Emergency Medicine (Quesmed) Flashcards

Question 1

Q

What are the 5 pathogenic causes and 3 other causes of Acute Epiglottitis?

Answer

A

Haemophilus influenzae b (Hib)
Streptococcus spp
Staphylococcus aureus
Pseudonomas
Herpes Simplex

Thermal Causes
Foreign Bodies
Radiotherapy Related Inflammation

Question 2

Q

What are the 5 signs of Acute Epiglottitis and what should be done in these patients?

Answer

A

Fever
Drooling
Stridor
Pain
Children would prefer to sit upright

These patient should not be examined, treated or cannulated but left alone as any upset or distress may lead to total airway obstruction

Question 3

Q

What is the 3 step management of Acute Epiglottitis?

Answer

A

An urgent referral to ENT and anaesthetics should be made urgently

After their airway had been secured, patients need to urgently intubated and ventilation and treatment should be provided

Depending on the cause, oral and IV antibiotics should be started

Question 4

Q

What are the causes of Acute Pancreatitis?

Answer

A

GET SMASHED

Gallstones (most common cause worldwide)
Ethanol (most common cause in Europe)
Trauma
Steroids
Mumps
Autoimmune diseases (Polyarteritis Nodosa/ SLE)
Scorpion fight
Hypercalcaemia, Hypertriglycerideamia, Hypothermia
ERCP
Drugs

Question 5

Q

What are the drug causes of Acute Pancreatitis?

Answer

A

FAT SHEEP

Furosemide
Azathioprine/ Asparaginase
Thiazides/ Tetracycline

Statins/ Sulfonamides/ Sodium Valproate
Hydrochlorothiazide
Estrogens
Ethanol
Protease Inhibitors and NRTIs

Thiazides, Furosemide, some HIV drugs (protease inhibitors and non-nucleoside reverse transcriptase inhibitors), Sulfasalazine and Gliclizide are classed as Sulfonamides

Question 6

Q

What are the 9 signs of Acute Pancreatitis?

Answer

A

-A Stabbing, Epigastric Pain which radiates to the Back and is relieved by sitting forward or laying in the foetal position

Vomiting
A Recent Alcohol Binge or a Recent History of Gallstones suggests Acute Pancreatitis
Hypovolaemia (Tachycardia, Dry Mucosal Membranes due to Third-space Loss of Fluids)
Fever is only present if the Pancreatitis has been complicated with Infection
Haemorrhagic Pancreatitis is rare but there may be Grey-Turner’s Sign which is Bruising along the Flanks
There may be Guarding in the Epigastric Region but this is a Non-Specific Sign
Cullen’s Sign is bruising around the Peri-Umbilical Region
Third-space Fluid Sequestration in Pancreatitis is the result of a Combination of Inflammatory Mediators, Vasoactive Mediators and Tissues which leads to Vascular Injury, Vasoconstriction and Increased Capillary Permeability- this leads to Extravasation of Fluid into the Third Space

(This can lead to Acute Respiratory Distress Syndrome, Pleural Effusions and Hypovolaemia which leads to Acute Kidney Injury)

Question 7

Q

What are the 5 Blood Tests should be ordered if Acute Pancreatitis is suspected?

Answer

A

FBC (Leukocytosis can indicates Necrotising Pancreatitis)

Urea and Electrolytes

LFTs may be abnormal in Gallstone Disease

Lipase is a more sensitive and specific marker than Amylase and should be used over Amylase

An Amylase level is 3 times the upper limit of normal, this suggests Acute Pancreatitis

Question 8

Q

What 3 conditions can also elevated Amylase in addition to Acute Pancreatitis?

Answer

A

A Perforated Duodenal Ulcer

Cholecystitis

Mesenteric Infarction

Question 9

Q

What are the 4 Imaging Investigations that should be ordered if Acute Pancreatitis is suspected?

Answer

A

Ultrasound Abdomen can look for Gallstones

MRCP can be used to look for Obstructive Pancreatitis

ERCP is preferred generally over MRCP

A CT Scan can be performed at a later stage if Complications of Pancreatitis are suspected- such as Pseudocysts or Necrotising Pancreatitis

Question 10

Q

What Glasgow Criteria Score suggests transfer to ITU in Acute Pancreatitis and how long after admission should this score be worked out?

Answer

A

A score above 3 suggests admission to ITU and this should be worked out 48 hours after admission

Question 11

Q

What is the Glasgow Criteria Score criteria?

Answer

A

PANCREAS

PaO2<8kPa
Age>55 years old
Neutrophils- WBC>15x10^9/L
Calcium<2mmol/L
Renal Function- Urea>16mmol/L
Enzymes- AST/ALT>200ui/L or LDH>600ui/L
Albumin<32g/L
Sugar- Glucose>10mmol/L

Question 12

Q

What is the 7 step management for Acute Pancreatitis?

Answer

A

(Maintain electrolyte imbalances and compensate for third space losses)

Aggressive Fluid Resuscitation with Crystalloids
(Aim to keep urine output>30mL/hour)
Start with a 1 litre bolus and try to maintain adequate urine output. This usually amounts to a fluid requirement of 3-5ml/kg/hour
Catheterisation
Analgesia (strong analgesia in the form of Opioids is needed)
Anti-emetics
IV Antibiotics are shown to have No Real Effect in Outcome unless Necrotising Pancreatitis is present. Necrotising Pancreatitis is a complication of Severe Pancreatitis representing inadequate fluid resuscitation in initial management. This is usually diagnosed through a CT scan. Routinely giving antibiotics in Acute Pancreatitis is not in current clinical practice
Calcium may be given if Hypocalcaemia is present but this is not prescribed prophylactically
Insulin may also be given if there is Hyperglycaemia due to the damaged pancreas not being able to release the hormone

Question 13

Q

What is Pulseless Electrical Activity and Asystole?

Answer

A

These are both Non-Shockable Rhythms (Use CPR Instead)

Pulseless Electrical Activity is where the ECG shows that a pulse should occur but you do not actually feel a pulse in the patient

Asystole is a Cardiac Arrest Rhythm with no discernible Electrical Activity on the ECG Monitor

Question 14

Q

What is the management of Pulseless Electrical Activity and Asystole?

Answer

A

CPR should be commenced immediately

Adrenaline 1mg IV should be given in the first cycle and if the rhythm continues, then give Adrenaline every other cycle (1st, 3rd, 5th etc)

Question 15

Q

What is Ventricular Fibrillation and Pulseless Ventricular Tachycardia?

Answer

A

These are both Shockable Rhythms

Ventricular Tachycardia is a regular broad complex tachycardia

Ventricular Fibrillation presents as chaotic irregular deflections of varying amplitude

Question 16

Q

What is the management of Ventricular Fibrillation and Pulseless Ventricular Tachycardia?

Answer

A

Defibrillation and CPR should be conducted

However, if the rhythms persist, Amiodarone 300mg IV and Adrenaline 1mg IV can be given after the Third Shock

Amiodarone is given as a One-Off Dose but Adrenaline can be repeated every other cycle (3rd, 5th, 7th etc)

Question 17

Q

What are the 7 causes of Airway Compromise?

Answer

A

Angioedema

Anaphylaxis

Thermal Injury

Neck Haematoma

Wheeze

Surgical Emphysema

Reduced Consciousness

Question 18

Q

What are 3 simple Airway Maneouvres?

Answer

A

Suction- if there is visible vomit, blood or foreign bodies in the Airway
(Turn patient onto their side if they are actively vomiting, unless they have a C-spine injury)

Head-tilt/ Chin lift- Aim for the Sniffing Position- can be achieved manually or by placing a pillow under the head

Jaw Thrust- Using both hands, hook your fingers under the angle of the patient’s jaw and move their mandible forward

Question 19

Q

What are 2 common Airway Adjuncts (ways to keep the airway open after manual manouevres) (3,2)

Answer

A

Oropharyngeal Airway-
- a Rigid Plastic Tube
- Measured from the Incisors to the Angle of the Jaw
- It is inserted upside down and then rotated 180 degrees to keep the tongue away from the Posterior Pharynx

Nasopharyngeal Airway-
- a Flexible Rubber Tube
- This passed through one of the Anterior Nasal Passages and sits Inferiorly at the Base of the Tongue
- This is typically used if the patients have a strong gag reflex to the Oropharyngeal Airway
- This is contraindicated if the patient has a Base of Skull Fracture

Question 20

Q

What is a Supraglottic Airway? (4)

Answer

A

They are Flexible Plastic Tubes with Inflatable Cuffs

They are devices which can be used with Ventilation Machines

Examples include the Laryngeal Mask Airway (LMA) or i-Gel

They sit over the Top of the Larynx

Question 21

Q

What is an Endotracheal Tube? (4)

Answer

A

It is a Flexible Plastic Tube with an Inflatable Cuff

It is inserted through a Laryngoscope and used for Prolonged Mechanical Ventilation

It protects the airways against Aspiration (Cuffed Endotracheal Tube with the Cuff Inflated below the Vocal Cords)

If this is not successful, you can insert a Supraglottic Airway such as an iGel or Laryngeal Mask Airway, or Bag-Valve Mask Ventilation

Question 22

Q

What are the 3 indications for Bag-Valve Mask Ventilation?

Answer

A

Respiratory Failure (Hypoxia or Hypercapnia) associated with a respiratory rate of less than 10

Apnoea

Cardiac Arrest

Question 23

Q

What are the 6 main signs of Opioid toxicity?

Answer

A

Poor Respiratory Rate/ Effort

Bilateral Pinpoint Pupils

Decreased Conscious Level

Multiple Needle/ Track Marks on Skin

Confusion

Cyanosis if severe

Question 24

Q

What 3 things should be identified in a patient presenting with Alcohol Withdrawal?

Answer

A

An Associated Health and Psycho-social problem

The severity of the alcohol misuse (AUDIT Questionnaire and SADQ Questionnaire)

Whether there is any risk to themselves or to others

Question 25

Q

What are the 7 presentation signs of a Simple Alcohol Withdrawal? (6-12 hours after the last drink)

Answer

A

Insomnia

Tremor

Anxiety

Agitation

Nausea and Vomiting

Sweating

Palpitation

Question 26

Q

What is the presentation of Alcohol Hallucinosis? (12-24 hours after last drink)

Answer

A

Visual, Tactile or Auditory Hallucinations

Question 27

Q

What are the 6 signs of Delirium Tremens?

Answer

A

Delusions

Confusion

Seizures

Tachycardia

Hypertension

Hyperthermia

Question 28

Q

What are the 7 indications for Inpatient Alcohol Withdrawal? (risk factors for them getting withdrawal while admitted)

Answer

A

Patients drinking >30 units of Alcohol per day

Scoring over 30 in the SADQ Score

High Risk of Alcohol Withdrawal Seizures (Previous Alcohol Withdrawal Seizures or Delirium Tremens or History of Epilepsy)

Simultaneous withdrawal from Benzodiazepines

Significant Medical or Psychiatric Comorbidity

Vulnerable Patients

Patients under 18 years old

Question 29

Q

What is the 4 step management for Alcohol Withdrawal?

(if drinking >15 units a day or >20 on the AUDIT Questionnaire)

Answer

A

Chlordiazepoxide prescribed in a reducing regimen according to the CIWA Score and Local Protocol

If they have Alcohol-Withdrawal Seizure, they should be prescribed a Rapid-Acting Benzodiazepine (like IV Lorazepam)

Pabrinex (1 pair of Ampoules a day to prevent Wernicke’s Encephalopathy)
- If there are signs of Wernicke’s Encephalopathy (Confusion, Ataxia, Ophthalmoplegia or Nystagmus), patients should be prescribed 2 pairs of Ampoules

In Delirium Tremens (Confusion and Visual Hallucinations 48-72 hours after Abstinence) give Oral Lorazepam first line. If symptoms still continue, then give Parenteral Lorazepam.

