain (thoracic descending aorta) * Abdominal pain (adbominal descending aortic; mesenteric arteries) * Flank pain (renal arteries) Pain is normally the worst at the onset of the tear and gets better overtime

Answer 196

* CT ( axial and coronal planes)

Answer 197

Inflammation and infection of the epiglottis - uncommon in the UK due to the introduction of the Haemophilus influenza vaccine but may be seen in patients who have not undergone the full course of their vaccines

Answer 198

* Steptococcus spp. * Staph Aureus * Haemophilus influenza B - most common cause in non vaccinated * Pseudomonas * Herpes simplex Non-infectious causes can include thermal causes, foreign bodies and radiotherapy related inflammation

Answer 199

Whooping cough presents as an infection of the trachea and bronchioles and is most commonly caused by Bordetella Pertussis

Answer 200

* Fever * Drooling * Stridor * Pain * Child prefers to sit upright These patients should not be examined treated or cannulated but left alone as any upset or distress may lead to total airway obstruction

Answer 201

* Refer to ENT and anaesthesia immediately * need urgent intubation and ventialtion and treatment with antibiotics after airway has been secured * Depending on cause IV or oral antibiotics can be started

Answer 202

* Start CPR and deliver unsynchronised DC cardioversion

Answer 203

Extradural Haemmorhage is a collection of blood between the inner surgace of the skull and the outer layer of the dura - Most commonly caused by a torn middle meningeal artery

Answer 204

* Headache * Nausea * Vomiting * Altered mental state and sometimes seizures They may regain normal level of consciousness (a lucid interval) before then gradually losing consiousness May also present with 6th nerve palsy - will present as being unable to turn eye in one direction - 6th nerve is particularly susecptible to damage following herniation secondary to intercranial pressure - it is known as a false localising sign (as it reflects dysfunction remote to the anatomical locus)

Answer 205

* CT Head * Will show up as bi-convex (lentiform) shaped haemotamoa which is hyperdense

Answer 206

Management can range from conservative monitoring, blood pressure reduction or if its severe surgery to evacuate the haemoatoma i.e burr holes

Answer 207

In distributive shock, there is a drop in systemic vascular resistance that leads to low BP as opposed to a drop in cardiac output - the vasodilation causes a decrease in SVR (in other forms of shock, the SVR increases to compensate for the Dropped CO so there are cold peripheries) The two most common causes of distributive shock are sepsis and anaphylaxis - in distributive shock patients are usually euvolaemic

Answer 208

* Cardiovascular drugs: Clopidogrel and Aspirin should be stopped 7 days before surgery - Warfarin should be generally stopped 5 days before surgery and patients should be on LMWH until the night before the surgery - ACE-I should be stopped the day before surgery * Diabetes Drugs: Insulin should be held on the day of surgery (only the short-acting preparations), sulfonylureas should be held on the day of the surgery (due to risk of hypoglycaemia) - metformin should be given as normal for short procedures, for long procedures when the patient is not eating and drinking for several days, metformin should be held and variable-rate insulin prescribed * The pill should be stopped 4-6 weeks before surgery and restarted at least 2 weeks after surgery when patient is mobile - this reduces the risk of DVT

Answer 209

When mediastinum is shifted contralaterly compared the side of pneumothorax and is a worrying sign

Answer 210

Presents in a non-specific manner * Confusion * Nausea and Vomiting * Cherry Red skin * Tachycardia * 100% oxygen saturation on pulse oximietry

Answer 211

* VBG/ABG - a Carboxyhaemoglobin concentration \>20% is diagnostic 1. 0-15% asymptomatic 2. 15-20% confused and/or complain of headache 3. 20-40% lethargy, nausea and disorientation common presentation - can be mistaken for intoxication 4. 40-60% ataxia hallucinations collapse and seizures are common 5. \>60% Dead * Chest x-ray - looking for signs of acute respiratory distress syndrome * ECG - looking for Ischaemic changes * Bloods including creatinine kinase (indicator of rhabdomyolysis

Answer 212

* VBG/ABG - a Carboxyhaemoglobin concentration \>20% is diagnostic 1. 0-15% asymptomatic 2. 15-20% confused and/or complain of headache 3. 20-40% lethargy, nausea and disorientation common presentation - can be mistaken for intoxication 4. 40-60% ataxia hallucinations collapse and seizures are common 5. \>60% Dead * Chest x-ray - looking for signs of acute respiratory distress syndrome * ECG - looking for Ischaemic changes * Bloods including creatinine kinase (indicator of rhabdomyolysis

Answer 213

* 100% oxygen via face mask - helps unbind CO from haemoglobin molecule * Hyperbaric oxygen - controversial but widely considered gold standard

Answer 214

Anorexia nervosa like other eating disorders, HIV and, malnutrition leads to a glutathione deplete state (glutathione inactivates NAPQI the toxic substance when paracetamol metabolised) - so there is an increased risk of toxicity in these patients and NAC should be administered immediately

Answer 215

PCI can be performed within 120 minutes of initial medical contact - is preferred over fibrinolysis - if PCI cannot be done within this window, then fibrinolysis must be done unless there is an absolute contraindication to fibrinolysis (AGAINST) like previous intercranial haemorrhage (stroke)

