ICU & FICM Flashcards

Question

What constitutes the Murray score?

Answer 1

Score for ECMO referral: - PF ratio on 100% - PEEP in cmH2O - Compliance in ml/cmH2O - CXR quadrants infiltrated Each component scored 0 - 4 Score >3 = severe resp failure

Answer 2

Reduction in V/Q mismatch Increase in FRC Recruitment of atelectatic lung PROSEVA trial showed NNT of 6

Answer 3

PAO2 = PiO2 - PACO2/RQ

Answer 4

Reactive oxygen species created when there is hyperoxia —OH* + 1O2 Damage DNA & RNA Impairs DNA repair Exposure time and PO2 will determine cumulative O2 dose

Answer 5

1. Increase in Reactive Oxygen Species & reduction in anti-inflammatory levels 2. Inflammatory stage - destruction of pulmonary lining and migration of inflammatory mediators 3. Proliferative phase - cellular hypertrophy & increased secretions from alveolar type II cells 4. Fibrotic phase - collagen deposition and interstitial thickening Irreversible changes Decreased Vital Capacity is first change in lung function seen Acute Lung Injury

Answer 6

- Hypoxic pulmonary vasoconstriction affected - Altered V/Q relationships from HPV changes - causes increased perfusion to hypoxic lung regions and increasing alveolar dead space (increasing CO2) - Absorption atelectasis - Systemic vasoconstriction - important in coronary/cerebral circulation: - Retinopathy in neonates - Bronchopulmonary dysplasia in neonates - Increased infarct size of MI/Stroke

Answer 7

``` CO poisoning Pneumothorax Cluster headache Hyperbaric O2 for wound healing Hyperbaric O2 for decompression sickness Possibly improved wound healing post surgery ```

Answer 8

2021 Resuscitation Council Guidelines Update state: MAP >65mmHg Targeted temperature management for all adults if unresponsive post-ROSC: -Aim 32-36 first 24 hours -Avoid pyrexia for 72 hours post ROSC Not for routine anticonvulsants but Keppra now first line (or valproate) ``` Neuroprognostication - poor outcome if: -Motor score <3 post arrest with no other reason PLUS -Absent corneal reflexes at 72 hours -Bilateral absent SSEPs at 24 hours -Highly malignant EEG at 24 hours -Neuro-specific enolase -Status myoclonus -Diffuse anoxic brain injury on CT/MRI ```

Answer 9

Extreme inverse ratio of BiPAP (I:E ratio 10:1) High pressure almost all the time; short period of Tlow means not enough time for alveoli to collapse Aids recruitment and maintains it Atelectetrauma reduced as alveoli remain splinted open

Answer 10

``` High Paw: -pneumothorax risk -impedes venous return Increased PVR High CO2 (think neuro patients) Staff and unit unfamiliarity ```

Answer 11

PHigh - set at current plateau pressure (25-30cmH2O) PLow - ALWAYS ZERO THigh - 5 seconds is a good place to start TLow - 0.5secs (This means I:E ratio is 10:1; each cycle taking 5.5secs) The main parameter to fine tune is TLow - find the peak flow at 75% of peak and set TLow there

Answer 12

1. Increase PHigh +/- THigh Check TLow = 75% of PEFR (derecruitment if TLow is too long) 2. Increase alveolar ventilation: increase PHigh +/- THigh Increase MV: decrease THigh and increase PHigh

Answer 13

Decrease PHigh while increasing THigh (eventually becomes CPAP) Once PHigh is ~20 then it is basically CPAP

Answer 14

—Steroids: Only for people on O2 Dex for 10 days —Tocilizumab: For patients on steroids Cannot have had any other IL-6 therapy on this admission No evidence of bacterial infection NEED to have: -A need for O2 with a CRP >75 OR are within 48 hours of starting NIV/HFNO/I&V Cannot use CRP for monitoring if have had Toci —Remdesivir: Not unless in a trial —VTE: If on HFNO/CPAP/NIV/I&V - double normal dose considered (“intermediate dose”)

Answer 15

Severe resp disease with raised CO2 High C spine injury Extensive facial trauma Thiopentone level >12mg/L

Answer 16

``` Vital Capacity of <15ml/kg Reduced inspiratory pressure (<30cmH2O) Reduced expiratory pressure (<40cmH2O) Rising PaCO2 Autonomic instability Bulbar involvement Poor cough ```

Answer 17

``` Older age Ventilatory support required Anti-GM1 Anti-ganglioside antibody (?) Upper limb involvement Campylobacter infection ```

Answer 18

MG history >6years No concurrent respiratory disease Pyridostigmine <750mg/day FVC >2.9L

Answer 19

1. Increased resistance to Sux 2. Increased sensitivity to NDMR

Answer 20

Resuscitation Redistribution Replacement & reassessment Routine (maintenance) fluid (20-30ml/kg in an adult)

Answer 21

Ring & Messmer Grade I & II - non life threatening (non-allergic) —Grade I - mucocutaneous signs —Grade II - moderate multi visceral signs - moderate hypotension/tachycardia with or without bronchospasm/GI upset Grade III & IV - life threatening IgE mediated anaphylaxis —Grade III - CVS compromise from vasodilatation and hypovolaemia —Grave IV - cardiac arrest

Answer 22

``` Antibiotics (Teicoplanin or Co-Amoxiclav) NMBDs Dyes - patent blue, methylene blue Chlorhexidine Povidone iodine Colloids Iodinated contrast agents Sugammadex ```

Answer 23

Reduced V/Q mismatch Improved FRC Recruitment of atelectatic lung PROSEVA - reduced 28 day mortality with NNT of 6

Answer 24

Biguanides (Metformin): increase insulin sensitivity in hepatic/peripheral tissues; decrease hepatic glucose output Sulphonylureas (Gliclazide): stimulates insulin release from pancreas; decrease insulin resistance in peripheral tissues Thizolidinediones (Pioglitazone): improve peripheral uptake/use of glucose in muscle & fat; decrease liver glucose production SGLT-2 inhibitors (Flozins): increase urinary glucose excretion; (sodium/glucose co-transporter type 2 inhibitors) DPP-4 inhibitors (Sitagliptin): stimulate insulin secretion/inhibit glucagon secretion Incretin analogues (Exenatide): reduce carb absorption, stimulate insulin secretion/inhibit glucagon secretion Meglitinides: stimulate insulin release Alpha-glucosidase inhibitors: slow/limit absorption of glucose

Answer 25

``` Poor wound healing Lower immunity - increased risk of infection Muscle wasting - respiratory muscle Impaired ventilatory drive Low mood ```

Answer 26

No oral intake for 5-10 days Unintentional weight loss of >10% over <3months Low BMI (<16 or <18 with other risk factors) Low electrolytes on admission Alcohol/chemotherapy

Answer 27

Free fatty acid metabolism changes back to carbohydrates Increased phosphate/thiamine requirements Release of insulin Acute thiamine deficiency Intracellular shift of K, Mg, Phosphate

Answer 28

``` Arrhythmia Hypotension Cardiac arrest Pulmonary oedema Lactic acidosis Respiratory muscle weakness/fatigue Confusion - Wernicke’s/Korsakoff’s Seizures, coma Immune dysfunction ```

Answer 29

Thiamine - high dose either Pabrinex or PO Start feed at 10kcal/kg/day with slow increase over 5-7 days Monitor fluid status Monitor K/Mg/Phos and replace as required Trace element supplementation

Answer 30

Direct: - Pneumonia - Aspiration - Lung contusion - Fat embolism - Drowning - Inhalational injury Indirect: - Pancreatitis - Sepsis - Major trauma - Massive transfusion - CPB

Answer 31

Normally metabolised by the liver NAPQI (minor metabolite) normally conjugated by glutathione Glutathione stores depleted in OD NAPQI binds to cellular proteins causing hepatocellular damage NAC is precursor of glutathione

Answer 32

``` Chronic liver disease Chronic kidney disease Malnourished Eating disorder Alcoholism Hepatic enzyme induction ```

Answer 33

Acute: King’s College Criteria: Paracetamol OD: —pH <7.3 OR —INR >6 (or PT>100) —Creatinine >300 —Encephalopathy 3 or 4 (Think ICE) —lactate >3 after resuscitation Non-paracetamol cause: —PT >100 OR 3 of: —Age <10 or >40 —PT >50 —Bilirubin >300 —Encephalopathy >7 days after jaundice —Disease aetiology: non-hep A/B hepatitis; drug induced; halothane hepatitis Chronic: UK MELD score (generally needs to be >49 to be eligible) - INR, bilirubin, Na, Creatinine (BINC)

Answer 34

Being ventilated NG tube Enteral feed Nasal intubation Immunodeficiency (from critical illness - decreased salivary fibronectin) Severe burns Supine position Excessive sedation Enteral feeding Long duration of mechanical ventilation

Answer 35

``` Avoid intubation Reduce duration of ventilation Hand hygiene Closed loop suction Limit disconnections in circuit Do not allow water pooling in circuit to run into patient Subglottic suction Antimicrobial coating on ETT Ventilator Care Bundle: -Head up -Sedation hold -Histamine H2 receptor blocker -Thromboprophylaxis (Reduce risk of aspiration or number of ventilated days and therefore risk of VAP) Oral hygiene ``` Recent study - PROPHY VAP - showed that one dose ceftriaxone reduced VAP in TBI patients

Answer 36

Common: ICU acquired weakness Pharmacological: NMBDs; steroids Nutritional: poor intake; low magnesium; low phosphate; refeeding syndrome Vascular: stroke Neuromuscular: Guillain Barre; Myasthenia Gravis Muscular: myositis

Answer 37

Definition: clinically detectable weakness where no other aetiology can be found ``` Features: After onset of critical illness Symmetrical Flaccid weakness Peripheral Cranial nerve sparing/autonomic sparing Muscle power weakness noted on >2 occasions 24 hours apart ``` Types: Critical illness polyneuropathy CIP Critical illness myopathy CIM: —cachectic myopathy, thick filament myopathy or necrotising myopathy —reduced CMAP amplitude, normal sensory function, normal conduction velocity & latency, reduced direct muscle CMAP on direct stimulation; abnormal muscle biopsy Critical illness neuromyopathy CINM

Answer 38

BEING UNWELL Elderly Female Severity of illness Mechanical ventilation - prolonged course Use of muscle relaxation (prolonged) Use of corticosteroids Use of RRT High dose vasopressors/inotropes

Answer 39

Diagnosis of exclusion Clinical diagnosis EMG Nerve conduction Nerve biopsy Muscle biopsy Imaging: CT/MRI

Answer 40

Slow mechanical wean Ventilator dependence Longer ICU stay Increased risk of VTE Increased risk of pressure damage Increased risk of pneumonia

Answer 41

Physiological and pathophysiological changes occurring in response to stimulus (e.g. of surgery) 1. Metabolic response 2. Immune response

Answer 42

Hypothalamic stimulation from ascending nociceptive pathways: - Release of ACTH from pituitary (HPA axis) - Release of adrenaline from adrenal medulla (SNS stimulated by hypothalamus) - Increased GH - Increased ADH - Stimulation of RAAS by SNS

Answer 43

Both innate and acquired immune systems used - Local response to tissue damage (neutrophils, macrophages, NK cells) release pro-inflammatory cytokines (IL-1, IL-6, IL-8, TNFa) and acute phase reactants - Systemic response to tissue damage causes suppression of T cell response

Answer 44

- Propofol and TIVA may reduce cortisol secretion - Etomidate will suppress adrenals - Volatiles have more of an effect than TIVA on immune function - Benzos inhibit HPA - a2-adrenergic agonists inhibit SNS - Systemic opioids - REGIONAL ANAESTHESIA - Surgical technique - minimally invasive - Good nutrition and enteral feeding; short fasting times

Answer 45

A process whereby pituitary and sympathetic nervous system activation leads to a number of predictable metabolic changes Co-ordinated by the hypothalamus (neural (ascending pathways) and endocrine (cytokines) activation) Pituitary - increased GH/ACTH/ADH Sympathetic - increased catecholamines/RAAS/glucagon Including: - Hyperglycaemia - Nitrogen/protein loss - Lipolysis - SIRS from cytokine - Increased circulating catecholamines - Fluid overload - Decreased CD4 and T helper cell activity

Answer 46

Pulmonary Extra-pulmonary

Answer 47

Secreted in response to SNS activation Action potential in pre-ganglionic sympathetic neurones terminate directly on chromaffin cells ACh released -> nicotinic receptors which increase Na/K permeability and depolarisation. Depolarisation opens Ca channels and triggers exocytosis of catecholamine containing granules Phenylalanine -> Tyrosine ->(rate limiting step) L Dopa -> Dopamine -> Noradrenaline -> Adrenaline (in the presence of PNMT, which is only functional in very steroid rich areas - hence why Addison’s patients collapse)

Answer 48