Question 30

Q

What are the 6 Gastrointestinal causes of Central Abdominal Pain and 3 Non-Gastrointestinal causes?

Answer

A

Gastrointestinal causes-
- Bowel Obstruction
- Early Appendicitis
- Acute Gastritis
- Acute Pancreatitis
- Ruptured Abdominal Aortic Aneurysm
- Ischaemic Bowel Disease

Non-Gastrointestinal causes-
- Pneumonia
- Acute Coronary Syndrome
- Diabetic Ketoacidosis

Question 31

Q

What are the 6 Clinical Features of Ascending Cholangitis?

Answer

A

Charcot’s Triad- but only occurs in a Third of Patients
(Right Upper Quadrant Pain, Fever, Jaundice)

Hypotension, Tachycardia and Confusion if the Sepsis is severe

Question 32

Q

What are the 3 causes of Ascending Cholangitis?

Answer

A

Biliary Calculi (stones)- 50% of cases

Benign Biliary Stricture

Malignancy

Question 33

Q

What 5 investigations should be ordered if Ascending Cholangitis is suspected?

Answer

A

Bloods- Raised LFTs and Raised Inflammatory Markers (WCCs and CRP)

Ultrasound Abdomen- to detect Bile Duct Dilatation- not good at picking up stones in the mid/distal area of the Biliary Duct

CT Scan- gives good detail of the Biliary Tree and can show Radiopaque Stones (although the most common stones are actually Radiolucent Stones)

MRCP is the most accurate imaging method and can view almost all causes of Biliary Tree Blockage

Once the cause is determined, use ERCP to Intervene

Question 34

Q

What is the 6 step management for Ascending Cholangitis?

Answer

A

Resuscitation (Intravenous Fluids and Antibiotics)- The patient may require Critical Care based on the Severity of Shock and Organ Failure

Biliary Drainage may be required

Endoscopic Drainage- ERCP (Endoscopic Retrograde Cholangiopancreatography)- stent placement for strictures

Percutaneous Drainage- PTC (Percutaneous Transhepatic Cholangiography)

Surgical Drainage

Assessment and management of Predisposing Cause- Like Cholecystectomy for Gallstones

Question 35

Q

What is the management of a Conscious Choking Adult? (4)

Answer

A

Encourage the patient to cough

Give them 5 back blows with the heel of the palm aiming between the shoulder blades

Give them 5 abdominal thrusts performed from behind the patient with a fist placed between the umbilicus and the xiphisternum, grasping it upwards and pulling upwards and inwards sharply

Continue these motions until the obstruction is dislodged or the patient becomes unconscious

Question 36

Q

What is the management of an unconscious choking patient?

Answer

A

Call for help and start ABC

Airway-
- Open the mouth and observe if the obstruction is visible and removable. Only attempt to remove an object if under direct vision
- Open the airway with a jaw thrust or head tilt/ chin lift

Breathing-
- If the patient is not breathing, start cardiopulmonary resuscitation

Question 37

Q

What are the 5 signs of Benzodiazepine toxicity?

Answer

A

Lethargy

Ataxia

Slurred Speech

Coma

Respiratory Distress

Question 38

Q

What are the 4 signs of Beta-Blocker toxicity?

Answer

A

Bradycardia

Hypotension

Mild Hypoglycaemia

Mild Hyperkalaemia

Question 39

Q

What are the 5 signs of Cyanide toxicity?

Answer

A

Nausea and Vomiting (if small doses)

Rapid Loss of Consciousness

Apnoea

Seizures

Cardiac Arrest

Question 40

Q

What are the 5 signs of Phenothiazine (Chlorpromazine) toxicity?

Answer

A

Dystonia

Sedation

Dry Mouth

Hyperthermia

Dysrhythmias

Question 41

Q

What are the 7 signs of Organophosphate toxicity?

Answer

A

Salivation

Lacrimation

Urination

Diarrhoea

Small pupils

Fasciculations

Bradycardia

Question 42

Q

What are the 6 signs of MDMA (Ecstasy) toxicity?

Answer

A

Agitation

Tachycardia

Hypo/ Hypertension

Hyperthermia

Acute Renal Failure

Mydriasis

Question 43

Q

What is Compartment Syndrome?

Answer

A

It is where Muscle Swelling and Inflammation leads to an Increase in Pressure in the Muscle Compartment

This is a Limb Threatening Condition as the increase in Pressure causes a Loss of Blood Supply to that limb and Ischaemia

Question 44

Q

What are the 5 signs of Compartment Syndrome?

Answer

A

Severe Pain (specifically in the Passive Flexion of the Toes)

Pallor

Paralysis of the Limb

Pulselessness

Paresthesia

Question 45

Q

What is the treatment of Compartment Syndrome (3)?

Answer

A

Urgent Fasciotomy

Analgesia

Fluids

Question 46

Q

What is Deep Vein Thrombosis?

Answer

A

The Intra-luminal Occlusion of any Vein that is within the Deep System of a Limb (either the arm or leg) or the Pelvis

Question 47

Q

What are the 11 risk factors for Deep Vein Thrombosis?

Answer

A

Age>60

Active Cancer

Dehydration

Recent Orthopaedic or Pelvis Surgery

Long-distance Travel

Obesity

Previous history of Venous Thromboembolism

Family history of Venous Thromboembolism

Thrombophilias

Combined Oral Contraceptives and Hormone Replacement Therapy

Pregnancy

Question 48

Q

What are the 4 signs of Deep Vein Thrombosis?

Answer

A

Unilateral warm, Swollen Thigh or Calf

Pain on Palpation of Deep Veins

Distension of Superficial Veins

Pitting Oedema

Question 49

Q

What 3 investigations should be ordered if Deep Vein Thrombosis is suspected?

Answer

A

D-dimer-
- Used when there is a low probability of DVT
- It is Highly Sensitive but not Specific so it can Only EXCLUDE DVT but not Confirm it
- Other things may raise D-Dimer such as (6) Malignancies, Pregnancies, Strokes, Myocardial Infarctions, Infections and Aortic Dissections

Doppler Ultrasound-
- This is the Investigation of Choice
- Do this if there is a high probability of a DVT
- It is not the Gold-Standard as DVTs can be missed if the image quality is suboptimal

Digital Subtraction or CT/MR Venogram-
- All three can be used to evaluate the extent of the DVT and look for rare underlying causes such as May-Thurner Syndrome
- Digital Subtraction Venography is the Gold-Standard but is rarely used as it is Highly Invasive

Question 50

Q

What is the 4 step management of Deep Vein Thrombosis?

Answer

A

Anticoagulation- either a Direct Oral Anticoagulant (DOAC), Low Molecular Weight Heparin (LMWH) or Warfarin (which can be bridged with LMWH). NICE Guidelines recommend a DOAC like Apixaban or Rivaroxaban as First-Line Therapy.
- Duration is at least 3 Months
- Patients with Active Cancer should be Anticoagulated for at least 3-6 Months
- Patients with Unprovoked DVTs should be considered for Anticoagulation for over 3 Months (Typically 6 Months)
- Those with Recurrent DVTs should be considered for Life-long Therapy

Percutaneous Mechanical Thrombectomy-
- Used in Massive DVTS

IVC Filter-
- This will not treat the DVT itself but will reduce the risk of the DVT embolising into the pulmonary arteries and causing a Pulmonary Embolism
- This is used in patients where Anticoagulation is Contraindicated

Further Investigations-
- Consider an investigation of Occult Malignancy if there are other Relevant Symptoms
- Consider a Thrombophilia Screening if this is clinically relevant

Question 51

Q

What are the 4 complications of a Deep Vein Thrombosis?

Answer

A

Pulmonary Embolism

Venous Insufficiency

Recurrent Deep Vein Thrombosis

Post-Thrombotic Syndrome- Pain, Swelling, Hyperpigmentation, Dermatitis, Ulcers, Gangrene and Lipodermatosclerosis= caused by Chronic Venous Hypertension

Question 52

Q

What is Disseminated Intravascular Coagulation (DIC)

Answer

A

This is the inappropriate activation of the clotting cascades which results in Thrombus Formation and Depletion of Clotting Factors and Platelets

Question 53

Q

What are the 7 signs of Disseminated Intravascular Coagulation (DIC)?

Answer

A

Excess Bleeding (Epistaxis, Gingival Bleeding, Haematuria, Bleeding from Cannula Sites)

Fever

Confusion

Coma

Petechiae (small pinpoint red/pink spots)

Brushing

Hypotension

Question 54

Q

What are the 5 risk factors of Disseminated Intravascular Coagulation (DIC)?

Answer

A

Major Trauma/ Burns

Multiple-Organ Failure

Severe Sepsis or Infection

Severe Obstetric Complications

Solid Tumours or Haematological Malignancies

Question 55

Q

What is the subtype of Acute Myeloid Leukaemia that is associated with Disseminated Intravascular Coagulation?

Answer

A

Acute Promyelocytic Leukaemia

Question 56

Q

What are the 4 investigation findings of Disseminated Intravascular Coagulation?

Answer

A

Thrombocytopaenia

Increased Prothrombin Time

Increased Fibrin Degradation Products (such as D-Dimer)

Decreased Fibrinogen

Question 57

Q

What 3 signs point to Moderate Asthma Exacerbation and what 4 signs point to Severe Asthma Exacerbation?

Answer

A

Moderate Asthma Exacerbation-
- Increasing Symptoms
- PEF> 50-75%
- No features of Severe Asthma

Severe Asthma Exacerbation-
- PEF 33-50%
- Respiratory Rate is 25 or more
- Heart Rate is 110 or more
- They are unable to complete a sentence in one breath

Question 58

Q

What are the features of Life-Threatening Asthma? (33,92 CHEST)

These patients Must be Admitted

Answer

A

PEF<33%

SO2<92% or PO2<8

Cyanosis

Hypotension

Exhausted, Altered Consciousness

Silent Chest

Tachyarrhythmias

Question 59

Q

What should be remembered about patients with Life-Threatening Asthma and their PCO2 levels?

Answer

A

They may have normal PCO2 levels (4.6-6) as they are unable to ventilate properly (even though you would expect them to have Low PCO2 levels)

A Raised PCO2 is a sign for Near-Fatal Asthma

Question 60

Q

What are the 6 Criteria for referring Asthma Exacerbation Patients to Intensive Care?

2 things about resporation
2 things about o2 and co2
peak flow

and one more thing

Answer

A

If they require Ventilatory Support

If they have Severe or Life-Threatening Asthma who is failing to respond to therapy which is shown by (5)-

Deteriorating Peak Flow Reading
Persisting or Worsening Hypoxia
Hypercapnia
Exhaustion, Feeble Respiration
Respiratory Arrest

Question 61

Q

What is the 4 step Immediate Management for an Asthma Exacerbation?

Answer

A

Sit up

100% O2 via a Non-Rebreathe Mask (aim for 94-98%)

Nebulised Salbutamol (5mg) and Ipratropium (0.5mg)

Hydrocortisone 100mg IV or Prednisolone 50mg PO

Question 62

Q

What should be added to the Immediate Management of an Asthma Exacerbation if the patient has Life-Threatening Asthma? (3)

Answer

A

Inform the Intensive Care Team

Magnesium Sulphate 2g IV over 20 minutes

Nebulised Salbutamol every 15 minutes

Question 63

Q

What should be done if there is no improvement in the Asthma Exacerbation following the Immediate Management? (4)

Answer

A

Nebulised Salbutamol every 15 minutes

Continue Ipratropium 0.5mg 4-6 hourly

Consider Aminophylline unless they are already on Theophylline

ITU Transfer for Invasive Ventilation

Question 64

Q

What 3 things should be done/ monitored in the Monitoring following an Asthma Exacerbation?