Answer 216

* Small T-waves * Prolonged PR interval (first degree heart block)

Answer 217

* Tall Tented T waves * Widened QRS complex most common complication of DKA

Answer 218

Should be given if systolic BP \<90mmHg

Answer 219

1. Switch oral steroids to 50-100mg IV hydrocortisone 2. If there is associated hypotension then fludrocortisone can be added (no need/ should be stopped temporarily if patient has hypertension) 3. For minor operations oral prednisolone can be restarted immediately post op. For major, patient may require IV hydrocortisone for up to 72 hours post op, and then oral steroids can be started again The increased dose of steroids is required to account for the stress response to surgery

Answer 220

* Encourage the patient to cough * 5 back blows with the heal of the hand aimed centrally between shoulder blades * 5 abdominal thrusts performed from behind the patient with a fist placed between the umbilicus and xiphisternum, grasping it with the other hand and pulling upwards and inwards sharply * continue these motions until the obstruction is dislodged or the patient becomes unconscious

Answer 221

if unconsious start ABCDE Airway: open the mouth and observe if the obstruction is observable and removable - only attempt to remove an object under direct vision - open the airway with jaw thrust or head tilt/chin lift If patient is not breathing, begin cardiopulmonary resuscitation

Answer 222

Centres around three things: * Oxygen - Sit-up, 24% O2 via venturi mask: SpO2 88-92% - Vary FiO2 and SpO2 targer according to arterial blood gas * Nebulised bronchodilators - Salbutamol 5mg/4h - Ipratropium 0.5mg/6h * Steroids - Hydrocortisone 100mg IV - Prednisolone 50mg PO for 5-14d add antibiotics if evidence of infection Further treatment is: * Repeat nebulisers and consider aminophylline IV * Consider NIV (BiPAP) if ph \<7.35 and/or RR\>30 * Consider invasive ventilation if pH\<7.26

Answer 223

* Angioedema * Anaphylaxis * Thermal Injury * Neck Haematoma * Wheeze * Surgical Emphysema * Reduced consciousness

Answer 224

* Suction (if visible vomit, blood, secretions or foreign body) - turn patient on side if actively vomiting ( not applicable in c-spine injury) * Head tilt/chin lift - can be achieved manually or by placing a pillow under the neck - aim for sniffing position * Jaw thrust - using both hands, hook the fingers under the angle of patient's jaw and lift the mandible forwards

Answer 225

* Oropharyngeal airway e.g Guedel - rigid plastic tube, approximately measured from the incisors to the angle of the jaw - inserted upside down and rotates 180 degrees to hold the tongue away from the posterior pharynx * Nasopharyngeal airway - flexible rubber tube, passes through one anterior nare to sit inferior to the base of the tongue, useful in patients with a sensitive gag reflex when using guedel - NPA contraindicated in base of skull fracture

Answer 226

* Supraglottic airway - Laryngeal mask airway (LMA) or i-gel - sits over the top of the larynx - can be used with ventilation machine * Endotracheal Tube - flexible plastic tube with inflatable cuff - inserted using a laryngoscope, used for prolonged mechanical ventilation - it is a protected airway as it protects against aspiration * Surgical airways - Tracheostomy, Cricothyroidotomy

Answer 227

The spleen is at particular risk during trauma and furhtermore many litres of blood can be lost into the abdominal cavity

Answer 228

Endscopy is method of choice for managing bleeding - theraputic measures can include clipping, thermal coagulation, fibrin or thrombin

Answer 229

* Generalised seizures are usually sudden onset * Lateral tongue biting + urinary incontinence may occur * Typically last \<5 minutes * Patient is often confused (though may recall onset, if secondary generalised) and may be left with residual focal neurological deficit (Todd's Paresis) There are two groups of seizures - provoked seizures and unprovoked seizures - In unprovoked there is an underlying tendency to spontaneous abnormal electrical brain activity (may be congenital or acquired tendencies)

Answer 230

Syncope features are distinguished from seizures by the absence of postictal confusion. Patients experiencing vasovagal syncope report narrowing of vision, sweating, and lightheadedness and usually have time to lower themselves to the floor without injury. In arrhythmogenic syncope (a.k.a stokes-adams attacks), are abrupt in onset without warning and may result in significant injury - in Syncope, myoclonic jerks and tonic posturing may occur during these episodes which may confound diagnosis

Answer 231

Pseudoseizures are prolonged episodes (rarely \<1 minute, often \>30minutes) usually in front of a witness and patient exhibits fluctuating motor activity and seizure-like convulsions. Tongue biting is rare. Video EEG recording may be iindicated to differentiate PNEAs (psychogenic nonepileptic attacks) from true seizures Can be differentially diagnosed as hemiplegic migraine, cerebrovascular events though consciousness is typically preserved In patients with true seizure activity **and** focal weakness, differentiating seizure plus todd's paresis from stroke with seizure at onset is difficult clinically and **often requires imaging**

