F1 knowledge test

Question 1

Head injury: indication for CT head

Answer 1

• On AC?
• GCS < 13
• Mechanism - eg. RTC

Question 2

AKI

Answer 2

-

Question 3

ACS.

a) Immediate management of all suspected ACS
b) STEMI* management (reperfusion therapy)
c) Further management to reduce myocardial oxygen demand

*Includes new LBBB and posterior STEMI (ST depression in V1-V3)

Answer 3

a) - A-E assessment
- MONA: Morphine IV (+ metoclopramide), Oxygen if SpO2 <94%, Nitrates (unless hypotensive) and Aspirin 300 mg oral
- 12 lead ECG
- IV access and bloods (FBC, U+E, clotting, troponins, glucose, lipids)

b) Within 12 hours of onset of chest pain:
- Primary PCI (if can be performed within 2 hours of call)
- Give loading dose of a platelet ADP receptor blocker (clopidogrel/ticagrelor) beforehand
- note: heparin given in the cath lab

After 12 hours of onset of chest pain:

• Thrombolysis
• Give loading dose of aspirin (300 mg), clopidogrel (300 mg) and LMWH/UFH/fondaparinux
• If this fails (ECG 60-90 mins post-thrombolysis shows <50% improvement) then transfer for ‘rescue’PCI’

c) - Beta-blockade (or diltiazem)
- IV nitrate infusion if angina persists despite GTN
- Early ACEI if there is LV systolic dysfunction/ CCF
- Diuretics may also be needed in heart failure causing pulmonary oedema

Question 4

Causes of a raised…

a) D-dimer
b) Lactate
c) Troponin
d) CRP

Answer 4

a) - VTE
- DIC
- Recent surgery
- Trauma
- Infection
- Liver or kidney disease
- Cancer
- Normal pregnancy, or eclampsia

b)
c)

d) - Infection
- Surgery
-

e)

Question 5

4 Hs and 4 Ts

Answer 5

• Hypoxia
• Hypovolaemia
• Hypothermia
• Hypo/hyper… kalaemia/glycaemia, etc*
• Thromboembolism
• Tamponade
• Tension pneumothorax
• Toxins
• Think of these when taking bloods off:
• FBC
• U+E
• Glucose
• VBG

Question 6

Falls in geriatric patients

a) Categorising causes
b) Drugs that increase risk of falls

Answer 6

a) Syncopal
- Hypovolaemic/hypotensive (postural, vasovagal, dehydration, hypoadrenalism, etc.)
- Arrhythmias - tachy and brady-arrhythmias
- Structural - AS, other LVOT obstruction, MI

Non-syncopal

• Environmental - shoes, rugs, etc.
• Sensory - peripheral neuropathy (diabetes, alcohol), poor vision
• Poor mobility, weakness, myopathy

b) Sedatives
- TCAs (especially as anticholinergic effects)
- Morphine (use oxycodone instead)
- Benzos
- Z-drugs
- Pregabalin/gabapentin

Antihypertensives
Diuretics

Question 7

Hyperlactataemia.

a) Physiological causes - type A and type B
b) What threshold generally indicates poor prognosis in sepsis?
c) Does it result in high or normal anion gap?

Answer 7

a) Lactate produced from pyruvate in anaerobic states. The usual ratio of lactate to pyruvate (L/P ratio) = 10:1
Type A (tissue hypoxia)
- Hypoperfusion - any cause of shock (e.g. sepsis), intestinal ischaemia
- Impaired oxygen delivery - anaemia, CO poisoning
- Anaerobic activity (e.g. seizures, intense exercise)
- Causes elevation of L/P ratio >10

Type B (no evidence of hypoxia)

• Normal L/P ratio
• ‘Failure’ states - liver or renal faiure
• DKA
• Thiamine deficiency
• Drugs
• Leukaemia

b) >4
c) High anion gap

Question 8

Anion gap.

a) Equation
b) Normal value
c) Why is there a gap in cation/anion?
d) Causes of high anion gap*
e) Causes of normal anion gap (ABCD)

Answer 8

a) {Na (+ K)} - {Cl + HCO3]
b) 8 - 16

c) Unmeasured anions:
- Albumin, phosphate, etc.

d) Production of organic acids:
- Lactate - type A (tissue hypoxia), type B (altered metabolism)
- Ketones - DKA, starvation, alcoholic
- Uraemia (renal failure)
- Ingestion - methanol, paracetamol, ethylene glycol

Note - the production of these acids leads to consumption of bicarbonate, hence lowering the anion gap

e) Hyperchloraemic acidosis (usually related to bicarb loss and resultant Cl reabsorption - hence normal AG)

A - Addisons
B - Bicarbonate loss in 90% of cases (GI loss - diarrhoea; renal loss - RTA)
C - chloride (excessive NaCl)
D - diarrhoea, diuretics