Answer

A

SpO2 should be kept above 92%

Take Peak Flow Measurements every 15-30 minutes pre- and post- Salbutamol

Take Consecutive Arterial Blood Gas measurements

Answer 65

A

Unstable Angina (the narrowing of coronary arteries caused by Ischaemia)
- Chest pain at Rest or at Minimal Exertion which lasts>15 minutes
- ECG Changes (new ST Depression or T Wave Inversion)
- No Rise in Troponin (no Myocardial Necrosis)

NSTEMI (Partially Occluded Coronary Arteries)
- Chest pain at Rest or at Minimal Exertion which lasts>15 minutes
- ECG Changes (new ST Depression or T Wave Inversion)
- Rise in Troponin (Myocardial Necrosis)

NSTEMI and Unstable Angina are differentiated by the Rise in Troponin seen in NSTEMI

STEMI (Completely Occluded Coronary Artery)
- Chest pain at Rest or at Minimal Exertion which lasts>15 minutes
- ECG Changes (new ST Elevation or Left Bundle Branch Block)
- Rise in Troponin (Myocardial Necrosis)

NSTEMI and STEMI are differentiated by their ECG Changes

Chest pain may not ALWAYS be there

Answer 66

A

New ST-segment elevation in 2 or more contiguous leads (leads next to each other)

The ST Elevation should be more that 2mm in the Precordial Leads or more than 1mm in the limb leads

Answer 67

A

MMONAC

Morphine
Metoclopramide
Oxygen (if sats are less than 94%)
Nitrates (GTN Spray)
Aspirin 300mg
Clopidogrel 300 mg (Although drugs like Ticagrelor are sometimes used instead in practice)

If the patient is within 12 hours of symptom onset and within 2 hours of medical contact- then consider Percutaneous Coronary Intervention. They should be Haemodynamically stable.

If they present within 12 hours of symptom onset but after 2 hours of medical contact- then consider Thrombolysis if they are stable and there are no contraindications. If there are contraindications, then consider Percutaneous Coronary Intervention.

If they present more than 12 hours of symptom onset, Pharmacotherapy should be considered if they are Asymptomatic and Unstable. Otherwise, Revascularisation can be considered.

Answer 68

A

Aortic Dissection

Gastrointestinal Bleeding

Allergic Reaction

Iatrogenic (Recent Surgery)

Neurological Disease (Recent Stroke (within 3 months), Malignancy)

Severe Hypertension (more than 200/120)

Trauma (including Recent CPR)

Answer 69

A

It is a type of Acute Coronary Syndrome with typical Acute Coronary Syndrome signs, no ST segment elevation on the ECG and Raised Cardiac Biomarkers

Answer 70

A

MMONAC

Morphine

Metoclopramide

Oxygen (if sats<94%)

Nitrates (GTN Spray)

Aspirin 300mg

Clopidogrel 300mg

After MMONAC, stratify the patient according to either the Thrombolysis in Myocardial Infarction Score (TIMI Score) or the GRACE model depending on the hospital’s choice

If the Patient has a high risk of death and further ischaemic events should be offered re-vascularisation within 12-24 hours

If the Patient has a low risk of death- they can be managed conservatively with Medications

They can be discharged after having stabilised (once they don’t have symptoms and their cardiac biomarkers are normal) and they should have Further Cardiac Investigations in the Future

Answer 71

A

Oxygen Therapy
- Sit up
- Administer 24% Oxygen via Venturi mask: SpO2 88–92%
- Vary FiO2 and SpO2 target according to the Arterial Blood Gases

Nebulised Bronchodilators (Air Driven)
- Salbutamol 5mg/4h
- Ipratropium 0.5mg/6h

Steroids-
- Hydrocortisone 200mg IV
- Prednisolone 40mg PO for 7-14d

Antibiotics (if evidence of infection)

Further treatments if no response
- Repeat Nebulisers and consider Aminophylline IV
- Consider NIV (BiPAP) if pH<7.35 and/ or Respiratory Rate >30
- Consider Invasive Ventilation if pH<7.26

Answer 72

A

It occurs when a high intra-ocular pressure causes damage to the Optic Nerve

This occurs due to the Closure of the Iridio-corneal Angle in the eye

Answer 73

A

Being Female, Being Asian, The use of certain medications such as those with Anti-muscarinic properties, such as Amitriptylline

Answer 74

A

Sudden Headache

Nausea

Red Eye

Symptoms worsen at night

Haloes when they look at Bright Lights

On Examination-
- Red Eye
- Cloudy Cornea
- Mid-dilated Pupil

Answer 75

A

Administering IV Acetazolamine and a Beta Blocker such as Timolol

Muscarinic Agonists such as Pilocarpine eye drops may be given

An urgent referral to Ophthalmology should be made

Definitive-
- Peripheral Iridotomy

Answer 76

A

Temporary loss of vision

Malignant Glaucoma

Iris Sphincter Atrophy

Permanently dilated pupil

Permanent Blindness

Answer 77

A

Type 1 IgE-mediated Hypersensitivity which occurs when a patient is exposed to certain medications or food or bee stings.

Patients are often Hypotensive

Answer 78

A

Skin Reactions (Widespread Urticaria, Itching, Flushed Skin)

Respiratory Symptoms (Swollen Tongue/ Lips, Sneezing, Wheeze)

Gastrointestinal Symptoms (Abdominal Pain, Nausea, Vomiting, Diarrhoea)

Tachycardia

Hypotension

Answer 79

A

Serum levels of Mast Cell Tryptase

Answer 80

A

Remove Trigger

Call for help early

ABCDE Assessment

Administer Oxygen

Lie Patient Flat and Raise Legs

Administer Adrenaline (500mg IM for Adults)

Administer Chlorphenamine and Hydrocortisone

IV Fluids should be given if they are Hypotensive

If skills and equipment are available-

Manage airway
Attach Patient to Monitoring
Consider Intensive Care referral

Answer 81

A

Abnormal Electrical Impulses start firing in the atria. These pulses override the heart’s natural pacemaker

For Fast Atrial Fibrillation, the heart rate is over 100bpm

Answer 82

A

Shock

Syncope

Acute Pulmonary Oedema (does not include Chronic Heart Failure)

Myocardial Ischaemia

Answer 83

A

Atrial Fibrillation with a duration of less than 48 hours can be safely cardioverted

If the duration is unknown or is more than 48 hours, Anticoagulation can be started at a minimum of 3 weeks before and 4 weeks after Cardioversion due to the risk of a Stroke from a Left Atrial Appendage Thrombus

If patients are not Cardioverted, they may need Life-long Anticoagulation based on their CHA2DS2 VaSc Score

Answer 84

A

If they have had issues with their boiling or heating at home

Answer 85

A

Confusion

Nausea and Vomiting

Cherry Red Skin

Tachycardia

100% Oxygen Saturation of Pulse Oximetry

Answer 86

A

VBG/ ABG- A Carboxyhaemoglobin Concentration of over 20% is diagnostic

Chest Xray- Evidence of Acute Respiratory Distress Syndrome (Asymmetrical Consolidations)

ECG- Ischaemic Changes

Bloods- including Creatine Kinase (Rhabdomyolysis)

Answer 87

A

100% Oxygen via Face Mask- helps unbind Carbon Monoxide from the Haemoglobin Molecule

Hyperbaric Oxygen- Controversial but it is the Gold Standard

Answer 88

A

It is the accumulation of blood in the Pericardial Sac

The volume and pressure of this blood can impact the cardiac filling

Answer 89

A

Penetrating wounds- caused by road traffic accidents or pacemaker insertions

Other causes include (3)
- Pericarditis
- Malignancy
- Inflammatory Conditions- like SLE

Answer 90

A

Beck’s Triad- Raised JVP, Hypotension and Muffled Heart Sounds

Kussmaul’s Sign- JVP raises with Inspiration

Pulsus Paradoxus- A Drop in the Systolic Blood Pressure with Inspiration

An ECG may show Electrical Alternans (Alternating Height

Answer 91

A

An Echocardiogram

Answer 92

A

Pericardiocentesis

Answer 93

A

Hyperglycaemia (may not always be present)
(Blood glucose over 11mmol/L)

Acidosis (Bicarbonate below 15mmol/L or Venous pH less than 7.3)

Ketonaemia (3mmol/L and over)

Answer 94

A

Infection (so they may have a Fever, which isn’t a symptom of DKA but of a potential cause of it)

Dehydration

Fasting

Presentation of Type 1 Diabetes

Answer 95

A

Smell of Acetone (Fruity Breath)

Vomiting

Dehydration

Abdominal Pain

Hyperventilation (Kussmaul/ Deep Sighing)

Hypovolaemic Shock

Drowsiness

Coma

Answer 96

A

Blood Glucose (>11.1 mmol/L)

Blood Ketones (>3mmol/L)

Urea and Electrolytes

Blood Gas Analysis

Urinary Glucose and Ketones

Blood Cultures (if evidence of Infection)

Cardiac Monitoring/ ECG- any Ischaemic changes or changes secondary to Hypokalaemia

Answer 97

A

If the patient is Alert, not significantly Dehydrated and able to Orally Intake without vomiting= Encourage Oral Intake and give a Subcutaneous Insulin Injection

If the patient is Vomiting, Confused or significantly Dehydrated= give IV Fluids (initial Bolus of 10ml/kg 0.9% NaCl then discuss with a senior) and Insulin Infusion at 0.1 units/kg/hour- 1 hour after starting IV Fluids. If there is evidence of a shock, the initial Bolus should be 20ml/kg

If the patient is Shocked or in Comatose- ABCDE Assessment should be carried out

Do NOT Stop the Intravenous Insulin Infusion until 1 hour after Subcutaneous Insulin Infusion had been given

Answer 98

A

Cerebral Oedema

It results from the rapid correction of dehydration with IV Fluids

This is why it is recommended fluid should be taken slowly over 48 hours

Answer 99

A

Ethylene Glycol is found in anti-freeze and can be ingested accidentally or intentionally

Answer 100

A

Early Features-

Apparent intoxication (similar to that of Alcohol)
Nausea and Vomiting
Haematemesis
Seizures
Ataxia
Ophthalmoplegia
Papilloedema
Raised Anion Gap Metabolic Acidosis
Pulmonary Oedema

Late Features-

Acute Tubular Necrosis
Hypocalcaemia
Hyperkalaemia
Hypomagnesaemia

Answer 101

A

Gastric Lavage or NG Aspiration if <1 hour since ingestion

Fomepizole (Competitive inhibitor of alcohol dehydrogenase)- prevents metabolism of Ethylene Glycol into toxic metabolites

Alcohol (Ethanol) can be used if Fomepizole is unavailable

Haemofiltration can be used in severe cases

Answer 102

A

It is a collection of blood between the inner surface of the skull and the outer layer of the dura. It is commonly caused by a Torn Middle Meningeal Artery

Answer 103

A

Recent Head Injury

Headache

Nausea and Vomiting

An Altered Mental State

Sometimes Seizures

6th Nerve Palsy- This nerve has a long Intracranial Course so is susceptible to damage following Herniation secondary to an Increased Intracranial Pressure- this is known as a False Localising Sign

Answer 104

A

CT Head- which shows a Bi-convex (Lentiform) shaped Haematoma which is Hyperdense

Answer 105

A

Conservative Monitoring

Blood Pressure Reduction

Surgery (if Severe) like Burr Holes

Answer 106

A

Infection

Medications that cause Fluid Loss or Lower Glucose Tolerance

Surgery

Impaired Renal Function

Answer 107

A

Nausea and Vomiting

Lethargy

Weakness

Confusion

Dehydration

Coma

Seizure

4 signs of extreme unwellness

Hypovolaemia
Tachycardia
Hypotension
Exhaustion

Answer 108

A

Severe Hyperglycaemia (30mmol/L or more) (not accompanied by Significant Acidosis (pH>7.3 or bicarbonate>15mmol/L) or Ketosis (ketones>3mmol/L))

Hypotension

Hyperosmolality (usually more than 320 mosmol/kg)

Answer 109

A

HHS and DKA, rather than being distinct entities are a spectrum of metabolic disturbance in diabetes.