Answer 232

* Generalised seizures - affecting the entire brain - can be subclassified depending on clinical manifestation - tonic, tonic-clonic, atonic, myoclonic or absense - Generalised tonic-clonic are the most typical and patient falls to the ground stiff (tonic phase) followed a series of rhythmic jerks (clonic phase) * Focal seizures - involving a subsection of the brain - can spread to involve the entire brain known as secondary generalisation - can be subclassified depending on key clinical features i.e which part of the brain is involved (temporal vs frontal lobe seizures) and whether consciousness is impaired (simple vs complex)

Answer 233

a.k.a orthostatic hypotension or postural hypotension - common in elderly or those taking BP lowering medication - no residual focal defecit and generally patient sitting or lying down for a long time before getting up leading to orthostatic syncope - patients are behaving normally within a few minutes after the episode

Answer 234

loss of consciousness whilst sitting or lying down - associated with chest pain and palpitations

Answer 235

Vasovagal syncope results due to either parasympathetic hyperactivity or sympathetic hypoactivity or combination of the two - can be caused by prolonged periods of standing and can be triggered by coughing, sneezing, swallowing or the valsalva manoeuvre - situations involving emotional stress can cause vasovagal syncope

Answer 236

Non invasive ventilation is the means by which patients can be assisted in breathing but does not involve intubation with an endotracheal tube Can be continuous positive airway pressure and bi-level positive airway pressure

Answer 237

CPAP is commonly used for type I respiratory failure (low oxygen and normal or low carbon dioxide levels), providing positive pressure to keep the alveoli open for a longer period of time to facilitate gas exchange

Answer 238

BiPAP is used in patients with type II respiratory failure (low oxygen with high carbon dioxide), with two different levels of positive pressure on inspiration and expiration

Answer 239

* Patient awake and able to protect airway * Co-operative patient * Consideration of quality of life of patient

Answer 240

* Facial burns * Vomiting * Untreated pneumothorax * Severe Co-morbidities * Haemodynamically unstable * Patient refusal

Answer 241

1. What is the time course? 2. What are the associated symptoms? 3. What is the medical history? 4. What does the retina look like?

Answer 242

Presents with sudden painless loss of vision and the view on fundoscopy is that of a “stormy-sunset” appearance - more common than central retinal artery occlusion Risk factors are: * Old age * Hypertension * Diabetes Mellitus * Polycythaemia * Arteriosclerosis

Answer 243

* CRAO much less common than CRVO and occurs more rapidly * On Fundoscopy, the view is that of a pale retina with a cherry red spot at the macula Risk factors for CRAO are: * Carotid Bruits * Hypertension * Atrial Fibrillation * Diabetes Mellitus * Smoking * Hyperlipidaemia

Answer 244

* Broad term that describes optic nerve damage due to lack of blood supply * There are different causes to the condition and each vary slighly in presentation - but generally, patients present with sudden onset monocular vision loss and colour blindness * On examination, a relative afferent pupullary defect is often elicited. On fundoscopy, it is common to see optic disc swelling in the acute phase or a pale optic disc in the chronic phase that suggests optic atrophy

Answer 245

* Most common form of arteritic anterior ischaemic optic neuropathy * Typically occurs in elderly females presenting with sudden onset painless loss of vision with headache, jaw claudication and scalp tenderness * Strong association between this condition and polymualgia rheumatic

Answer 246

* Presents with floaters or flashes followed by a curtain falling over their vision * Fundoscopy shows a pale-grey area of retina ballooning forward * Do not confuse it with amaurosis fugax, that presents similiarly but in a transient manner

Answer 247

* If minor - patients complain of floaters * If severe - patients complain of painless loss of vision * When bleed is large enough to cause visual loss, the retina is difficult to view on fundoscopy * Suspect this diagnosis in patients with neovascularisation due to diabetes mellitus or CRVO

Answer 248

* Typically progresses over hours to days and it is typically painful * Suspect this if ocular movement causes pain or there is “red desaturation” * Optic neuritis is the commonest initial feature of multiple sclerosis * In patients with MS and secondary ON - can see a relative afferent pupillary defect (relatively dilated pupil when the torch is swung towards it)

Answer 249

Bradycardia is defined as a HR \<60. Patients may not be symptomatic so may only require observation in the initial stages Bradycardia associated with haemodynamic compromise (i.e systemic hypotension, signs of cerebral hypoperfusion, progressive heart failure or angina) is a medical emergency

Answer 250

* Can be normal in athletic individuals * Electrolyte distrubances * Hypothyroidism * Myocardial infarction * Sepsis * Drugs e.g beta blockers * Increased intercranial pressure * Heart block

Answer 251

Medical therapy should be started immediately if there is evidence of haemodynamic compromise regardless of the cause and continued until temporary cardiac pacing is initiated Most common medication to increase ventricular rate are IV atropine, epinephrine and dopamine Patients who are not responsive to medical therapy require prompt temporary pacing - two most common modes being transcutaneous and transvenous

Answer 252

In patients with drug eluding stents, altering aspirin and clopidogrel may lead to stent stenosis so should be discussed with cardiology first