``` SARS-CoV-2 enters cells through Angiotensin Converting Enzyme 2 Causes: —ARDS —Thrombophilia and VTE —PTX —AKI/MOF ``` Diffuse alveolar damage: - Exudation - Proliferation - Fibrosis

Answer 49

—Reduces V/Q mismatch —Increases FRC —Allows recruitment of posterior alveoli Evidence from PROSEVA study

Answer 50

``` —Extubation —Endobronchial intubation —Pressure damage/areas —Oedema —Brachial plexus injury (& others) —Cardiac instability (e.g. if underfilled while proning) ```

Answer 51

Agitation/Sedation score used in ICU From -5 to +4 Aim is for a RASS of -2 to +2

Answer 52

25kCal/kg/day Carb: 2g/kg/day Protein: 1.5g/kg/day Fat: 1g/kg/day Trace elements Vitamins ``` Water: 30ml/kg Na: 1mmol/kg K: 1mmol/kg Mg: 0.1mmol/kg Ca: 0.1mmol/kg ```

Answer 53

Caused by Clostridium tetani - releasing a neurotoxin that binds irreversibly to neuromuscular junction and prevents release of inhibitory neurotransmitters - Muscle rigidity - Muscle spasms - Autonomic instability ``` Management: —Wound debridement —Antibiotics —Immunisation (immunoglobulin) —Monitoring/sedation +/- ICU ```

Answer 54

Metabolic disturbances occuring after reinstitution of nutrition in a patient who is malnourished or prolonged fasting Characterised by severe hypophosphataemia and arrhythmias/seizures/rhabdomyolysis

Answer 55

Prognosis After Resuscitation score: - Metastatic malignancy - Non-metastatic malignancy - Sepsis - Dependent functional status - Pneumonia - Cr >130 - Age>70 - Acute MI

Answer 56

—Clinical: corneal blink reflex, pupil response, myoclonus, ongoing seizures —Radiological: CT, MRI —EEG —SSEPs

Answer 57

``` ERC and ESICM 2021 guidelines: —after 72 hours of Targeted Temp Management in unconscious patient M <3 Need 2 of: -No pupillary/corneal reflex -Absent SSEP -Malignant EEG -NSE (blood test) high -Myoclonus -MRI/CT DAI/anoxic injury ``` MIRACLE study to determine who should go for PPCI Cerebral Performance Categories 1 - 5 mRS 0 - 6 Glasgow Outcome Scale Scoring System MIRACLE 2:

Answer 58

660nm (red) & 940nm (infrared) Isobestic point - 840nm

Answer 59

Prolonged QTc VF resistant to amiodarone Blindness Hypoglycaemia Not removed by CVVh

Answer 60

The 4 Ts: —Thrombocytopenia —Timing of platelet fall —Thrombosis —Exclusion of any other potential cause Max score of 8: 0-3 low probability; 4-5 intermediate (10-30%); 6-8 high pre-test probability for HIT (20-80%) Thrombocytopenia with >50% fall or down to 20 = 2 points

Answer 61

Complication of allogeneic haematopoietic stem cell transplant caused by T cells from donor attacking host tissue Involves skin, liver and gut: -Rash starts on palms/soles -Diarrhoea can become TEN -Jaundice and cholestasis Rx with steroids/immunosuppression

Answer 62

Steroids T-cell immunosuppression Anti-TNF antibodies MMF Prophylaxis: calcineurin inhibitors

Answer 63

Platelet count falls by 30-50% within 5-10days of starting heparin More common with UFH than LMWH More common in women Complex forms between heparin antigen and platelet factor 4, which is immunogenic. IgG antibodies attach to platelet/heparin complex causing consumptive coagulopathy Stop heparin. Use direct thrombin inhibitors or Factor Xa inhibitors to prevent thromboses

Answer 64

Stanford Classification: —Type A (ascending aorta) —Type B (descending) European Society Cardiology: —Types 1-5 DeBakey: —Types I-III

Answer 65

BP control - systolic 100-120mmHg Beta blockers Once blocked, SNP/GTN/hydralazine to vasodilate

Answer 66

Onset of diastole Timed against the middle of the T wave on the ECG/dichrotic notch on the A-line Deflates at onset of systole - the peak of the R wave on the ECG

Answer 67

Bilirubin Albumin INR Ascites Encephalopathy

Answer 68

UK Model for End stage Liver Disease Used for prognosis of liver disease and prioritising liver transplants If score >15 - suitable for transplant Vs (unclear books) If score >49, mortality without transplant = 9% at 1 year Uses: -Bilirubin -Creatinine -INR -Na

Answer 69

O’Grady: —Hyperacute (<1 week) —Acute (<1 month) —Subacute (<3 months) From jaundice to encephalopathy Bernuau: —Fulminant (1-2 weeks) —Subfulminant (>2 weeks) Jaundice to encephalopathy Japanese: —Fulminant (acute up to 9 days, subacute to 8 weeks) —Late-onset (8-24 weeks) Jaundice to encephalopathy

Answer 70

O - universal RBC donor AB - universal FFP donor Rh +ve can receive Rh -ve blood Rh -ve women should not receive Rh +ve blood

Answer 71

1 - 12 months = (0.5 x age in months) + 4 1 - 5 years = (2 x age) + 8 6 - 12 years = (3 x age) + 7

Answer 72

Adrenaline = 10mcg/kg Blood = 5ml/kg Glucose = 2ml/kg of 10% solution

Answer 73

—Small Vd —Low protein binding —High water solubility —Molecular weight (smaller molecules for IHD (500Da), larger for CVVH (40kDa)) —Low endogenous clearance —Extraction ratio exceeding endogenous elimination

Answer 74

Respiratory failure requiring I&V for >48 hours (most important) Coagulopathy Head injury Major burns (>35%) Spinal trauma Polytrauma Renal failure Liver failure Severe sepsis Shock Organ transplant Steroids Prev PUD

Answer 75

Osmolality is 280mOsm/kg Specific gravity = 1.005 Glucose = 1.5-4 mmol/L Cl- = 120-130mmol/L Bicarbonate = 25-30mmol/L Protein = 0.15-0.3g/L

Answer 76

Absolute: —abdominal adhesions —lack of trained staff —uncorrected mechanical defects (hernias) Relative: —intra-abdominal sepsis —wound infections —PD catheter leak —malnutrition —inflammatory/ischaemic colitis —newly placed foreign body in abdomen (e.g. clips)

Answer 77

Coagulase negative Staph Staph aureus Non-Pseudomonas Gram -ves

Answer 78

FiO2 <0.4 PEEP ~5cmH2O Patient is awake Patient is co-operative Not in pain but not overly sedated No ongoing infection Pulmonary compliance >50ml/cmH2O

Answer 79

If high hepatic clearance - hepatic blood flow is determining factor If low hepatic clearance - protein binding and hepatic enzyme activity AKI will affect drugs metabolised by the kidneys Ileus will affect enteric absorption of drugs

Answer 80

Co-trimoxazole Prednisolone

Answer 81

HCO3 loss replaced by Cl- so anion gap normal Excess Chloride Renal: -Renal tubular acidosis Types I, II & IV -Drugs that reduce ability to acidify urine (acetazolamide or spironolactone) Extra-renal: -Iatrogenic acids - TPN; 0.9% NaCl -Loss of alkaline - diarrhoea/fistulae -Ileal conduit; ileostomies

Answer 82

They are both spore forming Gram +ve anaerobic bacteria Botulism = flaccid paralysis -Blocks ACh release -descending paralysis -often early cranial nerve involvement -supportive treatment Tetanus = spastic paralysis -blocks GABA release -over 2 weeks - lockjaw/autonomic/respiratory/rigidity -tetanus immune toxin/supportive

Answer 83

Types I-IV I - 70% of cases; polymicrobial II - Group A Strep +/- Staph; Toxic Shock Syndrome III & IV - rare but high mortality

Answer 84

An enzyme-like protein with biological activity Gram -ve organisms often release ENDOtoxins (part of their cell structure) ->profound inflammatory response EXOtoxins are secreted by bacteria (Strep/Staph/Clostridium) Linezolid and Clindamycin have toxin-suppressing properties

Answer 85

According to the DoH’s ‘Health Building Note 04-02’ (2013)

Answer 86

20m2 or 25m2 for side rooms One washbasin per 2 beds at least

Answer 87

Electricity/heating etc Bed that can do Trendelenburg and chair Pressure relieving mattress Dual pendants with 28 single socket outlets, at least some with uninterrupted power supply Gas supply: 3-4 O2 outlets; 2 air outlets (4bar); 2-4 medical vacuum outlets 4 data outlets Emergency call system Telephone and TV outlet for patient use Equipment: -Computer -Monitoring -3-6 infusion pumps -4-10 syringe pumps -blood warmer -feeding pump -ventilation and humidification equipment

Answer 88

20% of beds should be side rooms Ideally with lobby

Answer 89

Level 1 patients = 1:4 Level 2 patients = 1:2.5 Level 3 patients = 1:1 May be higher e.g. for ECMO (2:1) There should also be a lead nurse supernumerary to assist (a 2nd if >10 beds occupied) Not more than 20% should be from agency bank nurses

Answer 90

Consultant 24 hour on call cover Ward round x2 per day at least Consultant:patient ratio of 1:8 - 1:15 Trainee:patient ratio 1:8 An appropriate airway skilled doctor is available to attend at all times

Answer 91

Identify deteriorating patients on wards Follow up of recent ICU discharges Rehab of ICU discharges Support ward nursing staff to deliver care beyond their normal Institute palliative care where appropriate

Answer 92

MERIT study Priestly study showed significant reduction in hospital mortality with CCOT intervention

Answer 93

Organ/disease specific (e.g. GCS, MELD) Generic scores (e.g. SOFA, MODS, APACHE)

Answer 94

Common language for discussion Comparator in clinical trials Quantification of severity of illness which may dictate resource allocation Estimators of prognosis

Answer 95

Predictive - predicts what it needs to predict (mortality, severity etc) Applicable - to a wide group of patients Calibrated - is a higher score worse than a lower score etc Easy to perform Discriminatory - reasonable level of detail (ideal = 1.0; accepted >0.7) Discrimination: —how effective a system is at predicting which patients will die vs which will survive —receiver operator curve (ROC) - constructed by plotting the true-positive rate (sensitivity) against the false positive rate (1-specificity) for a range of score cut offs. Analysis of area under ROC provides an indication of the ability of the scoring system to discriminate between 2 outcomes -1.0 represents perfect discrimination -0.5 suggests the scoring system is no better than a coin toss ->0.7 is accepted as adequate discrimination for a clinical score or test Calibration: —Examines the correlation between predicted and actual outcome over a range of probabilities —e.g. if a score predicts 60% mortality, comparing actual and predicted outcomes will determine the calibration —Simplified Acute Physiology Score (SAPS) is calibrated to different geographical regions Validity(?)