The main difference is that the presence of endogenous insulin production in Type 2 diabetics is sufficient to ‘switch off’ ketone production and prevent diabetic ketoacidosis

Answer 110

A

Rehydration to correct the Hypotension and Electrolyte Abnormalities.

Correction of Hyperglycaemia- Partially Achieved through Fluid Therapy

Answer 111

A

Thrombosis due to Hyperviscosity so VTE Prophylaxis is an important part of management.

Remember Virchow’s Triad (Blood Stasis, Endothelial Injury, Hypercoagulability)- Hyperviscosity leads to Blood Stasis

Answer 112

A

Fluid Resuscitation with 0.9% Saline (1L over 1–2 hours, 1L (+KCl) over 2-4 hours,1L (+KCl) over 4-6 hours, 1L (+KCl) over 6-8 hours, 1L (+KCl) over 8-10 hours)

Change to 0.45% Saline if failing to reduce osmolality by 5mOsm/kg/hour

Insulin at 0.05 units/kg/hour (only if ketones>1mmol/L or if Glucose fails to fall). Continue any Long Acting Insulin
Venous Thromboembolism Prophylaxis

Answer 113

A

The formula (Na + K) - (Cl + HCO3)

The normal anion gap is 10-18 mmol/L

When there are lots of Acids in the blood, The H+ depletes the HCO3 in the equation so the anion gap Increases causing Metabolic Acidosis

Answer 114

A

The accumulation of Endogenous Acids (Lactic Acid, Ketones, Urate) or Exogenous Acids (Salicylates, Ethylene glycol, Methanol)

Paracetamol overdose can also cause metabolic acidosis in extreme cases

SALICYLATE poisoning can cause Respiratory Alkalosis at early stages due to the respiratory centres being stimulated and hyperventilation occurring as a result

Answer 115

A

Sharp Pleuritic Chest Pain relieved by leaning forwards (they may have a had a Flu-Like Prodrome)

Pericardial Friction Rub (usually the Only Sign)

ECG- PR Depression and Saddle Shaped ST Elevation. Also slightly elevated Troponin levels

Answer 116

A

Analgesia (NSAIDs like Aspirin or Ibuprofen)

Bed rest

Colchicine

Steroids

Also treat the underlying cause

Answer 117

A

Cardiac Tamponade

Chronic Constrictive Pericarditis

Answer 118

A

Reduced Chest Expansion on the affected side

Hyper-resonant Percussion on the affected side

Reduced or Absent Breath Sounds on the affected side, with no added sounds

Vocal Resonance (or Tactile Vocal Fremitus) is reduced on the affected side

Additional signs seen in a Tension Pneumothorax- signs of Haemodynamic Compromise (Tachycardia and Hypotension) and Tracheal Deviation to the Contralateral side

Answer 119

A

Chest Xray

Answer 120

A

ABCDE algorithm. High flow Oxygen (15L/min) via a Non-rebreather Mask

Emergency management through Immediate Needle Decompression using a 16-gauge Cannula inserted at the Second Intercostal Space, Mid-Clavicular Line on the Affected Side

The needle should be inserted above the Third Rib to avoid damaging the Neurovascular Bundle. The needle decompression acts as a bridge before insertion of an Intercostal Chest Drain

Answer 121

A

If the patient is NOT Short of Breath AND the Pneumothorax is less than 2cm on Chest Xray they can be Discharged and reviewed in 2-4 weeks

If the patient IS Short of Breath OR the Pneumothorax is more than 2cm, the patient should be Aspirated with a 16-18 Gauge Cannula under Local Anaesthetic. If this is successful, the patient can be discharged. If not, an Intercostal Chest Drain is needed and the patient must be admitted

Answer 122

A

If the patient is NOT Short of Breath AND the Pneumothorax is less than 1cm on the Chest Xray, they do not require further invasive intervention and should be admitted for Observation for 24 hours and Admitted Oxygen

If the patient is NOT Short of Breath AND the Pneumothorax is 1-2cm on the Chest Xray, they need to be Aspirated. If this is successful, they can be admitted for 24 hours of Observation. If this is Not Successful, Intercostal Chest Drain is necessary

If the patient IS Short of Breath OR the Pneumothorax is more than 2cm on the Chest Xray, an Intercostal Chest Drain is necessary and they should be Admitted

Answer 123

A

Sudden onset of Shortness of Breath, Pleuritic Chest Pain and Haemoptysis (The Typical Triad although this is Rare)

If the Pulmonary Embolism is Massive, there will also be signs of Shock and Syncope

A Small Pulmonary Embolism may be Asymptomatic

Tachypnoea, Tachycardia and Hypoxia may be present. (Triad 2) There may be Low-grade Pyrexia and Tachycardia may be the only presenting symptom

A Massive Pulmonary Embolism may present with Hypotension, Cyanosis and signs of Right Heart Strain (Raised JVP, Parasternal Heave and loud P2)

Answer 124

A

May be normal or may have Sinus Tachycardia

If Massive Pulmonary Embolism, there may be evidence of Right Heart Strain (4) (P Pulmonale, Right Axis Deviation, Right Bundle Branch Block and nonspecific ST/T wave changes)

S1Q3T3 (deep S waves in lead 1, pathological Q waves in lead 3 and inverted T waves in lead 3) are very rare

Answer 125

A

Arterial Blood Gas- Type 1 Respiratory Failure, Hypoxia without Hypercapnia and/ or Respiratory Alkalosis (due to Hyperventilation occurring secondary to Hypoxia

FBC (patient may be Anaemic if they have Haemoptysis)

CRP may be raised

U&Es (to assess their Renal Function before CT Pulmonary Angiogram (CTPA))

Clotting Functions (important if the patient is to be started on LWMH or Warfarin)

D-Dimer- useful in Ruling out a Pulmonary Embolism but Not Confirming it

Answer 126

A

Chest Xray- Typically Normal in a Pulmonary Embolism but you may see (3) Fleischner Sign (Enlarged Pulmonary Artery), Hampton’s Hump (Peripheral Wedge Shaped Opacity) and Westermark’s Sign (Regional Oligaemia). Chest Xray can rule out differentials such as Pneumonia and a Pneumothorax

CT Pulmonary Angiogram- Diagnostic Test of Choice- will show a Filling Defect in the Pulmonary Vasculature. If the Patient has (3) a Renal Impairment, Contrast Allergy or is Pregnant, a V/Q scan is preferred

Lower Limb Duplex- helpful if a Deep Vein Thrombosis (DVT) is thought to be the cause of the Pulmonary Embolism (this is First Line if the patient is Pregnant)

Bedside Echocardiogram- Used if the Patient has a Massive Pulmonary Embolism (signs of Right Heart Strain/ Hypotension) in order to assess their suitability for Thrombolysis

Answer 127

A

If the Well’s Score is 4 or less, the D-Dimer should be measured. The D-Dimer has a High Negative Predictive value but a Low Specificity so it is only useful if the Suspicion of Pulmonary Embolism is Low

A Low D-Dimer Excludes a Pulmonary Embolism. A Raised D-Dimer suggests that they should have Diagnostic Imaging such as CTPA/V/Q scan

If the Well’s Score is more than 4, further Diagnostic Investigations are needed. Low Molecular Weight Heparin is usually given if the suspicion of a Pulmonary Embolism is high and should be administered if there is a delay in performing a CTPA anyway

Answer 128

A

DR ABCDE

Airway- Likely to be patent (normal airway, like if the patient is talking)

Breathing- They may be Tachypnoeic and Hypoxic and Oxygen should be Administered

Circulation- They may be Tachycardic. Signs of Right Heart Strain suggest a Sub-Massive Pulmonary Embolism. Hypotension suggests a Massive Pulmonary Embolism. Consider IntraVenous Fluids if their Systolic Blood Pressure is less than 90mmHg

Disability- Likely to be Unremarkable

Exposure- They may have Low-Grade Pyrexia. Check for signs of Deep Vein Thrombosis. Consider Analgesia at this stage, if the patient requires it

If there are signs of a Massive Pulmonary Embolism, Thrombolysis (through an IntraVenous Bolus of Alteplase) is needed. There is debate as to whether this should be done in a Sub-Massive Pulmonary Embolism

Answer 129

A

Anticoagulation should be administered

If in OutPatients, Direct Oral Anticoagulants like Apixaban or RIvaroxaban should be administered

If neither of the Above are suitable, Dabigatran, Edoxaban or Warfarin can be considered.

Low Molecular Weight Heparin should be continued for at least 5 days, until 48 hours of an INR lower than 2 has been achieved if they are on Warfarin. If they are on Dabigatran or Edoxaban, then Low Molecular Weight Heparin should be used for 5 days prior

The duration of anticoagulation treatment depends on the aetiology of the Pulmonary Embolism. A Provoked Pulmonary Embolism (where the cause can be identified such as Surgery or Pregnancy) should be treated for 3 months. Unprovoked Pulmonary Embolisms should be treated for Life

If a patient already on Warfarin has a Venous Thromboembolism (such as PE or DVT), the INR target should be increased 3 or 4

In the Inpatient/ Emergency Setting, Low Molecular Weight Heparin is used instead as it is Short-Acting

Answer 130

A

An Embolectomy may be considered in patients with a Massive Pulmonary Embolism when Thrombolysis is Contraindicated

An Inferior Vena Cava Filter may be considered in patients with Recurrent DVTs on Warfarin, OR patients who can not have Anticoagulation

Answer 131

A

Any seizure activity that lasts more than 5 minutes or if they experience more than one seizure and does not fully regain consciousness between the two seizures

Answer 132

A

ABCDE Approach

Oxygen

Ensure IV Access

Arterial Blood Gas

Take Bloods for (8) Glucose, FBC, U&Es, CRP, Calcium, Phosphate, Magnesium and Drug Levels if they are on Anti-epileptic Medication

Anaesthetic Review to ensure the Airway is managed

IV Lorazepam 4mg (a second dose should be given if there is no response) and if there is No IV Access, PR Diazepam or Buccal Midazolam should be given

If the initial Benzodiazepine fails, further Anticonvulsants can be used such as (3) Leviteracetam, Phenytoin, Valproate

If the Seizures continue to persist, Intubation and General Anaesthesia are needed

Answer 133

A

Any Narrow Complex Tachycardia (QRS width less than 120ms and Heart Rate more than 100bpm)

Three examples of Supraventricular Tachycardia include
- Atrial Fibrillation
- AV Re-entry Tachycardia
- AV Nodal Re-entry Tachycardia

Answer 134

A

HISS

Heart Failure

Ischaemia

Shock

Syncope

Answer 135

A

It depends on whether the arrhythmia is regular or irregular

Regular- Vagal Manoeuvres such as Carotid Sinus Massage or the Valsalva Manoeuvre should be attempted. If not, IV Adenosine 6mg should be administered.

Irregular- manage according to Atrial Fibrillation management

Answer 136

A

Difficulty Breathing

Chest Tightness

Flushing

Answer 137

A

It should be given rapidly over 1-3 seconds, followed by 20ml IV Saline bolus

If this fails, a second dose of Adenosine 12 mg can be administered, followed by another dose of 12mg

Answer 138

A

IV Adenosine 3mg should not be administered to Heart Transplant patients, patients with Central Line Access and patients on medications that can potentiate the effects of Adenosine, such as Dipyridamole or Carbamazepine.