Answer 253

* Reserve Tick ST depression with first degree heartblock

Answer 254

Features can be broken down into systems: * Peripheral features: Fine tremor, finger clubbing, sweating, pretibial myxoedema (like a localised lesion of the skin) * Head and neck features: Goitre (depending on cause), Thyroid bruit (continous sound heard over the thyroid mass) * Eye features: Lid retraction, lid lag, exophthalmos (graves' disease), perioribital oedema (graves' disease), opthalmoplegia (graves' disease) * Cardiac features: Atrial fibrillation, high output heart failure (if severe and prolonged) * Gastriointestinal features: Diarrhoea * Neurological features: muscle wasting, proximal weakness

Answer 255

* Graves' Disease * Toxic Thyroid adenoma * Multinodular goitre * Silent thyroiditis * De Quervain's thyroiditis (painful goitre) * Radiation In primary hyperthyroidism there is Low TSH and elevated T4 and T3

Answer 256

* Amiodarone * Lithium * TSH producing pituitary adenoma * Choriocarcinoma (beta-hCG can activate TSH receptors) * Gestational hyperthyroidism * Pituitary resistance to thyroxine (i.e failure of negative feedback) * Struma Ovarii (ectopic thyroid tissue in ovarian tumours)

Answer 257

* Palpitations * Restlessness * Tremor * Hyperthermia * Hypertension * Confusion

Answer 258

* Propranolol - used for symptom relief * Medical management is Carbimazole or Propylthiouracil (PTU) given either as “titration-block” or “block and replace” 1. Carbimazole is contraindicated in eraly pregnancy but perferred in later pregnancy 2. PTU is treatment of choice in first trimester pregnancy/thyroid storm * Radio-Iodine is the definitive management for multinodular goitre and adenomas - contraindicated in Graves eye disease becuase it may worsen symptoms * Thyroidectomy is indicated for recurrence, goitres that obstruct other stuctures, potential cancer - may lead to hypoparathyroidism, hypocalcaemia, laryngeal nerve damage and bleeding

Answer 259

Management can be broken down into symptom control, reducing thyroid activity and treating complications 1. Symptom control * IV propranolol * IV digoxin if propanolol fails or is contraindicated (e.g asthma, low BP) 1. Reduce thyroid activity * Propylthiouracil (PTU) through NG tube (because it inhibits peripheral thyroixine conversion) followed by Lugol's iodine 4-6 hours later * Methimazole/carbimazole is considered second line * Prednisolone/hydrocortisone 1. Treat complications (e.g. heart failure, hyperthermia)

Answer 260

* Thyroid storm (often precipitated by surgery, trauma or infection) - may present as high fever, tachycardia, confusion, nausea and severe vomiting * Atrial fibrillation * High output heart failure * Osteopenia/osteoporosis * Upper airway obstruction due to a large goitre * Corneal ulcers/visual loss in Graves' eye disease

Answer 261

Type I respiratory failure shows a low pO2 but a normal pCO2 Causes of Type I Resp failure can be: * Decreased atmospheric pressure * Ventilation-perfusion mismatch * Shunt * Pneumonia * ARDS * Pulmonary Embolism

Answer 262

Type II respiratory failure shows a low pO2 and a high pCO2 causing an acidosis Causes of Type II respiratory failure can be: * COPD * Brain stem disease/Lesion * Bronchitis * Motor Neuron Disease * Deformity e.g. ankylosing spondylitis, kyphoscoliosis

Answer 263

* Duloxetine * Amitrptyline * Pregablin and gabapentin

Answer 264

If patient was witnessed going into cardiac arrest with an initial shockable rhythm - should deliver up to three shocks immediately

Answer 265

In patients with nausea after surgery, they're likely to be given metoclopramide (an antidopaminergic - dopamine antagonist - anti-emetic) which can cause in an acute dystonic reaction ( forced extension of neck, rigid opening of jaw, sustained upward deviation of the eyes) - common in younger than 30s and when dose is greater than 30mg per day Metoclopramide should be discontinued and an anticholinergic agent should be prescribed such as Procyclidine or biperiden to alleviate the acute dystonic reaction

Answer 266

Raised Anion Gap Metabolic Acidosis Anion gap is the difference between measured cations and measured anions in the serum - calculated using ([Na+] + [K+]) - ([Cl-] + [HCO3]) - normal range is 10-20mmol/L In raised anion gap 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 ketones are the source of acidosis

Answer 267

* Uraemia (in renal failure) * Lactic acidosis (e.g in spesis) * Ingestion of drgus such as aspirin, methanol and ethylene glycol

Answer 268

In normal anion gap metabolic acidosis, there is a decrease in bicarbonate but there is a compensatory increase in reabsorption of chloride in the kidneys thereby negating the decrease in chloride on the anion gap Causes can be diarrhoea, renal tubular acidosis, addison's disease and over-infusion with normal saline

Answer 269

If patient is still symptomatic then PCI - if no contraindications (stroke) then thrombolysis Otherwise patient should be managed pharmacologically which normally includes aspirin, ticagrelor or Clopidogrel, fondaparinux in acute stages followe dby Bisoprolol and a statin

Answer 270

Bilateral blood pressure measurements (one in each arm) showing a difference of \>20mmHg especially in light of suggestive history points to aortic dissection - pulse differences in lower limbs may also be found

Answer 271

Cardiac tamponade is a life-threatening condition characterised by an accumulation of blood in the pericardial sac - volume and pressure of blood can impair cardiac filling