Answer 96

Admission scores: Acute Physiology and Chronic Health Evalutation (APACHE I-IV) Simplified Acute Physiology Score (SAPS) Injury Severity Score (ISS) Severity of illness scores: Sequential organ failure assessment (SOFA) Multiple organ dysfunction score (MODS) Nursing workload scores: Therapeutic intervention scoring system (TISS) Organ- or disease-specific scores: GCS MELD RASS CURB 65 Child-Pugh etc etc etc

Answer 97

Hospital mortality Standardised mortality ratio - score >1 is worse than expected; <1 is better than expected Early death (within 4 hours of ICU admission) Late death (within 7 days of ICU admission) Out of hours discharge (between 2200 and 0700) Delayed discharge (>4 hours) Unit acquired infections

Answer 98

Intensive Care National Audit and Research Centre

Answer 99

Higher risk of: -VAO -pneumothorax -atelectasis -hypoglycaemia -hyperglycaemia -hypernatraemia -increased length of stay Overall mortality was NOT affected

Answer 100

TPP = airway pressure - pleural pressure TPP is associated with ventilator-induced lung injury, rather than airway pressure alone Oesophageal pressure is a good surrogate for pleural pressure

Answer 101

Up to 50% of ICU survivors will experience cognitive, psychological and physical changes following discharge

Answer 102

SV x HR Normal value = 4.5-8L/min

Answer 103

CO/BSA Normal value = 2.7-4L/min/m2

Answer 104

(CO/HR) x 1000 60-130ml/beat

Answer 105

80 x (MAP-CVP)/CO Normal value = 770-1500dynes/s/cm5

Answer 106

80 x (PAP - PCWP)/CO Normal value = 100-250dynes/sec/cm5

Answer 107

(EDV-ESV)/EDV Normally >0.6

Answer 108

MAP = CO x SVR Normal = 80-90mmHg

Answer 109

Refer to the ICP over time rather than individual waves A = slow vasogenic waves seen in patients with critical cerebral perfusion. Mean ICP 50-100mmHg! A = ALWAYS PATHOLOGICAL Longer lasting - 5-20 minutes) B = cycles of 30s - 120s; transient increases of ICP to 20-30mmHg = evidence of normal autoregulation. Absence is a bad sign C = doesn’t matter. No clinical relevance

Answer 110

P1 >P2 >P3 P1 = percussion wave; transmitted arterial pressure from choroid plexus to ventricle P2 = tidal wave; reflection of the pressure waves from the skull. This can be affected by brain compliance P3 = dicrotic wave secondary to aortic valve closure

Answer 111

Moderate to severe head injury in those unable to be assessed Severe head injury (GCS<8) and abnormal CT head Severe head injury with normal CT head but 2/3 of: >40yrs, BP<90, abnormal motor GCS EVD may be the best choice (can measure and treat), but if ventricles squished may need intraparenchymal

Answer 112

ICP <20mmHg CPP >60mmHg

Answer 113

Increased age Poor motor GCS Lack of pupil reactivity CT head showing subarachnoid blood Increased Marshall CT grade (oedema/midline shift/extra-axial blood) Hypoxia or hypotension Co-morbidities

Answer 114

Invasive: ICP bolt EVD SjVO2 Brain tissue oxygenation Micro-dialysis catheter Non-invasive: CT head Transcranial Doppler NIRS

Answer 115

TBI with moderate/severe injury (=GCS<9) in those unable to be assessed Severe TBI and abnormal CT head (haematoma/contusion/swelling/compression) Severe TBI With normal CT head but 2/3 of >40yrs, BP <90, abnormal motor GCS Non trauma: Spontaneous ICH with coma Anoxic brain injury Hepatic encephalopathy and cerebral oedema associated with fulminant liver failure Intracranial infections

Answer 116

Insert to 50cm or so Confirm gastric placement Inflate gastric balloon with 250ml of air/saline Apply traction using 500ml or 1L bag (but lower preferred). If bleeding ongoing, inflate oesophageal balloon to manometer of 35-40mmHg, then deflate until bleeding restarts and keep it just above that. Deflate oesophageal balloon every few hours; leave gastric balloon for 12-24 hours

Answer 117

All who have an acceptable chance of survival, a GCS <9 and CT evidence of TBI Normal CT head if they ALSO have >1 of: age >40, motor score <4, hypotension <90 Ventricular site is the most accurate readings with reduced chance of drift/can be recalibrated

Answer 118

Males = 50 + 0.91 (height in cm - 152.4) Females = 45.4 + 0.91 (height in cm - 152.4)

Answer 119

Indirect calorimetry = gold standard —based on O2 consumption; difficult to do Measurement of CO2 production Estimate: —Schofield formula states: <65years = 25kcal/kg/day >65years = 20kcal/kg/day

Answer 120

Energy: -if <65years = 25kcal/kg/day -if >65years = 20kcal/kg/day Carbs: -3-4g/kg/day Protein: -1-1.5g/kg/day; increased in burns/major trauma/massive catabolism -essential and non-essential amino acids Lipid: -0.7-1.5g/kg/day Electrolytes: -Water 30ml/kg/day -Na+ 1-2mmol/kg/day -K+ 0.7-1mmol/kg/day -Ca 0.1mmol/kg/day -Mg 0.1mmol/kg/day -Phos 0.4mmol/kg/day Trace elements - selenium, copper, manganese, zinc, iron - unknown role

Answer 121

Vitamins a —Fat soluble vitamins: -A (eyes) -D -E (anaemia) -K —Water soluble vitamins: -B1 Thiamine (beri beri; Wernicke/Korsakoff) -B2 Riboflavin -B3 Niacin (pellagra) -B6 Pyridoxine (periph neuropathy) -Folic acid -B12 cyanocobalamin

Answer 122

<140mmHg Use beta blockers

Answer 123

BP <140mmHg Maintain MAP Neuroprotection Coiling preferred to clipping if possible Prophylactic nimodipine 60mg QDS for 21 days reduces delayed cerebral ischaemia/vasospasm

Answer 124

Clinical: -drop in GCS/neurology Digital subtraction angiography: -gold standard -allows treatment at same time if detected CT angiogram: Transcranial Doppler: -velocity in middle cerebral artery >200cm/s suggests DCI; confirmed using Lindegaard index (index >3 = DCI) EEG: -not as reliable

Answer 125

Hypertension - titrate to clinical response Hydration - euvolaemia Nimodipine - intra-arterial during angiography - should also be started on day 1 diagnosis to prevent DCI (60mg QDS) Balloon angioplasty Drugs still under investigation

Answer 126

Cerebral cortex: vascular event, encephalopathy Brainstem: stroke, compression Anterior horn cells/spinal cord: transverse myelitis, compression, ischaemia, infection, motor neurone disease, polio Peripheral nerves: Guillain Barre, critical illness polyneuropathy, Eaton-Lambert, uraemia, mononeuropathies NMJ: MG, botulism, NMBDs Muscle fibre: steroids, electrolytes, critical illness myopathy, disuse atrophy, polymyositis

Answer 127

2022 definition: Mean PASP >20mmHg at rest PVR >2 Wood units PAWP <15mmHg

Answer 128

TTE Tricuspid regurgitation velocity is used to estimate the PASP

Answer 129

Thrombotic Thrombocytopaenic Purpura Inhibition of ADAMTS13 (enzyme that cleaves vWF), causing increased platelet adhesion and microthrombi Neurological symptoms, microangiopathic haemolytic anaemia and renal failure

Answer 130

Plasma exchange —Removal of autoantibody against ADAMTS13 and replacing it with the normal enzyme from donor plasma Glucocorticoids Rituximab if severe

Answer 131

-Loss of renal function related to chronic hepatic failure -Probably due to inappropriate splanchnic vasodilation and decreased renal perfusion -Associated with poorly controlled ascites -High mortality Type 1 = x2 increase in Cr in <2 weeks (higher mortality) Type 2 = more slow

Answer 132

Cirrhosis with ascites Cr >133 No improvement in Cr after stopping diuretics and expanding with albumin (1g/kg up to 100g per day) Absence of shock No recent nephrotoxics Absence of parenchymal kidney disease

Answer 133

Atropine 1-2mg doubled every 5 mins until resp secretions and bronchospasm cleared Pralidoxime antidote - given early but NOT BEFORE atropine (OP can be absorbed through skin/lung/GIT. Bind to AChE and after time the enzyme is then irreversibly resistant to reactivation by oxime antidote)

Answer 134

1. Optimise RV preload - closely monitored fluid/diuretic/RRT 2. Augment the RV - milrinone strengthens RV contraction and reduces PVR; (also dobutamine, adrenaline, levosimendan) 3. Reduce RV afterload - optimise HPV factors; inhaled NO, milrinone, prostacyclin 4. Maintain systemic BP/coronary perfusion - noradrenaline/vasopressin (may cause pulm vasodilatation too and improve PVR/SVR ratio)

Answer 135

Jaundice Pyrexia Tender hepatomegaly

Answer 136

Moderate AST & ALT rise with AST:ALT ratio >2 Bilirubin and GGR raised Leukocytosis with neutrophils

Answer 137

Steroids if Maddrey discriminate function score >32 Pentoxifylline (?)

Answer 138

1. Increased response 2. Increased response 3. Normal response 4. Normal response 5. Decreased response 6. No response 7. No response 8. No response

Answer 139

A triad of: -change in mental state -neuromuscular abnormality -autonomic hyperactivity Treat with Benzos and Dexmedetomidine Cyproheptadine for severe cases

Answer 140

-Direct free radical scavenger, reducing production of radical oxygen species -Reduces cytokine release from B cells -Promote bacterial killing, lymphocyte proliferation and production of interferon -Co-factor in synthesis of vasopressin and catecholamines -Promotes wound healing, protects endothelial barrier and maintains microcirculatory patency Absorbed by Na-dependent transporters Trials have not shown benefit in sepsis yet (?)

Answer 141

-Thiamine is a necessary co-factor for the Krebs cycle -essential in neuronal signalling -works synergistically with Vit C

Answer 142

Rapid onset of: -delirium -respiratory depression -coma -seizures Synthetic derivative of GABA (actually quite similar to GHB) At therapeutic dose it works on spinal GABAb, but in excess it inhibits excitatory neurotransmission in all the CNS Can appear brain dead if OD is large enough

Answer 143

Concentrated factors II, IX and X at significantly higher levels than FFP

Answer 144

Aim systolic <140mmHg (INTERACT2 & ATACH trials)

Answer 145

If vital capacity falls <20ml/kg Negative inspiratory force <30cmH2O

Answer 146

Refers to a strain of Staph aureus Causes a necrotising, cavitating pneumonia in association with skin/soft tissue infection Low WBC Treatment: -Linezolid & Clindamycin -IVIG and Rifampicin if it gets really bad

Answer 147

Low Na in both CSWS: -diuresis and natriuresis -hypovolaemic Resuscitate with Na-containing fluids SIADH: -hypervolaemic Fluid restrict

Answer 148

Mainly diltiazem/verapamil - myocardial depressants (verapamil in particular) -Supportive; charcoal if MR -Glucagon will increase calcium entry into myocytes -Insulin - similar mechanism -Intralipid (CCBs are highly lipid soluble, highly protein bound) -Calcium!