Asthma is a contra-indication to the use of Adenosine so Verapamil should be used instead

Answer 139

A

Syncope

Deep Vein Thrombosis

Embolism

Cardiac Tamponade

Congestive Cardiac Failures

Myocardial Infarction

Death

Answer 140

A

Haemodynamic Instability (4)- Tachypnoea, Tachycardia, Hypotension and Raised JVP

Tracheal Deviation away from the Affected Side

Decreased Chest Expansion

Increased Resonance on Percussion

Decreased Breath Sounds

Decreased Vocal Resonance

Surgical Emphysema

Answer 141

A

A to E assessment to start with, focussing on IV Resuscitation and Blood Transfusion (if Hb<7) with or without Platelets and Frozen Fresh Plasma (every 4th unit of blood)

Over transfusion Increases Mortality therefore patients should NOT be transfused to a normal Haemoglobin

The patient should be Nil By Mouth and given Supplemental Oxygen

IV PPI may also be initiated

In Variceal Bleeding, IV Terlipressin and Antibiotics are used

Once it is stable, Upper GI Endoscopy is carried out to locate the source of the bleeding through (2) Adrenaline Injection and Ulcer Clipping

Answer 142

A

TIMMES

Toxins (4)- Clarithromycin, Anti-arrhythmics, Anti-psychotics and Tricyclic Antidepressants

Inherited- Congenital Long QT Syndromes such as Romano-Ward and Jervell and Lange-Nielson Syndromes

Ischaemia

Myocarditis

Mitral Valve Prolapse

Electrolyte Abnormalities such as Hypokalaemia and Hypocalcaemia

Subarachnoid Haemorrhage

Answer 143

A

Unstable (Haemodynamic Compromise)- DC Cardioversion

Stable- IV Magnesium Sulphate 2g over 1-2 minutes

Answer 144

A

Resting Tachycardia suggests a mild to moderate hypovolaemia (less than 15% of blood loss)

Orthostatic Hypertension suggests at least 15% blood volume loss

Supine Hypotension suggests over 40% blood volume loss

Answer 145

A

Oesophageal/ Gastric Varices

Peptic Ulcer Disease (H. pylori, NSAID use, Smoking)

Malignancy

Aorto-enteric Fistula (previous Abdominal Aortic Aneurysm or an Aortic Graft)

Angiodysplasia

Mallory Weiss Tear

Answer 146

A

IV Amiodarone

If the HISS Features (Heart Failure, Ischaemia, Shock, Syncope) are present, patients should be offered DC Cardioversion

Answer 147

A

A to E assessment to start with, focussing on IV Resuscitation and Blood Transfusion (if Hb<7) with or without Platelets and Frozen Fresh Plasma (every 4th unit of blood)

Over transfusion Increases Mortality therefore patients should NOT be transfused to a normal Haemoglobin

The patient should be Nil By Mouth and given Supplemental Oxygen

IV PPI may also be initiated

In Variceal Bleeding, IV Terlipressin and Antibiotics are used

Once it is stable, Upper GI Endoscopy is carried out to locate the source of the bleeding through (2) Adrenaline Injection and Ulcer Clipping

Answer 148

A

Age higher than or equal to 60

Systolic Blood Pressure> 100

Heart Rate> 100

Cardiac Failure

Liver Failure

Renal Failure

Blood in Upper GI (seen in Endoscopy) or Upper GI Malignancy

Answer 149

A

Glasgow Blatchford Score

Rockall Score

Answer 150

A

It is a Broad Complex Tachycardia (QRS Width>120ms) and HR>100

2 Other Types of Broad Complex Tachycardias include Torsades de Pointes and Supraventricular Tachycardia with Aberrant Conduction

Answer 151

A

Electrolyte Abnormalities (Hypokalaemia and Hypomagnesaemia)

Structural Heart Disease (Myocardial Infarction or Hypertrophic Obstructive Cardiomyopathy)

Drugs that cause QT Prolongation (Clarithromycin and Erythromycin)

Inherited Channelopathies (Romano-Ward Syndrome and Brugada Syndrome)

Answer 152

A

IV Amiodarone

If the HISS Features (Heart Failure, Ischaemia, Shock, Syncope) are present, patients should be offered DC Cardioversion

Answer 153

A

Hyperkalaemia

Pulmonary Oedema

Metabolic Acidosis leading to Nausea, Vomiting and Drowsiness

Chronic Kidney Disease

Death

Answer 154

A

Increase in Serum Creatinine of 26micromol/L within 48 hours

Or an increase in Serum Creatinine at least 1.5 times above the baseline value within 1 week

Or urine output less than 0.5ml/kg/hour for more than 6 consecutive hours

Answer 155

A

Either Find and Treat the Causes (Sepsis, Drugs, Obstruction)

Or Stop the Renotoxic Drugs

Or Give IV Fluids, Treat the Complications and Dialyse

Answer 156

A

Low Blood Pressure

Vomiting and Diarrhoea

Dehydration

Shock

Coma

Death

Answer 157

A

ACE Inhibitors/ ARBs

Spironolactone

Diuretics

Gentamicin

NSAIDs

Answer 158

A

Persistently high Potassium that is refractory to medical treatment

Severe Acidosis (pH<7.2)

Refractory Pulmonary Oedema

Symptomatic Uraemia (Pericarditis, Encephalopathy)

Drug Overdose (Aspirin)

Answer 159

A

Hyperkalaemia

Pulmonary Oedema

Metabolic Acidosis leading to Nausea, Vomiting and Drowsiness

Chronic Kidney Disease

Death

Answer 160

A

It is the body’s inability to produce a sufficient amount of Cortisol

Answer 161

A

Fluid Resuscitation if Hypotensive

IV Hydrocortisone 100mg (stat and then regularly)

IV Glucose if they are Hypoglycaemic

Swap back to their Prescribed Oral Steroids after 3 days

Consider Fludrocortisone if there is an Adrenal Disease

Answer 162

A

Low Blood Pressure

Vomiting and Diarrhoea

Dehydration

Shock

Coma

Death

Answer 163

A

Herpes Simplex Virus (most common cause)

Cytomegalovirus

Adenovirus, influenza virus

Tuberculosis

Listeria

Fungal (Cryptococcosis, Coccidiomycosis, Histoplasmosis)

Tick-borne Encephalitis

Answer 164

A

Fever

Headache

Altered Mental State

Personality Change

Focal Neurological Deficits

Convulsions

HSV1 Encephalitis is associated with Temporal Lobe Involvement so patient may experience Olfactory Symptoms (smell of Rotten Eggs)

Answer 165

A

CT Imaging (Medial Temporal and Inferior Frontal Lobe involvement with Petechial Haemorrhages seen in HSV Encephalitis)

MRI should also be performed after CT

Lumbar Puncture with CSF Analysis- Microscopy and Serology cultures needed to diagnose Encephalitis

Answer 166

A

IV Aciclovir and IV Ceftriaxone to cover for bacterial infections

Answer 167

A

Herpes Simplex Virus (Most common cause)

Cytomegalovirus

Adenovirus/ Influenza Virus

Tuberculosis

Listeria

Fungal Causes (3)- Cryptococcosis, Coccidiomycosis, Histoplasmosis

Tick-borne Encephalitis

Answer 168

A

Fever

Headache

Altered Mental State

Personality Change

Focal Neurological Deficits

Convulsions

HSV1 is associated with Temporal Lobe Involvement. So the patient may experience Olfactory Seizures such as the Foul Smell of Rotten Eggs

Answer 169

A

CT Scan- Medial Temporal and Inferior Frontal Lobe Involvement with the presence of Petechial Haemorrhages in HSV Encephalitis

MRI should be performed after

Lumbar Puncture with CSF Analysis- Microscopy, Serology and Cultures is needed to diagnose Encephalitis

Answer 170

A

IV Aciclovir and IV Ceftriaxone

Answer 171

A

Extreme Dyspnoea

Restlessness

Anxiety

Bilateral Reduced Air Entry

Inspiratory Crepitations

Raised JVP

S3 Gallop

Peripheral Oedema

Answer 172

A

Nausea and Vomiting

Tinnitus

Fever

Confusion

Tachycardia

Initial Respiratory Alkalosis (caused by activation of respiratory centres in the brain)

Later Metabolic Acidosis (caused by wasting of bicarbonate ions due to the ingested acid load)- this is often mixed with the respiratory alkalosis

Answer 173

A

Venous Blood Gases- look for acid-base imbalances

Salicylate levels

Answer 174

A

Activated Charcoal if Ingestion< 1 hour ago

IV Fluid, Sodium Bicarbonate and Potassium Chloride
- (The aim is to maintain good kidney function and to alkalise the urine in order to increase Salicylate Excretion)
- Monitor with Serial Venous Blood Gases

Dialysis- may be necessary if blood levels are high

Monitor them for complications (3)
- Renal Functions
- Chest X-ray: Pulmonary Oedema
- CT Head: if Signs of Cerebral Oedema

Answer 175

A

Cardiac Ischaemia

Arrhythmias

Non-compliance with Heart Failure Medication

Answer 176

A

Bedside Investigations

Arterial Blood Gases

ECG

Troponin- if there is concern for a new cardiac event

Serum BNP

Chest Xray

Answer 177

A

Take an ABCDE Approach

Sit the patient up

Administer Oxygen

Ensure IV Access

IV Furosemide

Consider Non-Invasive Ventilation such as CPAP if failed medical therapy

Consider further therapies in the intensive care setting such as invasive ventilation and inotropic support if the above fails

Answer 178

A

Acute Kidney Injury is largely Pre-renal due to Under-perfusion, which can be managed by Replacing Fluids as most patients are Hypovolaemic

But if patients have Heart Failure as well as Acute Kidney Injury, the Under-perfusion is because of a poor output from the heart

According to the Starling Curve, when the Left Ventricle End-diastolic Volume is too high, the Stroke Volume falls. This is what happens in Heart Failure patients with Fluid Overload

So by Off-loading fluid with Diuresis, the Stroke Volume improves, there is a greater output from the heart, so perfusion to the kidneys improve. Overall, when there is Elevated Central Venous Pressure, the Renal Function may recover with the aid of Diuresis

Answer 179

A

The use of Diuretics to treat Heart Failure would be detrimental to the patient’s Hypotension- this can severely impact the perfusion of vital organs

In patients with Heart Failure and a Low Left Ventricular Ejection Fraction, if the Systolic Blood Pressure is low (<85mmHg) or the patient is in Shock (Confusion/ Cold Extremities), then add an Inotrope after discussing with a senior colleague.
- Small Fluid challenges of 250ml boluses over 15-20 minutes can be given to keep the blood pressure above 90mmHg and this needs to be carefully titrated

Vasopressors (Noradrenaline) may play a role in patients with Heart Failure with Persistent Hypotension, alongside evidence of End-organ Hypoperfusion. But only give Vasopressors if the response to Inotropes is insufficient

These measures are only temporary and aim to maintain perfusion to the End-organs until the Acute Trigger for the deterioration (the original cause of it) has been reversed, or a Definitive Treatment (Coronary Revascularisation, Mechanical Circulatory Support or Heart Transplantation) has been employed.