Answer 272

* Penetrating wounds i.e. from road traffic accidents or pacemaker insertions * Pericarditis * Malignancy * Inflammatory conditions i.e SLE

Answer 273

* Beck's Triad ( Raised JVP, hypotension and muffled heart sounds) * Kussmaul's sign ( rise of JVP with inspiration) * Pulsus Paradoxus ( drop is systolic blood pressure with inspiration) * ECG may show electrical alternans (alternating height of QRS complex) and an echocardiogram is the most useful diagnostic investigation

Answer 274

Most appropriate treatment is pericardiocentesis where fluid is aspirated and subsequently drained from the pericardium

Answer 275

Lactic acidosis is a form of raised anion gap metabolic acidosis caused by increased lactate in the bloodstream

Answer 276

Two types: * Type A - Tissue Hypoxia * Shock (e.g. cardiogenic, hypovolaemic, haemorrhagic) * Hypoxia * Acute mesenteric ischaemia * Limb Ischaemia * Severe anaemia * Siezures * Vigorous exercise * Abnormalities in metabolism of lactate (Type B) * Diabetic ketacidosis * Cancer * Liver disease * Inborn errors in metablism * Drugs - Metformin (impairs liver metabolism of lactate), Aspirin Lactic acidosis is initially managed with a fluid bolus - 500mL 0.9% saline bolus

Answer 277

It is a life threatening infection of the subcutaneous soft tissue, with spread along the fascial planes but not the underlying muscle It is classified into 4 types. The most common are type 1 (polymicrobial infection with anaerobes) and type 2 (monomicrobial infection with group A streptococci

Answer 278

* Presents with rapidly spreading cellulitis and patient is systemically unwell * Patients often have a history of risk factors e.g. cutaneous portal of entry for the bacteria (trauma/surgery) or Insect bite * On examination the affected area will be blistering and erythematous - in early stages mild oedema may be the only sign - there will either be severe pain or anaesthesia over the site of cellulitis * In advanced cases, skin may be grey with overlying crepitus * Patients are typically pyrexial, tachycardic, tachypnoeic and hypotensive Signs of subcutaneous gas on x-ray suggest deep seated infection - purple colour can develop as a result of thrombosis within the local blood vessels 70% of nectrotising fasciitis occurs in people with some form of immunosuppresion or a significant chronic disease such as diabetes

Answer 279

Management is with: * Haemodynamic support * Urgent surgical debrinement and washout * Broad spectrum antibiotics Radiography or CT/MRI can confirm diagnosis but should not delay surgery

Answer 280

Wolff-Parkinson-White is caused by a congenital accessory electrical pathway which connects the atria to the ventircles bypassing the AV node - leads to supraventricular tachycardia

Answer 281

* Often Asymptomatic * Palpitations * Dizziness * Syncope

Answer 282

* Delta Waves (slurred upstroke into the QRS) * Short PR interval (\<120ms) * Broad QRS * If a re-entrant circuit has developed ECG will show a narrow complex tachycardia

Answer 283

* ECG * 24 hour ECG monitoring if paroxysmal symptoms * Routine blood including TFTs if non-cardiac causes of tachycardia are suspected * ECHO - to assess ventricular function * Intracardiac electrophysiological studies to map the location of the accessory pathway

Answer 284

* Radiofrequency ablation of the accessory pathway * Drug treatment (such as amiodarone or Sotalol) to avoid further tachyarrhthmias - these drugs are contraindicated in structural heart disease * Surgical (open-heart) ablation - rarely done and only used in complex cases * Digoxin and NDP-CCBs (Ca+ blockers e.g Verapamil) are contraindicated for long term use because they may precipitate ventricular fibrillation If patient is experiecing SVT, then management is dependent on stable or unstable, and if stable on the type of arrhythmias

Answer 285

If unstable: * Unstable (\<90/60mmHg or with signs of systemic hypoperfusion or fast atrial fibrillation) require urgent DC cardioversion If stable: * If patietn has orthodromic (in the same direction as nerve fibres) AV reciprocating tachycardia (narrow QRS with short PR) managment is first Vagal maoeuvres - if this fails then IV adenosine - in orthodromic AVRT, one limb of the aberrant cirucit involves AV node so slowing conduction through the AV node helps terminate the tachycardia * If patient has antidromic AVRT, AF or Atrial flutter, intravenous anti-arrhythmics (such as **procainamide** or **flecainide**) help prevent rapid conduction through the accessory pathway * DC cardioversion if symptoms persist

Answer 286

It is where the contents of a hollow organ that were joined surgically leak through the fault in the join - one of the most serious complications of intestinal surgery as bowel contents contaminate the peritoneal cavity and can lead to peritonitis, colonic abscess formation and abdominal sepsis Typically occur 5-7 days post surgery - more insidious leaks can occur later so anastamotic leak should be suspected in any patient after intesitnal surgery who has failure to thrive, persistent low grade fever or prolonged ileus

Answer 287

Radiological investigation i.e CT abdomen and Pelvis, should be done with contrast - as the inappropriate presence of IV contrast in the abdominal cavity shows the leak Before imaging, lactate levels in VBG can assess tissue ischaemia - patients also require investigations for sepsis Small leaks can be managed conservatively with bowel rest, IV fluids and antibiotics with repeat abdominal monitoring. Larger leaks require emergency laparascopic exploration with potential further surgery