Answer 149

—Hyperinflammatory state characterised by pathological macrophage and T cell activation from cytokine production -Can mimic severe sepsis without a source -Excess production of cytokines -Inflammatory dysregulation -End organ damage Can be familial Triggered by infection - often virus (EBV, CMV, HIV) Can be triggered as part of CAR-T therapy

Answer 150

3 Fs: —Fever —Falling blood counts —Ferritin High fever Hepatosplenomegaly Cytopaenia VERY high ferritin (>10,000) High triglycerides Liver transaminitis Low fibrinogen

Answer 151

H-score >169 Steroids Anakinra (recombinant IL-1 receptor antagonist) IVIG Etoposide Treat the underlying trigger

Answer 152

Assess for end organ damage (if present, likely compartment syndrome) Evacuate intraluminal contents 1. NG 2. Prokinetics 3. Enemas Evacuate intra-abdominal SOLs 1. Drain abscesses Improve abdominal wall compliance 1. Sedation/analgesia 2. Remove constrictive dressings; change position 3. Neuromuscular blockade Optimise fluid balance: 1. Aim negative fluid balance by day 3 2. Consider fluid removal/CVVH

Answer 153

Prodromal flu-like syndrome Psychotic episodes Seizures “” 60% of patients have associated malignancy (teratoma) Diagnosis by positive NR1 & NR2 antibodies in CSF + clinical picture Differentials = paraneoplastic encephalitis; voltage gated K+ channel antibody associated limbic encephalitis Treatment is with immunotherapy and removing tumour

Answer 154

900 - 1400 dynes/sec/cm5 — SVR = ((MAP - CVP)/CO) x 80dynes/s/cm5 —

Answer 155

~MAJOR: -BMI <16 -Weight loss 15% in last 3-6 months ->10 days without food -Low Mg/K/PO4 already ~MINOR: -BMI <18.5 -Weight loss 10% last 3-6 months ->5 days without food -Alcohol abuse, insulin, chemotherapy, diuretics

Answer 156

Quality of Reporting of Meta-analyses

Answer 157

Standards for Quality Improvement Reporting Excellence

Answer 158

Consolidated Standards of Reporting Trials (Most common for all RCTs)

Answer 159

Meta-analysis Of Observational Studies in Epidemiology

Answer 160

Strengthening the Reporting of Observational Studies in Epidemiology

Answer 161

1x consultant per 8-15 patients 1x junior doctor per 8 patients Level 3 patients: 1:1 nursing Level 2 patients: 1:2 nursing 1x supernumerary coordinating nurse 1x additional nurse for every 10 patients E.g. a 12 bedded ICU will need a nurse for every L3 patient, 1 nurse for every 2 L2 patients, 1 consultant, 2 junior doctors plus a supernumerary coordinating nurse

Answer 162

Measures flow velocities in cerebral arteries. Vasospasm indicated if: Flow velocity >120cm/s ——OR—— Ratio of flows >3 between middle cerebral artery and ipsilateral internal carotid artery

Answer 163

Loss of co-ordinated autonomic response below level of injury Uninhibited sympathetic response causes profound VASOCONSTRICTION BELOW the level of injury ->hypertension VASODILATATION ABOVE the level of injury and bradycardia from the baroreceptor response

Answer 164

Proximal descending aorta, at the site of the ligamentum arteriosum (just distal to the origin of the L subclavian artery)

Answer 165

Grading on imaging: -Grade I - intimal tear -Grade II - intramural haematoma -Grade III - pseudoaneurysm -Grade IV - rupture

Answer 166

1. Type A - tissue hypoxia (shock, anaemia, COHb) 2. Type B1 - underlying disease (renal, liver, diabetes) 3. Type B2 - drug/toxin (salbutamol, NRTIs) 4. Type B3 - inborn errors of metabolism (G6PD etc)

Answer 167

Target a decrease in 20% over 2 hour - reduce in hospital mortality in those with septic shock & lactate >3

Answer 168

M - major incident declared E - exact location of incident T - type of incident H - hazards A - access routes N - number/nature of casualties E - emergency services present/required

Answer 169

CSCATTT Command & Control Safety - of self/rescuers/scene/survivors Communications Assessment of scene Triage - sieve on scene, sort at hospital Treatment Transport

Answer 170

>10/hr Theatres = 25/hr Anaesthetic room = 15/hr Recovery = 10/hr

Answer 171

Well marked fire call points Fire extinguishers O2 shut off valves Isolation of zones of O2 cut off Small bays or side rooms Air changes (>10/hr) Ground floor location Interconnecting with theatres Separate clinical and non clinical areas Wide doors for bariatric patients Smoke control system; smoke lighting Sprinkler system ICU pendants reduce fire risk

Answer 172

1. Improve oxygenation 2. Improve respiratory mechanics 3. Homogenise pleural pressure gradient, alveolar inflation & ventilation distribution 4. Increase lung volume & decrease atelectatic regions 5. Facilitate drainage of secretions 6. Reduce VALI

Answer 173

= unmeasured anions (-ve charged) Lactate Ketoacidosis - diabetes/starvation/alcohol Acids - salicylates/methanol/ethylene glycol Pyroglutamic acid Isoniazid Cyanide Renal failure

Answer 174

GI loss - vomiting, diarrhoea, ileostomy Chloride Renal Tubular Acidosis (kidney unable to acidify urine -> acid retention) Addisons Acetazolamide

Answer 175

-4g bolus Mg -1g/hr for 24 hours -if further seizure, further 2g -deliver foetus once patient stable if possible

Answer 176

I - GCS 15; motor deficit absent II - GCS 13-14; motor deficit absent III - GCS 13-14; motor deficit present IV - GCS 7-12; motor deficit present OR absent V - GCS <7; motor deficit present OR absent

Answer 177

The duration of time following a sustained decrease in BP <50mmHg for >2mins until the organs have been cooled with cold perfusate in theatre <20mins ideally for liver 30 mins - liver & pancreas 60 mins - lungs 120 mins - kidneys Heart is not transplanted from DCD

Answer 178

PaO2 >10-13kPa PaCO2 4.5-5kPa MAP 80-90mmHg (if ICP unknown) CPP 60-70mmHg (CPP = MAP - ICP) Head up 30degrees Unobstructed venous drainage Glucose 6-10mmol Na 145-150 Normothermia/avoid pyrexia Hb >10g Sedation Antiepileptics

Answer 179

Sedation bolus +/- paralyse Osmotherapy: —hypertonic saline e.g. 100ml 5% bolus; aim to increase serum Na (but <155) —mannitol 1g/kg bolus; aim osmolality <320mOsm Further imaging - repeat CT Insert EVD (or drain CSF if already in situ) Strict temp control Hyperventilate to PaCO2 of 4kPa Consider surgery - decompressive craniectomy Consider thiopentone coma

Answer 180

Sustained increase in intra-abdominal pressure. Normal = <12mmHg. IAH graded 1-4: 1. 12-15mmHg 2. 16-20mmHg 3. 21-25mmHg 4. >25mmHg Abdominal compartment syndrome = IAP>20mmHg with new organ dysfunction

Answer 181

Using BTS guidelines: -initial IPAP of 10cmH2O -initial EPAP of 4-5cmH2O -IPAP can be increased 5cmH2O every 10 mins until response or tolerability reached (Most will need IPAP of 20cmH2O; keep EPAP at 5)

Answer 182

<25cmH2O; checked every 8 hours Ideally 20-25cmH2O Trachea capillary pressure is roughly 20cmH2O

Answer 183

The metabolic rate of a subject under standardised conditions at mental and physical rest, in a comfortable environmental temperature and fasted for 12 hours Amount of energy expended per unit time during a period of rest Normally 40cal/m2/hr

Answer 184

Directly: -Under steady-state conditions, can be measured by whole body calorimetry. (Heat produced per hour is measured) Indirectly: -Measure O2 consumptions of a subject at rest. O2 consumption is multiplied by 4.8kcal of heat produced per L of O2, to give heat produced per hour. Measured using a modified spirometer.

Answer 185

Insulin-dextrose infusion Stop precipitant Give a fibrate (?)

Answer 186

If <2m bowel left, need parenteral nutrition support If <50cm bowel, need TPN as nutrition If in between, may also have enteral but will definitely need parenteral support too

Answer 187

Infection Burns Trauma Pancreatitis ICH Cardiac arrest Rheumatoid arthritis does NOT raise PCT, so useful in determining if joint is septic or not

Answer 188

1. Cortisol 2. ADH 3. Thyroxine

Answer 189

Prompt rasburicase and IV fluid therapy Rasburicase CONTRAINDICATED in G6PD Benefit can be seen within hours of starting treatment

Answer 190

Steroids Tocilizumab/siltuximab/anakinra - suppress cytokine (IL-6)

Answer 191

Ciclosporin Azathioprine may rarely Tacrolimus and MMF are fine MMF may cause bowel perforation; if unwell can stop MMF

Answer 192

Permissive hypotension Haemostatic resuscitation Damage control surgery

Answer 193

Antifungals: Fluconazole > voriconazole > Amphoteracin Antibiotics: beta-lactams; quinolones Anti-coagulation

Answer 194

NSAIDs Calcineurin inhibitors - Cyclosporin Contrast HAART Acyclovir Ciprofloxacin Antibiotics Anticonvulsants

Answer 195

By CT - Marshall Classification: I - no visible intracranial pathology II - midline shift 0-5mm; basal cisterns remain visible; no high or mixed density lesions >25cm3 III - midline shift 0-5mm; basal cisterns compressed or completely effaced; no high or mixed density lesions >25cm3 IV - midline >5mm; no high or mixed density lesions >25cm3 V - any lesion evacuated surgically VI - high or mixed density lesions >25cm3; not surgically evacuated

Answer 196

Absolute: -Alcohol consumption (if disease caused by alcohol) -Illicit drug use Relative: -Dependence on drugs but engaging with programme -Poor social support

Answer 197

There aren’t many! Absolute: -Uncontrolled cancer -Active infection -Life expectancy <2 years Relative: -Life expectancy <5 years -Risk of graft loss >50% -Poor adherence -Likely to have problems with immunosuppression

Answer 198

WCC >15 AKI with Cr >50% above baseline T >38.5 Severe colitis on imaging Rx with PO Vancomycin

Answer 199

1. Artemisinin-based combination therapy (ACT) if falciparum; chloroquine if vivax/ovale/malariae 2. IV artesunate until can take oral ACT 3. 1st trimester: artmether-lumefantrine. 2nd trimester: ACT Pregnant or G6PD should NOT get primaquine

Answer 200

Proteus mirabilus

Answer 201

Meningitis & encephalitis Polio Hep A/B/C (acute) Anthrax Botulism Brucellosis Cholera Diphtheria Enteric fever (typhoid/paratyphoid) Haemolytic Uraemic Syndrome Infectious bloody diarrhoea Group A strep Scarlet fever Legionella Leprosy Malaria Measles Meningococcal sepsis Mumps Plague Rabies Rubella SARS Smallpox Tetanus TB Typhus Viral haemorrhagic fever Whooping cough Yellow fever

Answer 202

Chimeric antigen receptor therapy Artificial T cells that can target a specific antigen Used in B cell derived malignancy (myeloma, B cell lymphoma, ALL)

Answer 203

Cytokine release syndrome; usually happens a few days after CAR-T (2-3 days) Occurs in 80-90%(!) of patients Fever +/- hypotension +/- low SpO2 Rx = Tocilizumab (if no concurrent ICANS) Dexamethasone Supportive care 80-90% CRS 75% ICANS 2-4% may develop HLH

Answer 204

Haemophagocytic lymphohistiocytosis Usually with diffuse large B-cell lymphoma or B-cell ALL; caused by malignancy but exacerbated by CAR-T Massively high ferritin Rx: -Tocilizumab -Dexamethasone -Anakinra

Answer 205

Immune effector cell-associated neurotoxicity syndrome Encephalopathy from systemic inflammation; usually with CRS Occurs in 70%, usually 4-6 days after treatment Language abnormalities, especially word-finding; evolving aphasia “Encephalopathy with preserved alertness” Fluctuating course Rx= -thiamine supplements -Dexamethasone -anakinra

Answer 206

Body mass index (0-1) (< or > 21) airflow Obstruction (0-3) (FEV1 % predicted) Dyspnoea (0-3) (MRC score 0-4) Exercise (0-3) (6 min walk test) Predicts long term outcomes in COPD patients Need score >7 for lung transplant

Answer 207

Calculated once all injuries known (so can only be done in hospital) Max score = 75 >15 = major trauma

Answer 208

R time/CT - speed of fibrin formation; time taken to reach 2mm K time/CFT - kinetics of fibrin binding to platelets; time between 2mm and 20mm Alpha angle Max ampl/max clot firmness Lysis time - clot stability

Answer 209

1. FFP; PCC or reverse anticoagulation 2. Cryoprecipitate; fibrinogen concentrate 3. Cryoprecipitate; platelets; DDAVP; fibrinogen concentrate 4. TXA

Answer 210

Using ASIA impairment scale A = complete B = sensation but no motor below level C = some motor function below level, but most have MRC <3 D = some motor function below level, but most have MRC>3 E = normal sensory/motor Neurological level = lowest level of cord with normal sensation/motor bilaterally

Answer 211

Tetraplegia = injury within c-spine Paraplegia = injury within thoracic, lumbar or sacral plexus; arm function preserved

Answer 212

Mg/K exchange pump, where K is lost to retain Mg. Mg needs to be replaced to turn this pump off and prevent further loss of K

Answer 213

Alkalinisation I&V for low GCS Aim pH 7.5-7.55 Giving sodium to support cardiac cell function - sodium bicarb 1-2mmol/kg (100-150ml) 8.4%; Consider hypertonic saline if BP low despite NaHCO & fluid & pressors Mg if arrhythmia persists post NaHCO; lidocaine; lipid emulsion