Answer 180

A

Syncope is an acute transient loss of consciousness with a lot of Postural Tone

Seizures arise from a Sudden Synchronous discharge of Electrical Activity from neurons in the brain

Answer 181

A

Risk Factors-
- Syncope (3)- Heart disease (Arrhythmias), Peripheral Neuropathy, Drugs that cause Postural Hypotension (Diuretics, Antipsychotics, Antidepressants, Antihypertensives)
- Seizures (3)- Family or previous history of Epilepsy, Head Injuries, CNS Infections

Triggers-
- Syncope (5)- Pain, Heat, Exertion, Prolonged Standing, Emotion
- Seizures (4)- Alcohol, Sleep Deprivation, Bright Lights, Infections

Before the Episode-
- Syncope (4)- Dizziness, Light-headedness, Nausea, Tunnel-vision
- Seizures (4)- Aura: Strange Feelings like Epigastric Rising, Deja Vu, Visual or Smell Disturbances

During the Episode-
- Syncope (4)- Sudden loss of tone, May have tongue biting, May have incontinence, Brief Duration
- Seizures (4)- Tonic-clonic Jerking, May have tongue biting, May have incontinence, Brief or Prolonged Duration

After the Episode-
- Syncope- Complete and Rapid Recovery
- Seizures (2)- Post-ictal Confusion and Drowsiness, May have Todd’s Palsy- Focal Weakness after Seizure

Answer 182

A

Cardiac Pathology (3) (Arrhythmias, Valvular Disease, Cardiomyopathies)

Postural Hypotension (3) (Drugs, Volume Depletion, Autonomic Dysfunction)

Neurogenic Causes (Vasovagal Syncope)

Answer 183

A

Infections (2)- Meningitis, Encephalitis

Electrolyte Disturbances (6)- Hyponatraemia, Hypernatraemia, Hypoglycaemia, Hypocalcaemia, Hypokalaemia, Ammonia (Hepatic Encephalopathy)

Drugs (3)- Tricyclic Overdose, Alcohol and Benzodiazepine Withdrawal

Neurological Causes (4)- Stroke, Mass Lesions, Degenerative Conditions, Epilepsy

Obstetrics (Eclampsia)

Answer 184

A

Seizures which occur in known Epileptics

Can be caused by (4)- Poor medication compliance, Sleep deprivation, Alcohol, Stress

Answer 185

A

Arterial Blood Gases (Hypoxia and Hypercapnia- look for these in Acute Prolonged Seizures)

Blood Tests (4) (FBC, U&Es (Serum Calcium, Magnesium, Phosphate), LFTs, Glucose)

Urine Test- Urine Toxicology Screen

Imaging- CT Head

Answer 186

A

Dizziness

Nausea and Vomiting

Palpitations (due to Arrhythmias)

Bradycardia (usually Without Hypotension)

Yellow-Green Colour Disturbance

Visual Haloes

Confusion

Hyperkalaemia (but HypOkalaemia is a Risk Factor for Digoxin Poisoning)

Answer 187

A

Measure the Immediate Digoxin Level

IV Fluids

Correct Electrolyte Abnormalities

Continuous Cardiac Monitoring

Give Digibind if (3)
- Digoxin Level >15ng/ml after 6 hours of last dose
- Digoxin Level >10ng/ml within 6 hours of last dose
- Symptomatic

Answer 188

A

Shaking/ Trembling

Sweating

Palpitations

Hunger

Headache

Double Vision and Difficulty Concentrating

Slurred Speech

Confusion

Coma

Answer 189

A

Drugs-
- Insulin
- Sulphonylureas
- GLP-1 analogues
- DPP-4 inhibitors
- Beta blockers
- Alcohol

Acute Liver Failure

Sepsis

Adrenal Insufficiency

Insulinoma

Glycogen Storage Disease

Answer 190

A

Check the Medication History for Drug Causes

Serum Insulin, C-peptide and Proinsulin- to Distinguish the Presence of Exogenous and Endogenous Insulin
(High Insulin and High C-peptide and Proinsulin= Endogenous Production/ High Insulin and Low C-peptide and Proinsulin= Exogenous Administration)

72 hour Fast Test- to demonstrate Episodic Hypoglycaemia

8am Cortisol and/ or synACTHen testing- for Adrenal Insufficiency

Abdominal CT/MRI/ PET- to look for an Insulinoma

Answer 191

A

Mild Hypoglycaemia
- ABCDE
- Eat/drink 15-20g Fast-acting Carbohydrate such as Glucose Tablets, a small can of Coca Cola, Sweets or Fruit Juice
- AVOID Chocolate
- Eat some Slow-acting Carbohydrate afterwards (toast)

Severe Hypoglycaemia
- ABCDE
- 200ml 10% Dextrose IV
- 1mg/kg Glucagon IM- if there is no IV access (this will NOT work if the Hypoglycaemia is caused by Acute Alcohol as it blocks Gluconeogenesis)
- Treat Seizure if Prolonged or Repeated

After Care- (2)
- Consider Medication Changes
- Investigate non-drug causes if necessary

Answer 192

A

It is a Tumour in the Adrenal Medulla that secretes Catecholamines (Hormones produced by Adrenal Glands such as Noradrenaline)

If it arises in Sympathetic Nerve Tissue, it is called a Paraganglioma

Answer 193

A

Pyrexia

Dyspnoea

Hypertension

Postural Hypotension

Tremor

Hypertensive Retinopathy

Abdominal pain

Anxiety

Weight loss

Fatigue

Palpitations

Sweating

Headaches

Flushing

Answer 194

A

Stress

Exercise

Surgery

Straining and Various Drugs such as Beta Blockers

Anaesthetic Agents and Opiates

Answer 195

A

Plasma Metanephrines and then Urinary Metanephrines have the best Diagnostic Accuracy to Establish a Catecholamine Excess

24 Hour Urinary Catecholamines can be measured as well however they are of less value

Adrenal Imaging should not take place until the Biochemical Diagnosis has been confirmed

CT Chest Abdominal and Pelvis imaging is the imaging method of choice and should be followed with an MRI Scan (as an Extra-adrenal Pheochromocytoma can occur anywhere from the Base of the Brain to the Bladder as it develops in the Chromaffin Tissue of the Sympathetic Nervous System)

PET Scans can also help

Other tests include Metaiodobenzylguanide (MIBG) labelled with Iodine (which has a similar composition to Noradrenaline)

Answer 196

A

The definitive treatment is to Surgically Resect the Tumour

Pre-operatively, Alpha Blockade with Phenoxybenzamine is started First

This is followed by Beta Blockade to Expand the Blood Volume. This is to Expand the Blood Volume and Prevent a Hypertensive Crisis

Answer 197

A

Upper Motor Neuron Signs

Sensory Disturbance below the level of the lesion

Deep localised Back Pain may also be present

Also a Stabbing Radicular Sensory Disturbance at the Level of the Lesion

Bladder and Bowel Involvement may also be seen

Answer 198

A

Trauma

Neoplasia (Spinal Cord Compression is seen in 5-10% of Cancer patients, and is the presenting complaint in 20% of them)

Infection (especially Tuberculosis in at-risk patient)

Disc Prolapse

Epidural Haematoma

Answer 199

A

They should have a URGENT Whole Spine MRI with an aim to Surgically Decompress within 48 hours

If there is a Malignancy seen on MRI, or if the Clinical Suspicion of a Malignancy is high, Dexamethasone 16mg daily should be Administered- with PPI Cover

Answer 200

A

It is a life-threatening, hypermetabolic state caused by an excessive release of Thyroid Hormones

Answer 201

A

High Blood Pressure

High Temperature

Tachycardia

Answer 202

A

Symptom Control (2)
- IV Propanolol
- IV Digoxin if Propanolol fails or is Contraindicated (Asthma, low BP)

Reduce Thyroid Activity (4)
- Propylthiouracil through an NG tube- (preferred as it inhibits peripheral thyroxine conversion)
- Lugol’s iodine 4 hours later
- Methimazole/ Carbimazole is considered second line
- IV Hydrocortisone/ Prednisolone to reduce Thyroid Inflammation

Treat Complications (Heart Failure, Hyperthermia)

Answer 203

A

Alcohol

Antiplatelet Agents (Clopidogrel)

Aspirin and NSAIDs

Anticoagulants (Warfarin)

Coagulopathy (2)- Haemophilia, von Willebrand’s Disease

Trauma (Nasal Fracture)

Tumours

Surgery

Septal Perforation

Answer 204

A

DRABCDE

Brief history- which side? trauma? anticoagulants/ antiplatelets? relevant past medical history?

Answer 205

A

Direct Compression
- Direct Compression of the Nasal Alae (Cartilage part) is the First Line Management as most Anterior Nose bleeds resolve after 10-15 minutes of compression. Patient should be Sitting up and Leaning Forward. Compression of the Nasal Bones isn’t what controls the bleeding
- If this does not resolve the bleed, the next step is Cautery, especially if there is a Visible Bleeding sight and the patient suffers from Recurrent Nose Bleeds

Cautery-
- Before Cautery, a Topical Anaesthetic Spray and Vasoconstrictor (Lidocaine with Phenylephrine) is applied to Reduce the Pain and Help Control the Bleeding respectively
- Cautery can be Chemical or Electrical (Thermal)
- Chemical Cautery involves applying 75% Silver Nitrate sticks to the identified bleed for 3-10 seconds
- Afterwards, the cauterised area is dabbed with a clean cotton bud to remove excess Chemical and Blood. A Topical Antiseptic preparation such as Naseptin (Chlorhexidine and Neomycin) is applied to the nostrils 4 times a day for 10 days to reduce Crusting and Vestibulitis

Nasal Packing-
- If Nasal Cautery fails or if there isn’t a Bleeding Point or if there is Severe Bleeding, Nasal Packing should be attempted
- Nasal Tampons, Inflatable Packs and Ribbon Gauze Impregnated with Vaseline can be used in Nasal Packing

Aggressive Therapies-
- Nasal Balloon Catheter and Transnasal Endoscopy with Direct Cautery/ Arterial Ligation are reserved for patients with Posterior Bleeds and Uncontrollable Severe Bleeding unamenable to Nasal Packing

Answer 206

A

Also known as Infectious Mononucleosis- it is caused by the Epstein-Barr Virus. It is transmitted by saliva which is why it is known as the Kissing Disease

Answer 207

A

Fever

Sore throat

Fatigue

Hepatomegaly and/or splenomegaly may be found on palpation

Answer 208

A

The diagnosis is usually made clinically although the heterophile antibody “Paul Bunnell” test will be positive

Management is supportive and patients are advised against contact sports and heavy lifting for 1 month to minimise the risk of Splenic Rupture

Answer 209

A

Age

Male Sex

Family History of a Haemorrhagic Stroke

Haemophilia

Cerebral Amyloid Angiopathy/Hypertension

Anticoagulation Therapy

Illicit Sympathomimetic Drugs (Cocaine and Amphetamines)

Vascular Malformations (particularly in younger patients)

Non-steroidal Anti-inflammatory Drugs

Heavy Alcohol Use

Thrombocytopaenia

Answer 210

A

Neurosurgical and Neurocritical Care Evaluation due to the potential for surgical intervention (Decompressive Hemicraniectomy)

Admission to the Neuro ICU or Stroke Unit (patient may require Intubation and Ventilation or Invasive monitoring of ICPs)

Aim to keep Blood Pressure <140/80 as poor blood pressure control in the acute stage is associated with poorer outcomes later on

Answer 211

A

Pancoast Tumour (Affecting Sympathetic Nerve Supply)

Stroke

Carotid Artery Dissection (Red flag: Neck Pain)

Answer 212

A

Ptosis

Meiosis

With or Without Anhidrosis

It occurs due to the interruption of the Sympathetic Nerve Supply to the eye and can be classified into Pre-ganglionic, Central and Post-ganglionic causes

Answer 213

A

Peripheral Features-
- Fine Tremor
- Finger Clubbing
- Sweating
- Pretibial Myxoedema

Head and Neck Features-
- Goitre (depending on the cause)
- Thyroid Bruit

Eye Features-
- Lid Retraction
- Lid Lag
- Exophthalmos (Graves’ Disease)
- Periorbital Oedema (Graves’ Disease)
- Ophthalmoplegia (Graves’ Disease)

Cardiac Features-
- Atrial Fibrillation
- High output Heart Failure (if severe and prolonged)

Gastrointestinal Features-
- Diarrhoea

Neurological Features-
- Muscle Wasting
- Proximal Weakness

Answer 214

A

Primary Causes-
- Graves Disease
- Toxic Thyroid Adenoma
- Multinodular Goitre
- Silent Thyroiditis
- De Quervain’s Thyroiditis (Painful Goitre)
- Radiation

Secondary Causes-
- Amiodarone
- Lithium
- TSH-producing Pituitary Adenoma
- Choriocarcinoma (Beta HCG can activate TSH Receptors)
- Gestational Hyperthyroidism
- Pituitary Resistance to Thyroxine (the failure of the Negative Feedback Mechanism)
- Struma Ovarii (ectopic thyroid tissue in Ovarian Tumours)

Answer 215

A

Propranolol is given for Symptom Relief

Carbimazole and Propylthiouracil are given for Medical Management of Hyperthyroidism