Answer 288

Headaches occuring in patients who use analgesics such as paracetamol, NSAIDS and weak opiated to manage existing headaches - ironically leads to developing more frequent daily headahces which worsen with more frequent use of these drugs Mechanism of action is thought to be due to downregulation of pain receptors leading to a lack of efficacy for the analgesics

Answer 289

Most appropriate treatment is to withdraw the offending drugs, and consider restarting previously used drugs at lower dose or using different not previously used drug

Answer 290

It is when the spinal cord is compressed by an external lesion e.g bone fragment, tumour, abscess

Answer 291

Medical emergency as delays can lead to irreversible neurological dysfunction Most common cause of acute spinal cord compression is trauma but in older patients (especially those with a history of malignancy/lacking a history of trauma) malignant spinal disease must be suspected

Answer 292

* Back pain and lower limb weakness/stiffness are earlier signs * Bladder and bowel disturbance are late signs suggesting irreversible damage * Sensory symptoms include: * Band like pain around thorax/abdomen (in a dermatomal distribution) * Radicular pain (down a limb dermatome) * Reduced sensory level * Paraesthesia

Answer 293

* If metastatic aetiology is suspected, patients should be given Dexamethasone 16mg PO as soon as possible (to reduce tumour size and therefore relieve pressure) * Urgent Whole Spine MRI should be ordered * Urgent referral to neurosurgery should be made with a view to possible radiotherapy or decompressive surgery

Answer 294

Mechanical ventilation is the most effective management method - Non-invasive ventilation is not recommended for acute asthma exacerbations

Answer 295

Fentanyl can lead to sympathetic inhibition and significant hypotension - Metaraminol, an alpha agonist can counteract this effect and rapidly correct hypotension

Answer 296

Trigeminal Neuralgia is a chronic pain condition characterised by severe shooting or stabbing pain in the distribution of one or more divisions of the trigeminal nerve It can be triggered by light touch, eating or wind blowing on the person's face Neurological exam in these patients is normal but pain may be triggered by lightly touching the affected side of the face

Answer 297

Causes can either be primary or idiopathic and secondary Causes include: * Malignancy * Arteriovenous malformation * Multiple sclerosis * Sarcoidosis * Lyme disease

Answer 298

Can be treated either medically or surgically medical treatment: * Carbamazepine (first line) * Phenytoin * Iamotrigine * Gabapentin Surgical treatment: * Microvascular decompression * Treatment of the underlying cause and alcohol injections

Answer 299

When there is a high risk of aspiration during induction i.e in patients with symptomatic hiatus hernia

Answer 300

If patient does not have adequate respiratory effort i.e suddenly comatose, respiratory rate of \<10 and associated hypoxia, low oxygen and low resp rate Use manual ventilation with a bag mask connected to 15L/min oxygen at a rate of 10-12 breaths per minute

Answer 301

Caused by insufficient levels of cortisol - can come about in patients on long-term steroids who undergo additional physiological stresses (e.g surgery, infection) or those with existing addison's disease Rarer cause is meningococcal septicaemia causing bilateral adrenal haemorrhage (waterhouse-friderichsen syndrome)

Answer 302

Symptoms can be non-specific * Lethargy * Fever * Hypotension (often with postural drop) * Vomiting * Diarrhoea Biochemically: * Hyponatraemia (most classically) * Hyperkalaemia * Hypoglycaemia * Hypercalcaemia

Answer 303

* Fluid resus if hypotensive * IV hydrocortisone 100mg * IV glucose if hypoglycaemic * Swap back to their oral steroids after 3 days * Consider Fludrocortisone if there is adrenal disease

Answer 304

Symptoms and signs are classically consistent with those of cord compression, involving compression of upper motor neurons of both sensory and motor tracts * back pain * shooting sensation * bladder incontinence * Loss of sensation in lower limb dermatodes * hyperreflexia * increased tone bilaterally in both legs

Answer 305

90% of small and medium perforations heal within 6-8 weeks. Surgical repair should be considered for non healing perforations after 8 weeks

Answer 306

Non-selective adenosine receptor antagonist and phosphodiesterase inhibitor

Answer 307

A cluster headache is a unilateral headache that is typically worse around the eye - attacks occur in clusters over time and patients may suffer numerous episodes over a short period of time More common in middle aged men and can be triggered by alcohol or smoking

Answer 308

* A bloodshot or teary eye * Vomiting * Severe headache

Answer 309

* Treatment of Cluster headaches acutely is with 100% Oxygen and Sumatriptan * Prophylactic treatment may have some effect and includes Verapamil and Steroids

Answer 310

* Panda Eyes * CSF or blood in nose or ears Nasopharyngeal airways are contraindicated in these patients and can cause further damage - Head tilt chin lift contraindicated in trauma patients at risk of a C-spine but Jaw thrust is the manoeuvre of choice

Answer 311

ABG with co-oximetry - the co-oximeter can differentiate between carboxyhaemoglobin and oxyhaemoglobin so is much more accurate than the false high reading from the pulse oximeter