Answer 214

Stage 1: -Increase in Cr by >26.5 within 48 hours -Increase in Cr by >1.5x within 7 days -UO <0.5ml/kg/hr for 6 hours Stage 2: -Increase in Cr by >2-3x baseline -UO <0.5ml/kg/hr for >12 hours Stage 3: -Increase in Cr by >3x baseline -UO <0.3ml/kg/hr for >24 hours or anuria for 12 hours -Cr >254 -Initiation of dialysis

Answer 215

6 organs, scoring 0-4 Resp: PaO2:FiO2 ratio CVS: BP +/- pharmacological support Neuro: GCS Liver: Bilirubin Renal: Cr or UO Coag: Platelets Can be modified for chronic liver failure (CLIF-SOFA) to be more accurate for cirrhotics

Answer 216

Early = <72 hours -Strep pneumoniae -H. Influenzae -Staph aureus -Klebsiella pneumoniae -E coli Later = >72 hours: -Pseudomonas -MRSA -Aceinetobacter -Stenotrophomonas maltophilia

Answer 217

Selective Digestive Decontamination: 1. Enteral antimicrobials e.g. in gel form to mouth/NG 2. IV abx that covers pseudomonas 3. Strict hygiene 4. Regular surveillance cultures of rectum and throat Potentially decreases VAP but concern about resistance

Answer 218

AKI GFR <30 Albuminuria ACr >300mg/g Urinary red cell casts CKD plus HTN despite 4 agents K abnormalities persisting Hereditary kidney disease Nephrolithiasis recurrent CKD progressing >5 GFR per year

Answer 219

Oral NAC with IV fluid filling - isotonic crystalloids (e.g. isotonic sodium bicarbonate) in at risk patients

Answer 220

Co-trimoxazole (If significant hypoxia (PaO2 <9.2kPa on air), add in prednisolone 40mg BD for 5 days) Alternatives: Dapsone Clindamycin/primaquine Pentamidine

Answer 221

1. Voriconazole or liposomal amphotericin B 2. superficial - clotrimazole/nystatin -systemic - caspofungin/anidulafungin or liposomal amphotericin B 3. Liposomal amphotericin B 4. Liposomal amphotericin B 5. Co-trimoxazole

Answer 222

Used to determine the prognosis of Chronic Liver Disease Ascites Albumin Bilirubin Hepatic encephalopathy INR A = 5-6 points B = 7-9 points C = >10 points (45% 1 year survival)

Answer 223

Primary repair is gold standard Fluid resuscitation and broad antibiotic cover (anaerobic and aerobic Gram -ve) NBM PPI TPN Conservative management if small tear and no leak Stent if iatrogenic and no sepsis

Answer 224

6 organ systems scored 0-4 For each organ: -1-2 organ dysfunction -3-4 organ failure Resp: PF ratio CVS: MAP & pharmacological support CNS: GCS Renal: Cr or UO Liver: bilirubin Haem: Plt count

Answer 225

Sepsis screening tool -RR >22 -SBP <100mmHg -GCS <15 If 2 out of 3 present with infection, then increased risk of mortality

Answer 226

1. Initiation: -Plasma exposure to Tissue Factor -TF binds Factor VII -> activates Factor X ->Factor V 2. Amplification -Factor Xa/Factor Va produce Thrombin (Factor II) -Thrombin activates & aggregates platelets -Activated platelets bind vWF and activate VIII 3. Propagation -TF/VIIa activate Factor IX -IX & VIII bind on the platelet surface to form a complex, activating Xa further -Xa & Va bind, producing a burst of Thrombin for a clot

Answer 227

If Neutrophils <0.1 & evidence of infection Continued until neutrophils >0.5

Answer 228

Classic type - dislocations, hernias, bruising Hypermobile type - benign really; generally minor problems Vascular type - bruising and dissections/ruptures Kyphoscoliosis type - significant kyphoscoliosis from birth, joint dislocations, poor wound healing & blindness

Answer 229

Pharm: -Perfenidone -Nintedanib -treat GORD aggressively Non-pharm: -pulmonary rehab -O2

Answer 230

Life threatening organ dysfunction caused by dysregulated host response to infection

Answer 231

Equipment classified into whether it is designed to prevent: —Macroshock: -Class I - earthed -Class II - double insulated -Class III - battery or transformer to reduce voltage from mains —Microshock: -Type B - max leakage of 500microamps (class I) or 100microamps (class II) -Type BF - same as B, but floating -Type CF - max leakage of 50microamps (class I) or 10microamps (class II) (only one allowed to use in direct contact with heart)

Answer 232

Bind to transpeptidase active site, interrupting cross linking & prevent cell wall synthesis Act on penicillin-binding proteins (different penicillin = different PBP affinity) Better at treating Gram positive as they have to get through the cell wall in order to work (Gram negative have got a thick cell wall)

Answer 233

1. Inhibit cell wall synthesis - penicillin, glycopeptides 2. Inhibit protein synthesis (ribosomes) - tetracyclines, aminoglycosides, macrolides 3. Inhibit DNA synthesis/function - quinolones 4. Inhibition of THF synthesis - trimethoprim

Answer 234

Gram +ve cocci - Strep, Staph Gram -ve cocci - Neisseria, Moraxella Gram +ve bacilli - Clostridium, Listeria, Diptheria Gram -ve bacilli - everything else

Answer 235

1. Intrinsic (Gram -ve thick wall) 2. Acquired drug inactivation (beta-lactamase) 3. Acquired reduced permeability 4. Acquired efflux of drugs (pump out antibiotic) 5. Acquired alteration of molecular target (low affinity binding site - penicillin binding proteins) 6. Reduced number of pores

Answer 236

Intrinsic: —thick call wall —biofilm —lack of penicillin-binding proteins Acquired resistance mechanisms: —lack/reduce pores —decreased permeability Sporadic mutation Horizontal gene transfer -transformation - free DNA from dead bacteria -transduction - transferred by virus -conjugation - plasmids -transposition MRSA reduces its Penicillin Binding Proteins - making it resistant

Answer 237

Brainstorm - stroke, ADEM Spinal cord pathology - MS/TM, GBS Polyneuropathy - polio, AIP, diphtheria Neuromuscular junction - MG, botulism Muscle - rhabdo, myosotis

Answer 238

Failure of the bowel to open for 3 days Intestinal blockage in the absence of physical obstruction

Answer 239

Modifiable: -Delayed enteral nutrition (>24hours) -Reduced mobility -Sedation -Opiates -Electrolyte derangement -Anticholinergics/calcium channel blockers -Dehydration -Hypotension -Hypoxia Non-modifiable -Abdo surgery -Severe illness -Paralysis (of spinal cord) -Alcohol/cannabis use -Nicotine withdrawal

Answer 240

Longer ICU stay Slower weaning Delirium Increased mortality (?!!!) Vomiting/aspiration Reduced nutrition Bowel obstruction/perforation Translocation of bacteria

Answer 241

Constipation: -stool softeners -stimulant laxatives -soluble fibres -osmotic laxatives -enemas Ileus: -prokinetics -opiate antagonists Neostigmine

Answer 242

Activated protein C causes anticoagulation Endothelial glycocalyx releases heparin when disrupted Loss of fibrinogen Platelet dysfunction from initial hyper activation as a result of widespread ADP release from endothelial cells

Answer 243

Atlanta classification: Mild - no organ failure/complications Moderate - transient organ failure or local complications Severe - persistent organ failure >48 hours

Answer 244

WHO 2017: Life threatening condition defined as organ dysfunction resulting from infection during pregnancy, childbirth, post-abortion or post-partum period

Answer 245

Clinical Pulmonary Infection Score: -Temp -Leucocytosis -PF ratio -CXR -Tracheal secretions -Cultures

Answer 246

Body weight x % dehydration x 10

Answer 247

1. Use minimum necessary personal info 2. Manage and protect information 3. Be aware of responsibilities 4. Comply with the law 5. Share relevant information for direct care in appropriate manner 6. Ask for consent to disclose 7. Tell patients when you disclose 8. Support patients to access their information

Answer 248

Disruption of the glycocalyx causes endothelial dysfunction. Results in: 1. Vasodilatation 2. Loss of barrier function 3. Increased leukocyte adhesion 4. Procoagulant state Causes release of cytokines - IL-1, IL-6, TNF-a Reactive oxygen species damage DNA and impair mitochondrial function

Answer 249

Neuts <0.5 Neuts <0.5 plus Temp >38 or signs of infection = neutropaenic sepsis

Answer 250

1. Dilution —massive transfusion/fluid administration 2. Sequestration —hypersplenism; extreme hypothermia 3. Decreased production - bone marrow suppression —Drugs: alcohol, Linezolid, chemo —Bone marrow: myelofibrosis, anaemias —Viral: HV, Hep C, EBV —Nutrition: B12, folate —Liver disease - decreased TPO 4. Increased destruction —Drugs: Heparin —Autoimmune: TTP, HUS, ITP, MAHA, Anti-phospholipid, SLE —Haem: DIC, HELLP —Machinery - CPB, IABP, RRT

Answer 251

Blood film - platelet clumping Coagulation profile with XDP & fibrinogen (DIC) FBC - macrocytosis B12 HITTS screen - anti-platelet factor 4 antibody and platelet aggregation tests (ELISA for anti-PF4) Autoimmune screen - ESR, ANA, ENA, dsDNA, anti-cardiolipin, RF, anti-CCP, ANCA, complement ADAMTS13 level - if low = TTP

Answer 252

1. High anion gap metabolic acidosis OR ALKALOSIS (due to an increased strong ion difference) 2. Low Ca2+ with high/normal total calcium (if acidotic you should normally have a high ionised calcium) Pre-disposing risks: —Liver disease —Coagulopathy —HITTS —Hypocalcaemia —Decreased hepatic blood flow

Answer 253

Hand hygiene Asepsis 2% chlorhex/alcohol prep Avoid femoral Daily review and removal if not needed

Answer 254

Clinical pulmonary infection score 1. Tracheal secretions 2. CXR infiltrates 3. Temp 4. WCC 5. PF ratio 6. Micro Score >6 - likely VAP

Answer 255

1. FLORALI 2. TRISS/TRICC/TRICS III 3. ALBIOS/SAFE 4. DESTINY/DECIMAL/HAMLET 5. RESCUE ICP/DECRA 6. ARDSNet 7. RECOVERY 8. PROSEVA 9. CRASH II/WOMAN/PATCH 10. CESAR/EOLIA 11. PAC-Man 12. NICE-SUGAR 13. ProCESS/ProMISe/ARISE/PROWESS-SHOCK (ProtC) 14. TracMan 15. TTM/TTM2 or cardiac arrest; EUROTHERM for TBI 16. VASST/VANISH 17. AKIKI 1+2 18. PROPPR 19. ISATf 20. Cochrane review 2015 - improved mortality on ICU (just); no improved hospital mortality 21. MERIT/Priestly - reduced mortality 22. ADRENAL/CORTICUS/APPROCCHSS 23. REVISE 24. SMART, SPLIT, BaSICS, PLUS

Answer 256

Early <48 hours: —hyper metabolic causes: sepsis, thyroid, SS/NMS/MH —drugs: transfusion reaction, withdrawal, beta-lactams, anti-epileptics —post op - normal healing process —adrenal insufficiency Late >48 hours (operation-related vs ICU-related?): —infection - HAP, wound etc —anastomotic leak —VTE —pancreatitis —drugs —alcohol/drug withdrawal

Answer 257

1. Upward resetting of hypothalamus from PGE2 2. Core body temp >37.5 without hypothalamic involvement (unresponsive to anti-pyretics) 3. Temp >41

Answer 258

Mental Capacity Act 2005 Mental Health Act 1983/2007 Human Rights Act 1998 Equalities Act 2010

Answer 259

Blood 5ml/kg & FFP 5ml/kg —after 15ml/kg of FFP and RBC, give 5ml/kg plt and 5ml/kg cryo TXA 15mg/kg Aim for normal BP Check blood glucose more Calcium chloride 0.1ml/kg after each MHP cycle Be even more avid for hypothermia Think of NAI