Carbimazole is contraindicated in Pregnancy, Propylthiouracil is given in the First Trimester in Pregnancy or in a Thyroid Storm

Answer 216

A

Radioiodine is the definitive management for Multinodular Goitre and Adenomas

Radioiodine is Contraindicated in Graves Eye Disease as it may worsen the symptoms

Answer 217

A

It is indicated for (3) Recurrence, Goitres that obstruct other structures and Potential Cancers

Complications- Hypoparathyroidism, Hypocalcaemia, Laryngeal Nerve Damage, Bleeding

Answer 218

A

Thyroid Storm (often precipitated by Trauma, Surgery or Infection)- this may present as (5)- High Fever, Tachycardia, Confusion, Nausea, 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 219

A

Bradyarrhythmias (4) (Sinus Bradycardia, Atrial Fibrillation with a Slow Ventricular Response, Slow Junctional Rhythms, Varying degrees of AV block)

Osborne Waves (J Waves)- a positive deflection at the J Point- between the end of the QRS and beginning of the ST Segment

Prolonged PR, QRS and QT Intervals

Shivering Artefact

Ventricular Ectopics

Cardiac Arrest (Ventricular Fibrillation, Ventricular Tachycardia or Asystole)- patients with hypothermia are at high risk of a Cardiac Arrest

Answer 220

A

Cover Patients with a Warm Blanket and supply Warm Drinks

Passive Warming can be done through the Intravenous Admission of Warm Fluids and Application of Warm Air (like through a Bair-Hugger). Patients are at a high risk of Cardiac Arrest and CPR may be used

Answer 221

A

It results in an Intracranial Pressure (opening pressure> 25cmH2O)

It occurs commonly in Young and Obese Women

Answer 222

A

Headache and Visual Disturbance

The headache is Non-Pulsatile, Bilateral and Worse in the Morning and after Lying Down or Bending Forward

Visual Disturbances include Transient Visual Darkening or Loss- probably due to Optic Nerve Ischaemia. In Fundoscopy, Bilateral Papilloedema is seen. If left untreated, the visual loss may be permanent

Patients may even report Morning Vomiting. A Key Differential for Morning Headache in these Obese Patients is Sleep Apnoea

Answer 223

A

Oral Contraceptive Pills

Steroids

Tetracyclines

Vitamin A

Lithium

Answer 224

A

Weight Loss (First line and only intervention supported by good evidence)

Carbonic Anhydrase Inhibitors are given if this doesn’t work (Acetazolamide) but it has 3 side effects (Peripheral Paresthesia, Anorexia and Metallic Dysguesia). Topiramate and Furosemide can also be used

Invasive Strategies to lower CSF include Therapeutic Lumbar Punctures and Surgical CSF Shunting

In patients with prominent visual symptoms, Optic Nerve Fenestration may protect against visual loss

Answer 225

A

GCS less than 13 on initial assessment in the emergency department

GCS less than 15 at 2 hours after the injury

Suspected Open or Depressed Skull Fracture

Any sign of Basal Skull Fracture (4) (Haemotympanum, Panda Eyes, Cerebrospinal Fluid Leak from the Ear or Nose, Battle’s Sign)

Post-traumatic Seizure

Focal Neurological Deficit

More than 1 episode of vomiting

Answer 226

A

Age 65 or older

Any history of Bleeding or Clotting Disorders

Dangerous Mechanism of Injury (struck by Motor Vehicle, Ejected from Motor Vehicle, fall from a height greater than 1 metre)

More than 30 minutes of Retrograde Amnesia of events immediately before the Injury

Answer 227

A

Cardiac Causes-
- Myocardial Infarction
- Arrhythmias
- Coronary Artery Spasms
- Aortic Dissections
- Severe Hypertension

Non Cardiac-
- Chronic Kidney Disease
- Pulmonary Embolism
- Sepsis

Answer 228

A

ABCDE Algorithm

Stabilising the C-Spine and Airway

Recognising Haemorrhage and Treating the Pain

Answer 229

A

Subcutaneous Haematoma

CSF Rhinorrhoea (from the Anterior Nares (Nostrils))

CSF Otorrhoea (leakage of CSF from the External Auditory Meatus)

Subcutaneous Haematoma around the Orbits (Panda Eyes)

Haemotympanum

Subcutaneous Haematoma behind the Ear (Battle Sign)

Subcutaneous Emphysema

Cranial Nerve Palsies (arise 1-3 days after the Trauma)

Answer 230

A

Nasopharyngeal Airways are Contraindicated as they can cause further damage to the patients

Head tilt, Chin Lift is Contraindicated in Trauma patients at risk of a C-Spine Injury

Answer 231

A

First line is Plain CT Head

CT Cervical Spine to look for Spinal Fractures

CT Angiogram to look for Local Vascular Injuries

Plain Skull Xray to look for Orbital Fractures

Answer 232

A

Respiratory Droplet Spread

The pathology is triggered when the bacteria enters the circulation, initiates the inflammatory process leading to capillary leakage and intravascular thrombosis

Answer 233

A

Meningococcaemia (Septicaemia)

Meningitis (non-specific signs such as (5) Lethargy, Headache, Fever, Rigors and Vomiting)

A mixture of both Meningitis and Meningococcaemia associated with a Rapidly Developing Purpuric Skin Rash

Hypovolaemic Shock may present with (4) Cold Peripheries, Poor Capillary Refill Time and Tachycardia, with Decreased Urine Output

When this is associated with Massive Adrenal Haemorrhage and Septic Shock, the presentation is known as Waterhouse-Friderischsen Syndrome. This is rare

Answer 234

A

Blood or CSF Cultures

Polymerase Chain Reaction Testing for Neisseria Meningitidis is highly sensitive

Answer 235

A

Early Antibiotic Treatment should be given. This will usually be Broad Spectrum IV Antibiotics until confirmation of the pathogen, after which antibiotics may be narrowed to Penicillin-based drug if Sensitivities permit

Patients are likely to need PICU admission is Septicaemia

Infections caused by Neisseria meningitidis are notifiable diseases

Answer 236

A

All household or close contacts should receive Ciprofloxacin or Rifampicin as Post-exposure Prophylaxis

Multiple strains of Neisseria Meningitidis covered as part of the Routine Immunisation Schedule

Answer 237

A

ITU/ HDU care

IV T3/ T4

50-100mg IV Hydrocortisone

Mechanical Ventilation and Oxygen (if Hypoventilation)

IV Fluid- to correct Hypovolaemia

Correct Hypothermia

Correct Hypoglycaemia

Treat any Heart Failure

Answer 238

A

It is a life-threatening infection of the subcutaneous soft tissue, which spreads along the fascial planes but not the underlying muscle

Answer 239

A

Rapidly spreading cellulitis and patients are systemically unwell. There is often a history of risk factors (cutaneous portal of entry for bacteria, like Trauma or Surgery)

On physical examination- the affected region will be Blistering and Erythematous. But a Mild Oedema may be the only sign. There will be severe pain or anaesthesia over the site of Cellulitis. In advanced stages, the skin may be grey with overlying Crepitus. The patient is typically (4) Pyrexial, Tachycardic, Tachypnoeic and Hypotensive

Answer 240

A

Haemodynamic Support

Urgent Debridement Surgery

Broad Spectrum Antibiotics

Radiography or CT/MRI can confirm the diagnosis but should not delay the surgery

Answer 241

A

Reflux of Gastric Contents

Drugs

Infections

Allergens (Eosinophilic Oesophagitis)

Answer 242

A

Heartburn (retrosternal burning pain)

Nausea and Vomiting

Odynophagia (painful swallowing)

Answer 243

A

Endoscopy allows for a direct visualisation of the Oesophagus and can be used to Grade the degree of Oesophagitis (Savary-Miller Grading System, Los Angeles Grading System)

Biopsy can be taken with the Endoscopy

If reflux is suspected as the cause, Oesophageal pH monitoring can be used to identify whether the timing of the symptoms and the reflux correlates

Answer 244

A

As reflux is the most common cause,

Lifestyle changes such as (3) Weight loss, Stopping smoking and Reducing Alcohol intake and…
Pharmacological treatment such as Protein Pump Inhibitors can be administered

Answer 245

A

the Tibia and the Phalanges

Answer 246

A

The Prompt Administration of Antibiotics (open fractures are at risk of infection)

Debridement and Irrigation

Reduction and Fixation

Answer 247

A

No symptoms may be present

Nausea and Vomiting

Loin Pain

Haematuria and Proteinuria

Jaundice

Abdominal Pain

Coma

Severe Metabolic Acidosis

Answer 248

A

When overdosed, the metabolism of Paracetamol results in a buildup of a toxic substance called NAPQI (N-acetyle-p-benzoquinone-imine)

NAPQI is inactivated by Glutathione usually, however in an overdose, the Glutathione stores are rapidly depleted and NAPQI damages the Kidneys and Livers

Answer 249

A

If the ingestion is less than 1 hour ago and the dose is greater than 150mg/kg- Administer Activated Charcoal

If they had a Staggered Overdose (duration of overdose>1 hour) or ingestion was more than 15 hours ago or there is any uncertainty about the timing- Start N-acetylcysteine immediately

If ingestion <4 hours ago, wait until 4 Hours to take a level (blood paracetamol level) and treat with N-acetylcysteine based on their level (refer to a Nomogram)

If ingestion is 4-15 hours ago, take an immediate level and treat based on their level

Obtain bloods for (4)- FBC, Urea and Electrolytes, INR and Venous Gases

Consider the need for transfer to Liver Unit if blood tests are Worsening

Answer 250

A

Anaphylactoid Reactions. These are not true Anaphylactic Reactions and can be managed by stopping the Infusion Temporarily and restarting at a Lower Rate

Answer 251

A

Patients on long-term Enzyme Inducers

Regular Alcohol Excess

Pre-existing Liver Disease

Glutathione-deplete States- Eating Disorders, Malnutrition and HIV

Answer 252

A

Type A
- Central chest pain (Coronary Ostia- leads to Myocardial Infarction)
- Dyspnoea (Ascending Aorta- leads to Aortic Regurgitation and therefore Congestive Heart Failure)
- Neck/ Jaw Pain (Aortic Arch)
- Horner’s (Cervical Sympathetic Ganglia)
- Symptoms of Stroke (Carotid Arteries)

Type B
- Interscapular pain (Thoracic Descending Aorta)
- Abdominal pain (Abdominal Descending Aorta or Mesenteric Arteries)
- Flank pain (Renal Arteries)

Answer 253

A

Aortic Dissection pain is worst at onset and gets better

Myocardial Ischaemia pain gets worse as the Ischaemia Worsens

Answer 254

A

Syncopal Episodes and Pseudoseizures

Answer 255

A

Sudden Onset

Lateral tongue biting and Urinary Incontinence may occur. After the event, the patient is usually confused (but may recall the onset especially if secondary generalised seizure). They may be left with a residual focal neurological deficit (Todd’s Paresis)

There are two groups of Seizures- Provoked and Unprovoked Seizures, where there is an underlying tendency to spontaneous abnormal electrical brain activity (which manifests clinically as seizures), these may be Congenital or Acquired Tendencies

Answer 256

A

The Absence of Postictal Confusion. With Vasovagal Syncope, patients report (3) Narrowing of Vision, Sweating and Lightheadedness and have time to safely lower themselves onto the floor.

Arrhythmogenic Syncope (Stokes-Adams attacks) are abrupt in onset without any warning and may result in significant injury. Myoclonic Jerks or Tonic Posturing may occur during these episodes which may confound diagnosis

Answer 257

A

They are called Psychogenic NonEpileptic Attacks. They are often Prolonged Episodes (rarely< 1 minute, often> 30 minutes)

The patient often has Seizure-like Convulsions and Fluctuating Motor Activity.