Answer 312

The classic thumb sign on a lateral C-spine radiograph - represents an enlarged and oedematous epiglottis Remember that

Answer 313

The space bounded by the lateral edge of pectoralis major, the lateral edge of latissimus dorsi and the lower border of the 5th intercostal space

Answer 314

Suxamethonium apnoea is when individuals have a prolonged period of paralysis following administration of Suxamethonium - It occurs in patients which do not possess/ have a defect in the enzyme plasma cholinesterase to metabolise suxamethonium leading to its sustained action on the post synaptic membrane of the neuromuscular junction Management is to keep them on a ventilator for longer to help the patient's breeathing while the drug wears off

Answer 315

Major Haemorrhage protocol is used when a patient has a large haemorrhage making them haemodynamically unstable and requiring urgent resuscitation with blood - It is used to supply O (universal donor) blood

Answer 316

Recommended for any patient with suspected sepsis who displays the signs of shock (SBP \<90mmHg) or has a high lactate above 4mmol/L

Answer 317

Respiratory Alkalosis

Answer 318

Capillary Blood glucose - as hypoglycaemia can cause irreversible brain damage and should be rapidly identified and corrected during ABCDE assessment

Answer 319

Obstructive shock - the tamponade is preventing the heart from filling adequetly therefore obstructing the heart and leading to obstructive shock

Answer 320

Measure the Serum Mast Cell tryptase - anaphylaxsis results in a rise in Mast cell tryptase during and after the reaction - samples should be taken during, 4h and 12 h post reaction

Answer 321

Ascending cholangitis is a bacterial infection of the biliary tree

Answer 322

Clinical features are: * Charcot's Triad (found in ⅓ of patients) - Right upper quadrant pain, Fever, Jaundice * Hypotension, tachycardia and confusion are also common symptoms if the sepsis is severe

Answer 323

The underlying causes are: * Biliary calculi (stones) - 50% * Benign biliary stricture - 20% - these can be congenital, post-infectious or inflammatory * Malignancy - 10-20% - these can be due to tumours in the gallbladder, bile duct, ampulla, duodenum, pancreas

Answer 324

* Basic blood panel will show rasied LFTs with rasied inflammatory markers (WBC and CRP) * US abdomen can detect bile duct dialtion but not very good at picking up stones in mid/distal area of biliary duct * CT gives anatomical detail of biliary tree and visualises radiopaque stones - but CT is poor at viewing radiolucent cholesterol stones which are the most common * MRCP is the most accurate modality to determine disease including gallstones and strictures - can also view all causes of biliary tree blockage * once aetiology determined, ERCP can be used as therapeutic intervention

Answer 325

* Resus using IV fluids and antibiotics - may need critical care depending on presence/severity of shock and organ failure * Biliary drainage may be required * Endoscopic drainage - ERCP (Endoscopic retrograde cholangiopancreatography) - may involve placing stent for strictures * Percutaneous Drainage - (Percutaneous transhepatic cholangiography) * Surgical Drainage * Assessment and management for predisposing factors i.e if cause is gallstones consider cholecystectomy

Answer 326

It is a syndrome of unknown aetiology that results in raised intracranial pressure (opening pressure \>25 cmH2O) most commonly in young and/or obese women (sex ratio 9:1)

Answer 327

Clinical features include: * Headache - usually non-pulsatile, bilateral and worse in the morning (after lying down or bending forwards) - key differential in obese patients for these headaches is sleep apnoea * Patients may report morning vomiting * Visual disturbances - includes transient visual darkening or loss, probably due to optic nerve ischaemia - bilateral papilloedema is seen on fundoscopy * If left untreated permanent visual damage may result ( in untreated, 1-3% of patients may lose vision in a year)

Answer 328

* Oral contraceptive * Steroids * Tetracycline * Vitamin A * Lithium

Answer 329

First line management is always weight loss - because patients are generally obese If this doesn't work then pateints can try carbonic anhydrase inhibitors (i.e acetazolamide) but they have large profile of side effects (peripheral paraesthesia, anorexia and metallic dysgeusia) so they're poorly tolerated Topiramate and furosemide are also commonly tried More invasive stratgies to lower CSF pressure include therapeutic lumbar punctures and surgical CSF shunting - these are tried in resistant cases In patients with visual symptoms (but manageble headache) optic nerve sheath fenestration may protect against visual loss

Answer 330

It is an extreme complication of hypothyroidism Management involves the following: * ITU/HDU care * IV T3/T4(thyroxine) * 50-100mg IV hydrocortisone * Mechanical ventilation and oxygen - if hypoventilation * IV fluid - to correct hypovolaemia * correct hypothermia * correct hypoglycaemia * Treat any heart failure

Answer 331

Causes can be pre-renal, renal, post-renal Pre-renal: * Hypovolaemia * Hypotension * Dehydration Renal: * Acute Tubular necrosis Post-Renal: * Benign Prostatic hypertrophy * Anticholinergic or alpha adrenoreceptor antagonist drugs (commonly anaesthetics) * Pain (particularly hernia operations) * Psychological inhibition * Opiate analgesia If there is sudden reduction of urine output and a catheter has recently been changed, the first step is to ensure the catheter patency by flushing with water for injection