Answer 260

Complex constellation of physical, cognitive and mental dysfunctions that severely impact patients’ lives after hospital discharge

Answer 261

Hospital wide practice that links infection control measures with judicious antibiotic management

Answer 262

E - enterococcus faecium S - Staph aureus C - C diff A - Acinetobacter P - Pseudomonas E - enterobacteriaceae

Answer 263

Cardiac - acute MI, cardiogenic shock/pulmonary oedema Vascular - aortic dissection; pre-eclampsia CNS - PRES; SAH, ICH; malignant hypertension Renal - AKI; sclerodermic renal crisis

Answer 264

Epilepsy Vascular - stroke; eclampsia Infection - meningitis/encephalitis Neoplasm - SOL Drugs - withdrawal (alcohol, benzo) or excess (TCAs, cocaine) Trauma - post traumatic Endocrine - low electrolytes

Answer 265

Diffuse Alveolar Haemorrhage —from pulmonary microvasculature -autoimmune - vasculitides, connective tissue disease -infection -CCF -DIC/thrombocytopaenia -drugs like cocaine Focal Haemorrhage —from bronchial circulation or lung parenchyma -PE -Neoplasm -trauma (bronchoscopy) -suppurative lung disease -AV malformation, vascular erosion

Answer 266

ABCDE -prevent asphyxia -treat haemorrhage -DLT or large ETT -bronchoscopy -thoracic surgery opinion Ix: -CT angio -flexible bronchoscopy

Answer 267

Mild: GCS 13 - 15 Moderate: GCS 8 - 12 Severe: GCS <8

Answer 268

Intracranial: —seizures - CMRO2 —haematoma - ICP —hydrocephalus - ICP —infection - CMRO2 & ICP Extracranial: —hypoxia —hypercapnoea —hypocarbia —pyrexia —hyponatraemia —hypoglycaemia (impaired cerebral metabolism)

Answer 269

In response to TSH Iodine + Tyrosine + thyroid peroxidase enzyme = T3 and T4 Stored on thyroglobulin; cleaved and released when TSH binds to G protein receptors; bind to albumin or globulin

Answer 270

-Enter target cell via membrane transporter proteins -Enter nucleus to bind receptor -Effect on DNA (T4 -> T3 in liver and kidneys)

Answer 271

1. Seattle - predict survival at 100 days; grades I - IV 2. Gurd - 1 major (rash/resp/CNS signs) + 4 minor criteria to diagnose FES 3. ScoreTEN/ABCD-10 - predict mortality 4. Braden 5. Baux - mortality; age, burn size +/- inhalational injury (also modified AIS) 6. ISTH - >5 = DIC (uses disease trigger, plts, PT, D-dimer & fibrinogen) 7. H-score - if >169, likely HLH

Answer 272

1. Gas exchange —PaO2 / PaCO2 2. Capnography 3. Lung volumes —ventilator waveforms - asynchrony —auto triggering 4. Lung mechanics —oesophageal balloon —measure PEEP -> end expiratory hold = static iPEEP 5. P0.1 (negative pressure in first 100ms of inspiration) —on a patient on support mode it gives an idea of the work of breathing —normal = 1-5cmH2O 6. Airway occlusion pressure 7. Diaphragm ultrasound

Answer 273

Rapid decline in liver failure with jaundice, coagulopathy and encephalopathy in a patient with a previously healthy liver Acute liver injury = coagulopathy without encephalopathy

Answer 274

Intra-hepatic/Assess liver function: -ALT -AST -Bili -Albumin -GGT -Coagulation - INR -Lactate -Blood sugar -Blood gas -Ammonia level Extra-hepatic: -U&Es -FBC -Blood group -Amylase/lipase Causes: -Paracetamol levels, other drug screen -PREGNANCY TEST -Viral screen - Hepatitis, EBV/CMV etc -Autoimmune screen - ANA, SMA, AMA, copper levels

Answer 275

Glasgow Outcome Scale (Extended) 1 - 8 (1 being dead; 1-4 unfavourable) 4 - 8 favourable

Answer 276

International Society of Thrombosis and Haemostasis uses a table that comprises: 1. Underlying predisposing clinical condition 2. Platelet count 3. FDP/D-dimer 4. Fibrinogen level 5. Prothrombin time prolongation Score >5 = DIC

Answer 277

Acquired syndrome characterised by the intravascular activation of coagulation with loss of localisation arising from different causes Usually caused by sepsis

Answer 278

Blood sugar >11 Blood ketones > 3 Bicarbonate <15 or pH <7.3

Answer 279

1. Fluid/electrolyte replacement as per Joint British Diabetes Societies 2. Insulin therapy to stop ketogenesis —Blood ketones 0.5mmol/hr —Venous bicarbonate 3mmol/hr —Blood sugar 3mmol/hr 3. Treat underlying cause 4. Prophylaxis (VTE, ulcer)

Answer 280

Only fluid if proper shocked Delay insulin by 1 hour Give fluid over 48 hours rather than 24 hours

Answer 281

Hyperosmolar hyperglycaemic state -Serum osmolarity >320mosm/kg -Serum glucose >30 but without significant ketones/acidosis -Severe fluid deficit Often type 2 diabetics

Answer 282

1. Normalise osmolality: —how do you calculate osmolality? 2. Replace fluid and electrolytes as per JBDS 3. Reduce blood sugars (only add in insulin once blood sugars stop dropping with rehydration) 4. Treat underlying cause 5. Prevent thrombotic events

Answer 283

Carefully -Ketamine for induction and maintenance -Prepare for haemodynamic instability at induction - preload with fluid (high losses from high RR) -Volume control (SIMV) with volumes low-ish e.g. 400ml -Monitor plateau pressure (aiming <35cmH2O) -Low or no PEEP (or 1/3 intrinsic PEEP) -Low RR 10-12 -I:E ratio - prolong expiratory time; 1:4 or 5

Answer 284

Nosocomial infection occurring 48-72 hours after intubation Common - 25% Mortality can be up to 50%

Answer 285

ALL have risk of: -haemorrhage -ischaemia-reperfusion injury -infection -AKI -Complications from immunosuppression incl. renal failure, liver failure, malignancy, infections 1. —Primary graft dysfunction - hyperkalaemia, poor UO —hypovolaemia 2. —Primary graft dysfunction - lactate, clotting —hepatic artery/vein/IVC thrombosis —biliary tree obstruction 3. —Primary graft dysfunction in 30% (grades 0 - 3) - poor oxygenation, diffuse alveolar opacities —MODS, haemothorax, pneumothorax, anastamotic leak —CVS - RV dysfunction; vasoplegia —Dynamic hyperinflation —aspergillus —post transplant lymphoproliferative disease 4. —Primary graft dysfunction - LVEF <40% despite inotropes —Secondary graft dysfunction —Cardiac allograft vasculopathy (accelerated IHD) —Arrhythmias —tamponade, pulmonary hypertension

Answer 286

>3 days length of stay (although RVI only offers if >7 days) Postpartum patients Post-anaphylaxis Should be offered to everyone 30-45mins, 2-3 months post hospital discharge

Answer 287

1. Psychological stress: —Pain —Lack of sleep —Noise —Lights —Delirium —Change in personal identity 2. Physical stress: —Weakness —Pain —Deconditioning —Restriction in movement 3. Physiological stress: —Cortisol and effects …

Answer 288

Use of tools such as HADS or PTSS score Predisposition: -substance abuse -alcohol abuse -pre-existing cognitive impairment/disease -pre-existing anxiety/depression

Answer 289

Generally means reducing support of ventilator with aim to liberate the patient from mechanical ventilation Occupies 40% of the time a patient spends on mechanical ventilation Need: —SBTs with insp pressure support —minimal sedation —NIV post extubation —weaning protocols —cuff leak test

Answer 290

Metoclopramide —dopamine & muscarinic antagonist —5HT agonist —dystonic reactions; tachyphylaxis Erythromycin —motilin receptor —prolong QTc; tachyphylaxis Naltrexone: —mu opioid antagonist —only works in opioid induced Neostigmine: —acetylcholinesterase inhibitor (causes increased parasympathetic tone) —bradycardia

Answer 291

(from GPICS) Onset of hepatic encephalopathy 1. Acute 2. Acute on chronic liver failure (in those with cirrhosis) 3. Following liver resection 4. From multi-system illness (sepsis, low CO, malaria, dengue, HLH or malignancy)

Answer 292

1. Increased heat loss Trauma, surgery, GA, immersion, burns 2. Decreased thermogenesis Hypothyroidism, elderly 3. Impaired thermoregulation Drugs - either directly or by impairing behaviour 4. Altered hypothalamic set point Burns

Answer 293

Acute: —infection —haemorrhage —acute GvHD —interstitial pneumonitis —aplastic anaemia Chronic (>100 days): —chronic GvHD —chronic pulmonary disease —infections —autoimmune disorders

Answer 294

Using care bundles (such as shown in Matching Michigan programme) 1. Hand hygiene 2. Strict asepsis with barrier precautions 3. 2% chlorhex in 70% alcohol 4. Avoid femoral 5. Daily review and removal asap

Answer 295

Bloods: —FBC; U&E; glucose; cholesterol/triglycerides —TFTs —Aldosterone & Renin —Cortisol Urine: —blood/protein —casts —metanephrines Radiology: —CXR —CT head —Renal USS ECG Echo

Answer 296

(Evidence of retinopathy, encephalopathy, MAHA, nephropathy) —Lower diastolic BP to 100mmHg over 2-6 hours —Slow reduction - 25% MAP over 24 hours vs reduce by 25% in first hour (conflicting books!?!?!) Use labetalol, GTN, SNP IV nicardipine also a possible Alpha blockers ACEi - caution if renal artery stenosis

Answer 297

Abrupt increase in BP causes acute confusion & visual disturbance MRI - hyperintense white matter on T2 in parietal and occipital

Answer 298

RNA retrovirus causing destruction of CD4

Answer 299

HIV: —Stage 0 - early infection, normal CD4 —Stage 1 - acute infection, CD4 >500 —Stage 2 - chronic infection, CD4 200-500 —Stage 3 - AIDS, CD4 <200

Answer 300

The measure of distensibility or the ease with which something can be stretched Lung compliance = change in lung volume per unit change in transpulmonary pressure Specific compliance is compliance divided by FRC (compensates for different body sizes) Relastance = reciprocal of compliance Static: -Chest wall compliance -Lung tissue compliance Dynamic: -includes airways resistance

Answer 301

The term used to describe the difference between inspiratory and expiratory compliance The energy applied to the lung during inspiration is not recovered in expiration Compliance is greater during expiration than inspiration Due to: -surfactant -alveoli recruitment -gas absorption during measurement

Answer 302

Generally they inhibit: 1. Bacterial cell wall synthesis —Beta lactams —Glycopeptides (Teic/Vanc) 2. Bacterial protein synthesis —30S - aminoglycosides, tetracyclines, tigecycline —50S - macrolides, lincosamide (Clindamycin), oxazolidinone (Linezolid), chloramphenicol 3. Bacterial DNA synthesis —fluroquinolones - cipro —anti-folates —imadazoles - metronidazole

Answer 303

Alkylating agents - platins Anti metabolites - MTX Anti-tumour antibiotics - rubicin Hormones - tamoxifen Monoclonal antibodies - rituximab Topoisomerase inhibitors

Answer 304

Pulmonary toxicity —pneumonitis —fibrosis Cardiac: —arrhythmias, MI, CCF —cardiomyopathy Renal: —CKD Liver: —fatty change, hepatocellular necrosis Neuro: —peripheral and cranial neuropathies, autonomic dysfunction, seizures

Answer 305

-Pathogen-associated molecular patterns and damage-associated molecular patterns (PAMPs & DAMPs) are detected by innate immune system -triggers release of pro-inflammatory cytokines (TNFa, IL-1, IL-6) -trigger widespread cell death -trigger complement & acute phase protein synthesis -trigger increased expression of tissue factor - high risk of thrombus This leads on to systemic injury when: -ROS damage cell components/DNA/mitochondria -Complement increases ROS etc