Video EEG Recording helps to differentiate Pseudoseizures from True Seizures

Differential Diagnoses include Hemiplegic Migraine and Cerebrovascular Events, although Consciousness is typically preserved in Pseudoseizures

If patients have True Seizure Activity and Focal Weakness, differentiating Seizure plus Todd’s Paresis from Stroke plus Seizure Onset is difficult clinically and Requires Imaging

Answer 258

A

Focal (or Partial Seizures) may spread to involve the entire brain- these are called Secondary Generalised Seizures. Focal Seizures may be subclassified on the basis of Key Clinical Features, in particular the part of the brain that they involve (Temporal vs. Frontal lobe seizures) and whether consciousness is impaired (Simple vs. Complex)

The clinical manifestation of a Generalised Seizure may be described. These are either (4) Tonic, Tonic-Clonic, Myoclonic or Absence. Generalised Tonic-Clonic (or Grand Mal) seizures are the most typical- the patient falls to the ground (Tonic) and has rhythmic jerks (Clonic Absence)

Answer 259

A

2 or more of:

> 38 degrees or <36 degrees temperature
Heart Rate>90 (not 100 like Tachycardia)
Respiratory Rate>20
WBC> 12,000/mm cubed or <4,000/mm cubed

Answer 260

A

SIRS and a presumed Infection

Answer 261

A

Sepsis and evidence of Organ Dysfunction (4)- Confusion, Hypoxia, Oliguria, Metabolic Acidosis

Answer 262

A

Severe Sepsis with Hypotension despite (3) Adequate Fluid Resuscitation or Lactic Acidosis (Lactate>3mmol/L)

Answer 263

A

Fever, Sweats or Chills
Breathlessness
Headache
Nausea and Vomiting
Diarrhoea
Tachycardia
Hypotension
Pyrexia
Peripherally Vasodilated
Hypoxia
Tachypnoea

Answer 264

A

ABC (Airways, Breathing, Circulation) + Sepsis Six

Take Bloods (FBC, U&Es, LFT, CRP, Lactate)
Take Blood Cultures
Administer Oxygen if required (Sats<94%)
Administer IV Antibiotics
Administer IV Fluid Resuscitation (Fluid Challenge- Crystalloid if (2) Systolic BP<90mmHg or Lactate>4mmol/L and high risk of Sepsis)
Catheterisation and monitor urine output

4 Investigations-
- Imaging (CXR, Echocardiogram, Abdominal Ultrasound)
- Viral PCR for any viruses like Influenza for example
- Urinalysis, with or without Culture
- Lumbar Puncture

Ongoing Management (depends on the Source and the Severity)
- IV Antibiotic Therapy
- Surgical Removal of Source of Infection
- Critical Care Involvement

Answer 265

A

Mental State Changes

Autonomic Hyperactivity (arousal of the sympathetic nervous system typically- results in signs of Anxiety (5)- Sweating, Lightheadedness, Dry Mouth, Palpitations, Upset Stomach

Neuromuscular Abnormalities (muscle weakness, paresthesia)

It usually presents within the first couple months of starting an SSRI or because of drug interactions like Tramodalol and Sertraline

Answer 266

A

Hypovolaemic Shock (Blood Loss)
Septic Shock (Severe Systemic Infections)
Anaphylactic Shock (Allergy)
Cardiogenic Shock (Poor Cardiac Output)
Neurogenic Shock
Obstructive Shock (A Physical Obstruction of the Vessels or the Heart)

Answer 267

A

1.5-2L Warmed IV Crystalloid
Assess for response
If the response to the fluid is inadequate, arrange O Negative Blood
Give fully cross-matched blood as soon as possible
If the patient is Severely Shocked, initiate the Massive Haemorrhage Protocol

Answer 268

A

A Prominent Headache worse when (4) Waking up, Lying down, Coughing/ Straining and associated with Vomiting

Early symptoms of a Raised ICP are Non-specific and include a Headache associated with morning Nausea and Vomiting

Patients may have Cranial Nerve Palsies- especially within the Abducens Nerve

In Advanced Cases, Drowsiness and Seizure Activity may occur with Pupillary Abnormalities and Papilloedema

The Cushing’s Reflex may also be demonstrated where a patient has Raised Blood Pressure, Bradycardia and Abnormal Breathing (including Cheyne-Stokes Respiration)

Answer 269

A

There are 4 types of Space Occupying Lesions (Tumours, Vascular Lesions, Infective Processes, Granulomata)

Space Occupying Neoplasia can occur secondary to Metastatic Disease (from Breasts, Lungs or Melanoma) or as a Primary CNS Tumour

Infective Processes include Cerebral Abscesses and rarer diseases such as Tuberculosis

Patients who are immunosuppressed are more prone to Intra-cerebral Infections so look for risk factors such as HIV

Answer 270

A

Cranial MRI is more useful that Cranial CT

Answer 271

A

What is the Time Course?
What are the associated symptoms?
What is the Medical History?
What does the Retina look like?

Answer 272

A

Central Retinal Vein Occlusion (More common than CRAO)

Central Retinal Artery Occlusion

Ischaemic Optic Neuropathy

Giant Cell Arteritis

Retinal Detachment

Vitreous Haemorrhage

Optic Neuritis

Answer 273

A

Central Retinal Vein Occlusion (More common that CRAO)-
- Stormy Sunset Appearance on Fundoscopy

Old Age
Hypertension
Diabetes
Polycythaemia
Arteriosclerosis

Central Retinal Artery Occlusion-
- Pale Retina with Cherry Red Spot at the Macula

Carotid Bruit
Hypertension
Atrial Fibrillation
Diabetes Mellitus
Smoking
Hyperlipidaemia

Answer 274

A

Ischaemic Optic Neuropathy
- Optic Nerve Damage due to a lack of blood supply
- Different causes and so patients present differently, but generally have Sudden Onset Monocular Vision Loss and Colour Blindness
- Relative Afferent Pupillary Defect is seen on examination. On Fundoscopy, Optic Disc Swelling if it is acute and a Pale Optic Disc if it is chronic suggests Optic Atrophy

Giant Cell Arteritis
- Commonest form of Arteritic Anterior Ischaemic Optic Neuropathy
- Typically Elderly Female presenting with Sudden Onset Painless loss of vision with (3) Headache, Jaw Claudication and Scalp Tenderness
- There is a strong association between this condition and Polymyalgia Rheumatica

Retinal Detachment
- Patients present with Floaters and Flashers followed by a Curtain Falling over their Vision
- Don’t confuse this with Amaurosis Fugax which is the same as this but is Transient
- Fundoscopy shows a Pale-grey area of Retina Ballooning forward

Vitreous Haemorrhage
- If it is minor, patients complain of Floaters, if it is severe then patients complain of a Painless Loss of Vision
- When the bleed is large enough to cause visual loss, the retina is Difficult to View on Fundoscopy
- Suspect this is in patients with Neovascularisation in Diabetes Mellitus or Central Retinal Vein Occlusion

Optic Neuritis
- This is not a Sudden loss of vision as it progresses over Hours to Days- it is also Painful
- Suspect this if Ocular Movement causes pain or if there is a Red Desaturation
- Optic Neuritis is the most common initial feature of Multiple Sclerosis

Answer 275

A

An Anastomotic Leak- the Contents of a Hollow Organ which was joined Surgically leaks through a fault in the join

The bowel contents can leak and contaminate the Peritoneal Content and this can lead to (3) Peritonitis, Abscess Formation and Abdominal Sepsis

Suspect this in patients who have had an Intestinal Surgery and have (3) Failure to Thrive, a Persistent Low Grade Fever or Prolonged Ileus (lack of normal muscle contractions of the Intestine)

Radiological Investigations can be used to identify any Inappropriate Presence of IV Contrast in the Abdominal Cavity

Lactate Levels from a VBG can be used to assess Tissue Ischaemia. Patients require Investigations for Sepsis which is another Complication

A small leak can be managed conservatively with (3) Bowel Rest, IV Fluids and Antibiotics. They require repeated Abdominal Monitoring

Larger Leaks may require Emergency Laparoscopic Exploration with potential further Surgery

Answer 276

A

Motor Score
6- Obeys Command
5- Localises to Pain
4- Withdraws to Pain
3- Flexor Response to Pain
2- Extensor Response to Pain
1- No Response to Pain

Verbal Score
5- Oriented
4- Confused Conversation
3- Inappropriate Speech
2- Incomprehensible
1- None

Eye Score
4- Spontaneous
3- Open in Response to Speech
2- Opens to Pain
1- No Eye Opening

GCS of 8 or Lower suggests the patient is unable to Maintain their own Airway and warrants urgent assessment by the Anaesthetic Team

Answer 277

A

Systemic Hypotension
Signs of Cerebral Hypoperfusion
Progressive Heart Failure
Angina

Answer 278

A

Normal in Athletic Individuals
Electrolyte Disturbances
Hypothyroidism
Myocardial Infarction
Sepsis
Drugs (Beta Blockers)
Increased Intracranial Pressure
Heart Block

Answer 279

A

If there is evidence of Haemodynamic Compromise- Medical Therapy should be started immediately regardless of the cause

3 Medications used to increase Ventricular Rate are Intravenous Atropine, Epinephrine (Adrenaline) and Dopamine

Patients who do not respond to Medical Therapy require Temporary Pacing (2)- Transcutaneous and Transvenous Pacing are the most common types

Answer 280

A

Drowsiness
Confusion
Arrhythmias
Seizures
Vomiting
Headache
Flushing
Dilated Pupils

Answer 281

A

FBC
U&Es
CRP
LFTs
Venous Blood Gas (look for Evidence of Acidosis)

QT interval prolongation- which precipitates Cardiac Arrhythmias

Answer 282

A

Overall management is based on the patient’s symptoms

Patients should be reviewed by Intensive Care if (2) there is any concern about their Airway (especially if they are drowsy) or if there is Severe Metabolic Acidosis which may require Renal Replacement Therapy

Activated Charcoal can be considered 2-4 hours After the Overdose

Answer 283

A

It is due to a Congenital Accessory Electrical Pathway which connects the Atria to the Ventricles, bypassing the AV Node

This Accessory Pathway leads to the likelihood for Re-entrant Circuits to form leading to Supraventricular Tachycardia

Answer 284

A

No Symptoms- Patients with Wolff-Parkinson-White are often Asymptomatic
Palpitations
Dizziness
Syncope

Answer 285

A

Delta Waves (Slurred Upstroke in the QRS)
Short PR Interval (<120ms)
Broad QRS
If a re-entrant circuit has developed, the ECG will show Narrow Complex Tachycardia

Answer 286

A

ECG

24 Hour ECG monitoring if Paroxysmal Symptoms

Routine bloods include 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 287

A

Radiofrequency Ablation of the Accessory Pathway

Drug Treatment (Amiodarone or Sotalol) to avoid further tachyarrhythmias. These are contraindicated in Structural Heart Disease

Surgical (open heart) Ablation- rarely done and only done in Complex Cases

Answer 288

A

Unstable Patients (3) (Blood Pressure<90/60mmHg or with signs of Systemic Hypoperfusion or Fast Atrial Fibrillation) require Direct Current Cardioversion (DC Cardioversion)

Answer 289

A

They are managed according to their Rhythm

If they have an Orthodromic AV Reciprocating Tachycardia (Narrow QRS Complex with Short PR Interval), management is with Vagal Manoeuvres (Carotid Sinus Massage or Valsalva Manouevre). If this fails, then IV Adenosine should be Administered
In Orthodromic AV Reciprocating Tachycardia, one limb of the aberrant circuit involves the AV node so slowing conduction through the AV Node helps to Terminate the Tachycardia
In Antidromic AV Reciprocating Tachycardia (Wide QRS Complex), Atrial Fibrillation or Atrial Flutter, Intravenous Antiarrhythmics (such as Procainimide or Flecainide) help prevent Rapid Conduction through the Accessory Pathway
DC Cardioversion may be used if the symptoms still persist

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Emergency Medicine (Quesmed) Flashcards

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