Answer 332

You should start by inserting an oropharyngeal airway as in these cases ventilation without airway adjunct is unlikely to be successful in isolation

Answer 333

It is cardiogenic syncope due to bradycardia - presents with sudden onset, short duration and associated facial colour change due to oxygenated blood in the pulmonary capiliries accumulating and the being released into the systemic circulation, leading to flushing The initial management is that of bradycardia with adverse features which is 500 micrograms of atropine IV if patient is unstable and can be repeated every 3-5 min to a total of 3 mg

Answer 334

Bogginess of skull on palipatation suggests the presence of a depressed skull fracture. This a high risk factor for intercranial haematoma Retrograde amnesia of the hours preceding the injury is a "medium" risk factor for head injury

Answer 335

Malignant hyperthermia is a life-threatening syndrome triggered by inhalation anaesthetics or suxamethonium

Answer 336

Most common cause is an autosomal dominant mutation in the ryanodine receptor 1, increasing calcium levels in the sacroplasmic reticulum and increasing metabolic rate

Answer 337

Patients typically present at the induction of general anaesthesia with increased body temperature, muscle rigidity, metabolic acidosis, tachycardia and increased exhaled carbon dioxide

Answer 338

Definitive diagnosis is made through genetic testing after the episode

Answer 339

It is managed by: * Stopping the triggering agent * Administring 200mg IV Dantrolene (a ryanodine receptor antagonist) * Restoring normothermia

Answer 340

Local anaesthetic can lead to toxicity due to blockage of sodium channels

Answer 341

* Numbness or tingling around the mouth * Restlessness/agitation * Tinnitus * Shivering * Vertigo/Dizziness * Subtle tremors of the face and extremities * Hypertension * Tachycardia * Decreased consiousness * Respiratory distress * Hypotension * Apnoea * Seizures * Sinus Bradychardia * Ventricular arrhytmias * Asystole

Answer 342

* Stop administration of local anaesthetic * ABCDE approach including ECG monitoring * Lipid emulsion (20% intralipid) 1mL/Kg every 3 minutes up to a dose of 3mL/kg * Initiate lipid emulsion infusion at a rate of 0.25mL/Kg/min * Maximum total dose = 8mL/Kg

Answer 343

DIC describes inappropriate activation of the clotting cascades resulting in thrombus formation and depletion of clotting factors and platelets

Answer 344

Patients present with excess bleeding e.g epistaxis, gingival bleeding, haematuria, bleeding from cannula sites Patients may also present with fever, confusion or coma Often in the context of severe systemic disease Physical signs include petechiae, brushing, confusion and hypotension

Answer 345

* Major Trauma or burns * Multiple-organ failure * Severe Sepsis or infection * Severe obstetric complications * Solid tumours or haematological malignancies * Acute promyelocytic leukemia is an uncommon subtype of acute myelogenous leukemia that is associated with DIC

Answer 346

* Thrombocytopenia * Increased prothrombin time * Increased fibrin degradation products (such as D-dimer) * Decreased fibrinogen

Answer 347

Sinus tachycardia The S1Q3T3 pattern is often quoted but rarely seen in clinical practise

Answer 348

A needle is inserted just left of the xiphoid process, aiming towards the left shoulder

Answer 349

* Prothrombin time gives an indication of the clotting ability and reflects the synthetic function of the liver - it is the best prognostic factor of basically how much damage the paracetamol has done to the liver

Answer 350

* Headache - worse when waking, lying down, coughing/straining and may be associated with vomiting * Early signs of Intracranial pressure often non specific * Patient may demonstrate cranial nerve palsies - specifically the abducens nerve which is pressed against the sphenoid bone as pressure increases * In advanced cases, drowsiness and seizure activity may develop with pupillary abnormalities and pailloedema * Cushing triad can be seen which is physiological response to raised ICP: Increased blood pressure, Bradycardia, and irregular breathing (including cheyne-stokes respiration)

Answer 351

* 4 major groups of cause: tumours, vascular lesions, infective processes and granulomata * Space occupying neoplasia may include both metastatic disease and primary CNS tumours ( these can be bening like meningiomas or malignant like glioblastoma - but all can be life threatening because of the physical constraints of the cranium * Infective processes include cerebral abscesses and much rare diseases like cysticercosis, amoebiasis, tuberculosis and many others * Immunocompromised patients are much more prone to intra-cerebral infection so look for risk factors like HIV

Answer 352

* Made with cranial imaging - MRI more useful than CT for detecting and characterising lesions * In equivocal cases, a biopsy of the lesion may be indicated

Answer 353

* Patient needs rapid assessment * Assessment of airway is important as smoke inhalation can lead to airway edema and swelling that can cause total upper airway obstruction so early intubation is vital * IV fluid resus is essential in burns patients with parkland formula used to calculate the amount of fluids given : 4 x weight (kg) x %burn =ml fluid required in the first 24 hours * Referral to burns unit should be made if patient has sustained full thickness burns (\>5% body surface), partial thickness burns (\>10% body surface) and if patient is particulary young or old

Answer 354

Associated with ICP Increased Blood Pressure, Bradycardia, Irregular Breathing