Answer 306

B - LPV, HFNC rather than NIV C - lactate, CRT D - insulin if >10mmol/L E - feed within 72 hours, stress ulcer prophylaxis, VTE prophylaxis Hb 70 as transfusion threshold Rehab referral if I&V >48 hours or in ICU >72 hours

Answer 307

Fluids - ARISE, ProMISe, ProCESS BP target - SEPSISPAM & 65 Vasopressin - VASST Steroids - ADRENAL, CORTICUS Transfusion thresholds - TRISS, TRICC Fluids - FEAST, 6S, ALBIOS, SPLIT BM - NICE-SUGAR

Answer 308

2 or more organ systems have altered function during an acute illness such that homeostasis cannot be maintained without intervention

Answer 309

3 hour bundle: -lactate -blood cultures -antibiotics -30ml/kg for hypotension or lactate >4 6 hour bundle: -vasopressors if MAP <65 after fluids -re measure lactate if elevated

Answer 310

Protein/glycoprotein web on top of cell wall Regulates: -permeability -vascular tone -leukocyte recruitment -coagulation If disrupted, it activates pro-inflammatory pathways and disrupts starling forces across cell membrane

Answer 311

Decreased intake: —starvation —alcohol dependence —TPN Redistribution: —treating DKA —refeeding syndrome —pancreatitis —alcohol withdrawal Loss: —D&V —renal

Answer 312

Laboratory Risk Indicator for Nec Fasc (LRINEC) score Score >6 has high PPV Variables: -CRP -WCC -Hb -Na -Cr -Gluc

Answer 313

1. If CVS unstable: 10mg bolus then 90mg over 2 hours If arrest: 50mg bolus, further 50mg if 15 mins and no ROSC 2. If no contraindications & within 4.5 hours, calculate dose and give 10% as bolus, followed by the rest over 60 mins

Answer 314

Diagnostic, therapeutic or combined Aspiration Infection Lobar collapse/mucus plug Airway assessment/management Foreign body Strictures/stenosis Haemoptysis

Answer 315

Airway obstruction Laryngospasm Bronchospasm Hypoxaemia Arrhythmias Hypotension Vagal Haemorrhage Pneumothorax

Answer 316

Have indication & consent Monitoring Appropriate sedation/muscle relaxation 100% FiO2 Stop feed/aspirate Position patient and self/equipment Saline flushes etc Post procedure: —Clean/decontaminate/sterilise —document —CXR

Answer 317

Using sPESI (simplified Pulmonary Embolism Severity Index) Score for: -Age >80 -Cancer -Chronic heart or lung disease -Systolic BP <100 -HR >110 -SpO2 <90% 0 points = 30 day mortality of 1% >1 point = 30 day mortality of 10%

Answer 318

Massive PE -haemodynamic instability ->15% PE related mortality -5% of all cases Submassive PE -haemodynamic stability but evidence of RV strain -3-10% PE related mortality -15% of all cases Low risk -stable, no RV strain -75% of all cases

Answer 319

General suppression Cortisol may increase Cortisol may lose diurnal variation

Answer 320

Abnormal findings on TFTs that occur in the setting of a non thyroid illness

Answer 321

A set of clinical signs/symptoms classically due to a group of drugs/toxins Cholinergic: —confusion, salivation, bronchorrhoea, bradycardia, emesis, incontinence, sweating —organophosphates, some mushrooms —give atropine, pralidoxime Anti-cholinergic: —tachycardia, hypotension, confusion, coma, dry skin, fever, flushed, urinary retention —antihistamines/antidepressants/TCAs/anti-parkinsonian/antipsychotics/atropine —supportive care Opioid: —pinpoint pupils, respiratory depression, coma —opioids —naloxone Hypno-sedative: —ataxia, coma, hypothermia, hypotension —Benzos, alcohols —supportive care Serotonin: —autonomic dysfunction, agitation, neuromuscular excitability —serotonin drugs/ecstasy/amphetamines —Benzos, cyproheptadine Sympathomimetic: —delusions, paranoia, tachycardia, hypertension, hyperreflexia —cocaine/amphetamines —Benzos

Answer 322

Fomepizole Alcohol dehydrogenase inhibitor - prevents breakdown into toxic metabolites

Answer 323

Hypertension overwhelms the autoregulatory mechanisms of the cerebral circulation Resultant hyperaemia causes cerebral oedema

Answer 324

—‘Normal’ HTN —Pain/agitation —Excessive vasoconstriction —Neurogenic (ICP related) —Drug related - cocaine, ecstasy —Vascular - dissecting aneurysm, vasculitis —Renal - renal failure, renal artery stenosis —Endocrine - phaeochromocytoma, Cushing’s —artefact

Answer 325

1. Hypertensive crisis/malignant hypertension with end organ failure: -renal dysfunction -cardiac failure -encephalopathy 2. Aortic dissection 3. Pre-eclampsia 4. ICH

Answer 326

1. Toxins - paracetamol; antibiotics; antiepileptics 2. Vascular - hepatic vein thrombus 3. Viral - Hep B/C; CMV; EBV; HSV 4. Pregnancy - HELLP; AFLP

Answer 327

Loss of liver function: 1. Gluconeogenesis = hypoglycaemia 2. Lactate clearance = lactic acidosis 3. Ammonia clearance = hyperammonaemia/encephalopathy 4. Synthetic function = clotting factors

Answer 328

1. Increase myocardial contractility 2. Increase heart rate 3. Increase relaxation 4. Vasoconstriction leading to increased SVR/PVR; increase vascular tone

Answer 329

—Surface tension - surfactant —Lung volume (e.g. at FRC vs at extremes of lung volume) —Lung elasticity (fibrosis, congestion etc) Static: —Lung parenchymal disease - ARDS, pneumonia, fibrosis —Chest wall - kyphoscoliosis, obesity, raised intra-abdominal pressure Dynamic: —Airways resistance

Answer 330

Movement of gas in/out of lungs dependent on: 1. respiratory muscles and actions -diaphragm and accessory resp muscles 2. compliance of chest wall and lungs -lung & thoracic wall 3. gas flow in the airways -types of flow -airway resistance

Answer 331

By type: I - IgE; anaphylaxis II - IgG/IgM; antibody mediated hypersensitivity e.g. rheumatic heart disease, anti-GBM III - IgG & complement; immune complex mediated e.g. rheumatoid arthritis; lupus nephritis IV - T cells; delayed hypersensitivity e.g. chronic transplant rejection, coeliac disease

Answer 332

Any extrusion from a normally gas-filled cavity Continuous Inspiratory Expiratory Forced expiration

Answer 333

Resuscitation initially and diagnose with CXR/CT/bronchoscopy Treat PTX Large bore chest drain -potentially suction on drain Control active infection if the cause Ventilatory measures: -Reduce PEEP -Encourage spontaneous ventilation -2 ventilator ventilation potentially - using DLT Surgery: -bronchoscopic repair -thoracoplasty -stapling ECMO

Answer 334

Ligamentum arteriosum - just distal to the L subclavian Aortic root Aortic hiatus Injury can extend partially or completely through aortic wall CT probs best to diagnose

Answer 335

Inadequate volume -haemorrhage -severe dehydration - burns, diarrhoea, laparotomy Inappropriate vasodilatation -anaphylaxis -sepsis -pregnancy -neurogenic shock Inadequate pump -cardiac failure -obstruction to cardiac output: —PE, tamponade, pneumothorax Iatrogenic -excess treatment for HTN

Answer 336

3 classes - amlodipine/verapamil/diltiazem Act on L-type calcium channels in: -vascular smooth muscle -cardiac muscle (Phase 2 plateau) -pacemaker cell (Phase 0) Actions depend on their selectivity for where the channels are: -relaxation of vascular smooth muscle -decreased cardiac contractility and heart rate

Answer 337

1. Benzos (lorazepam 0.1mg/kg or midazolam 0.15mg/kg) 2. Levetiracetam 40mg/kg OR Phenytoin 20mg/kg slowly OR Phenobarbital 20mg/kg 3. I&V - doesn’t matter which you use

Answer 338

Congenital: -Romano Ward -Long QT Acquired: -Electrolyte abnormalities - hypo K/Mg/Ca -Drugs - macrolides, antipsychotics -Hypothermia -SAH -Ischaemia

Answer 339

—Mainly in bone/intracellular PTH/renal at the PCT Calcitonin Vitamin D —Roles: Energy production - ATP Membrane (phospholipid bilayer) 2,3-DPG Buffer —Hyperphosphataemia causes Renal failure (reduced excretion) Rhabdomyolysis (intracellular release) Tumour lysis Haemolysis Raised PTH Rx with Aluminium, Ca, Mg (some sort of binder) —Hypophosphataemia: Renal loss Refeeding Recovery from DKA Insulin Sepsis Adrenaline

Answer 340

Found in bone/muscle/soft tissues Renal homeostasis & PTH Essential enzyme component DNA/RNA synthesis Calcium antagonist/regulation of calcium flux —Hypermagnesaemia (ECG - prolooongation or PR, QRS; bradycardia) Iatrogenic Rx with calcium —Hypomagnesaemia (ECG - ectopics, VT/torsades/VF): Refeeding Hyperaldosteronism/volume expansion DM D&V Alcohol Hyperparathyroidism; hypercalcaemia

Answer 341

—Mainly in bone PTH Vitamin D Calcitonin — Essential in muscle contraction - skeletal/cardiac Pacemaker cells Coagulation Second messengers Neuronal function —Hypercalcaemia: Malignancy - myeloma, small cell, prostate mets Primary hyper-PTH TB Drugs —Hypocalcaemia: Vit D deficiency Drugs - furosemide Tumour lysis; rhabdomyolysis Pancreatitis Renal failure Hypo-PTH Citrate - massive transfusion, RRT

Answer 342

—Homeostasis: -Aldosterone -Insulin -Osmolality -B-adrenoceptor/adrenaline —Role: -maintains RMP of neuronal tissue -muscle contraction -nerve conduction -regulate acid base —Hyperkalaemia: Impaired excretion - Addison’s, AKI/CKD Altered balance - haemolysis, rhabdo etc, DKA, hyperosmolality, acidosis Increased intake - transfusion —Hypokalaemia: Renal loss - Conn’s, RTA, drugs Balance - alkalosis, refeeding, hypothyroidism, drugs GI loss - D&V, fistula

Answer 343

—Homeostasis: -RAAS -ADH -thirst -PCT reabsorption mainly Exchanged for K -Atrial natriuretic peptide & BNP - increase GFR to cause natriuresis and diuresis; reduce renin/angiotensin II/aldosterone levels Role: -osmolarity key determinant -regulates extra cellular volume Hyponatraemia: -Hypervolaemic: heart failure, liver failure, renal failure -Euvolaemic: SIADH, adrenal insufficiency (Addison’s), hypothyroidism -Hypovolaemic: D&V, diuretics, burns, pancreatitis Hypernatraemia: -HHS -DI

Answer 344

Low Vd, low protein binding, water soluble MALE VC Methanol Aspirin Lithium Ethylene glycol Valproate Carbemazepine

Answer 345

Early: -AF -Pneumonia -Anastamotic leak -Chylothorax Generic: -VTE -Infection -Wound breakdown Later: -Delayed gastric emptying/reflux

Answer 346

1. CVS: Hyper dynamic circulation - decreased SVR, increased CO Cardiomyopathy - blunted response to catecholamines, diastolic dysfunction 2. GI: Alterations in hepatic/splanchnic blood flow - varices; ascites 3. Renal: Hepatorenal syndrome from renal vasoconstriction 4. Pulmonary Hepato-pulmonary - VQ mismatch 5. Haematological 6. Neurological Encephalopathy without raised ICP (in contrast to ALF) 7. Immune Relative immunodeficiency

Answer 347

According to 2021 Surviving Sepsis campaign Can be used if using high amounts of crystalloid Useful in liver patients ?

Answer 348

By type: —Type A - due to ALF —Type B - due to porto-systemic bypass e.g. TIPSS —Type C - related to cirrhosis West Haven

Answer 349

1. Beta chain; valine for glutamic acid Autosomal recessive Qualitative problem with Hb 2. Alpha or beta; reduced production Autosomal recessive Quantitative problem with Hb

Answer 350

Due to metabolic effects of excess citrate Citrate normally metabolised to HCO3 with NADH generation via Kreb’s cycle in liver/kidneys/skeletal muscle -increased citrate administration - RRT; massive transfusion -decreased citrate clearance - liver failure; decreased CO/hepatic blood flow -exacerbating factors - hypocalcaemia; hypoalbuminaemia HAGMA -initially alkalosis due to increased HCO3 production from increased SID Suspect if: -acidotic -low ionised calcium (with high total to ionised calcium ratio)

Answer 351

-Give calcium (but caution with rebound hypercalcaemia afterwards) -Decrease citrate dose or decrease blood flow rate -Stop anticoagulation and switch to alternative -Stop dialysis -Improve hepatic blood flow

Answer 352

Fibrinogen (Factor I) Factor VIII Factor XIII Von Willebrand factor

Answer 353

MRSA Gram -ve Anaerobes Alkaline pH - Proteus

Answer 354

Serious Hazards of Transfusion Haemovigilance reporting Promote transparency, accountability and improvement in blood transfusion practices

Answer 355

Injury either from inhalation of hot gases, from particulate matter or CO/cyanide Divided into: —Supraglottic airway - from thermal transfer —Tracheobronchial - chemical/particulate/fibrin —Alveolar/parenchymal - CO; cyanide Graded on bronchoscopy: I - mild injury II - erythema, deposits of carbon III - inflammation and friable tissues IV - sloughing, necrosis Rx: -BAL -Nebs - NAC/Heparin/Salbutamol Modified Baux score: Mortality from: TBSA burn & presence of inhalational injury & age

Answer 356

Traumatic: —trauma - crush —muscle strain —electric shock Non-traumatic: —drugs - statins, cocaine, MDMA, amphetamines —hyperthermia - MH, NMS, sepsis —infections - nec fasc —autoimmune - dermatomyositis

Answer 357

-ATP depletion from muscle activity -disruption of cellular transport mechanisms and electrolytes -rise in intracellular calcium -hyperactivity of proteases -> produces free radicals which damage cell membrane -cell content leaks

Answer 358

—Secretory due to infection with e.g. toxin laxative —Osmotic enteral-feed-associated —Inflammatory IBD —Dysmotility Post-ileus recovery

Answer 359

—Infective: bacterial/viral/fungal/parasitic —Non infective: IBD Drugs - abx, Mg, laxatives Feed Ischaemic bowel Post-ileus Coeliac/lactose/IBS

Answer 360

10 second triage pre-hospital (the sieve) - can be non-medic Further triage at hospital (the sort) - usually experienced ED cons

Answer 361

1. Clinical assessment 2. ICP/CPP monitoring (bolt, EVD, optic nerve, pupillometry) 3. CBF (Doppler) 4. Cerebral oxygenation (NIRS, SjvO2, bran parenchymal oxygen tension) 5. Cerebral metabolism (micro dialysis catheter - glucose, lactate/pyruvate, glutamate, glycerol) 6. Electrophysiological activity (EEG, SSEPs)

Answer 362

1. Intermittent vs continuous 2. Dose of effluent i.e. how much filtrate produced ~25-35ml/kg/hr 3. Pre or post-dilution fluid replacement (usually 30:70) 4. Fluid balance target in 24 hours 5. Anticoagulation 6. Blood flow - 250ml/min

Answer 363

Rising BP -> Cushing’s reflex Hyperadrenergic state Once coned, there is loss of sympathetic tone Raised hydrostatic pressure causes pulmonary oedema Pituitary and hypothalamus ischaemia -> DI, hypothermia, hypothyroidism —CVS: -HR 60-120 -BP >100mmHg -MAP 60-80 -CI >2.1 —RS: -recruitment -4-8ml/kg -optimum PEEP 5-10 -PIP <30cmH2O -chest physio —Metabolic: -Methylpred -Warming to 36 —Endocrine: -Insulin infusion -Vasopressin -Rarely thyroid replacement -Sodium control

Answer 364

Mild illness: -scarlet fever -impetigo -cellulitis -pharyngitis Severe INVASIVE illness: -necrotising fasciitis -necrotising pneumonia -Strep toxic shock Treatment: -Abx - board spectrum beta lactam +/- clindamycin -IVIg consideration

Answer 365

Orthomyxovirus 2 glycoproteins embedded in cell surface: —Haemagglutinin - binds virus to host respiratory cells —Neuraminidase - releases new virus particles from infected cell

Answer 366

1. Idiopathic interstitial pneumonia IPF COP AIP NSIP 2. Known cause/association Connective tissue disease Occupational Drugs 3. Granulomatous disease Sarcoidosis Hypersensitivity Infection 4. Other Lymphangioleiomyomatosis Langerhans cell histiocytosis Or Exposure related Autoimmune related Idiopathic

Answer 367

1. Reduce the rate down to see what the intrinsic rate is 2. Check for capture threshold: set the pacing rate ~10 beats above the intrinsic rate, then increase the output (mA) until sustained capture is seen Then double the capture threshold 3. Check the sensitivity threshold: set the pacing rate ~10 beats below intrinsic rate, then reduce the sensitivity (by increasing the voltage/raising the wall) until it stops sensing anything Then increase the sensitivity (lowering the voltage/the wall) until the sensor flashes at the native rate; the value at which this occurs is the sensitivity threshold Set the sensitivity to 30-50% of measured/or at 2mV if no underlying rhythm

Answer 368

Decreased myocardial cytosolic calcium β-blockers act on beta-receptors through competitive inhibition, indirectly decreasing the production of cAMP and thereby limiting calcium influx through L-type calcium channels with a resulting negative effect on heart rate and cardiac contractility CCBs exert their therapeutic and toxic effects by the direct blockade of L-type calcium channels causing relaxation of the vascular smooth muscle with subsequent vasodilation, and in the case of verapamil and diltiazem, inhibition of the sinoatrial and atrioventricular nodes. Calcium channel blockade concurrently triggers the heart to switch to preferential carbohydrate metabolism as opposed to the free fatty acid oxidation that occurs in the myocardium in the non-stressed state In beta-islet cells of the pancreas, calcium channel antagonism inhibits insulin secretion, producing insulin resistance and hyperglycemia

Answer 369

—Usually gallstones —Strictures (PSC) —Malignancy (pancreas)

Answer 370

—CNS: GBS MG —Renal Anti-GBM ANCAs causing RPGN or diffuse alveolar haemorrhage Microscopic polyangiitis Granulomatosis with polyangiitis —Haem: TTP (note need detergent FFP replacement) Catastrophic anti-phospholipid syndrome

Answer 371

Because we may unintentionally malnourish patients (CVVH removes, or inadequate feed requirements) Zinc is needed for normal function of basement membrane —essential in burns, who are trying to re-grow basement membrane Selenium needed in the immune system

Answer 372

From FUNDICU (2024 consensus definitions) Can be difficult to detect colonisation vs infection Invasive candidiasis most common; mortality can be >50% -Split into: 1. Candidaemia - grown on blood culture 2. Deep seated candidiasis (usually intra-abdo); can be difficult to diagnose but sample from sterile site Invasive aspergillosis -usually pulmonary Diagnosed on: 1. Detection of Aspergillus in normally sterile site 2. Certain clinical features/bronchoscopic appearances & BAL culture alongside galactomannan Pneumocystis jirovecii - cough/dyspnoea/hypoxia -detection in BAL fluid/sputum

Answer 373

Candida (can form biofilm): -Echinocandins (anidulafungin etc) -Fluconazole for Candida albicans Aspergillosis: -Voriconazole PJP: -Co-trimoxazole - +/- steroids if PaO2 <9kPa

Answer 374

1. Vaso-occlusive crises (painful; most frequent reason for attendance): -usually in bones/joints -Analgesia, hydration -Antibiotics if infection; O2 if hypoxaemic 1b. Stroke 2. Acute chest syndrome: -pain/fever/infiltrates -may be difficult to distinguish from infection -O2, sometimes ventilation 3. Anaemia - usually have Hb between 50-100 4. Aplastic crisis from parvovirus 5. Sequestration & asplenism

Answer 375

Blood transfusions Hydroxyurea - reduces frequency of attacks Voxeletor - reduces sickling

Answer 376

Whether they act on DNA or RNA viruses ?DNA: Guanosine analogues - acyclovir Neuraminidase inhibitors - oseltamivir RNA (anti-HIV): NRTI - nucleoside reverse transcriptase inhibitor NNRTI Integrase inhibitor Protease inhibitor Fusion inhibitors

Answer 377

—Infection: Viral: HIV, EBV, CMV, HSV Bacterial: mycobacteria Parasitic: malaria Fungal: PJP, candida, aspergillus —Malignancy: Lymphomas Treatments: chemo

Answer 378

Usually in cirrhotic liver disease —increased portal pressure/hypertension —decreased albumin —increased aldosterone (due to RAAS and also decreased hepatic clearance) Chronic splanchnic vasodilatation also worsens effect of RAAS, and causes HRS Other causes of ascites may depend on serum-ascites albumin gradient (transudate vs exudate)

Answer 379

Transudates vs exudates - SAAG 1.1g/dL Transudates: -cirrhosis -heart failure -nephrotic syndrome Exudates: -peritoneal metastasis -cancer -pancreatitis

Answer 380

Infection - SBP HRS Malnutrition GORD UGIB (may also have varices) Splinting of diaphragm

Answer 381

Tib tub - 2cm inferomedial Humeral head - 1-2cm above surgical humeral neck on most prominent aspect of greater tubercle Distal femur

Answer 382

Sudden rise in BP causing: -headache -confusion -seizures -visual disturbance Often due to: -pre-eclampsia -drugs - ciclosporin -renal disease Diagnosed on MRI with hyperintense lesions in white matter on T2-weighted MRI in parietal and occipital lobes

Answer 383

—Imminently dying - deteriorating despite best therapy —Qualitative reasons - poor functional outcome —Lethal conditions - coexisting severe disease

Answer 384

(Virchow’s triad (venous stasis, vascular endothelial injury & alterations in coagulation)) Pharmacological: -LMWH (& heparin) -DOACs -Regional anaesthesia -Danaparoid/fondaparinux Non-pharmacological: -TEDS -SCDs -IVC filter -mobilising -hydration -physio

Answer 385

Act on excitatory synapses (inhibits) or inhibitory synapses (enhances): -GABA - benzodiazepines; barbiturates -SV2A - levetiracetam -Sodium channel - phenytoin, carbamazepine, sodium valproate -NMDA receptor - ketamine

Answer 386

1. Most common from Graves, toxic multinodular goitre, thyroid adenoma —Supportive: -O2 -fluids -cooling —Specific: -Propranolol -PTU/carbimazole -Steroids! 2. Iodine deficiency, Hashimoto’s thyroiditis —Supportive: -airway -CVS support -temp control -treat hypoglycaemia/electrolyes —Specific: -liothyronine vs levothyroxine -steroids BEFORE replacing thyroid

Answer 387

Presence of flail segment, contusions etc Scoring systems: Rib fracture score Chest trauma score RibScore STUMBL scoring system: +1 per 10 years >10 +2 per 5% reduction in SpO2 in air +3 per individual fracture +4 anticoagulant/antiplatelet +5 chronic lung disease >30 = severe

Answer 388

Progressive deterioration in hepatic synthetic & metabolic function over >26 weeks Without encephalopathy Causes: -alcohol -autoimmune -viral -NAFLD Inflammation -> fibrosis -> cirrhosis

Answer 389

—Pathogen associated molecular patterns (PAMP) bind to pattern recognition receptors (PRR) on the surface of neutrophils/mast cells/dendritic cells/NK cells —Triggers cascade causing activation of: -pro-inflammatory cytokines -iNOS -acute phase proteins - CRP, fibrinogen, ferritin -coagulation factors

Answer 390

Disruption of glyocalyx resulting in: 1. Vasodilation 2. Loss of endothelial integrity 3. Reduced myocardial contractility 4. Activation of coagulation cascade and fibrinolysis 5. Mitochondrial dysfunction

Answer 391

Road Traffic Act - they can take whatever they want If serious crime (>5 years jail time) and holding suspect and in need of more info to secure conviction If concern others may come to harm