MCQ Flashcards
1
Q
What systolic target in trauma? What’s the exception?
A
80-90mmHg, in TBI have to balance needs
2
Q
What did the PROPPR trial show?
A
pragmatic randomised optimal platelet and plasma ratios trial
showed a sig decrease in exsanguination for 1:1:1 vs 1:1:2 FFP:plt:RBC
BUT no mortality benefit at 1 and 3 days
Sig underpowered
3
Q
In trauma when should cryo be used?
A
When fibrinogen <1.5-2g/dl
4
Q
In trauma, if pelvic bleeding what would make surgical packing more appropriate than IR?
A
FAST positive
5
Q
How does audio-guided USS work when putting in lines?
A
It does not make image just a doppler sound
6
Q
What are the two complications more likely in landmark vs uss technique for line insertion?
A
PTX and arterial puncture
7
Q
What are the commonest causes and absolute % for end-stage renal failure in UK?
A
DM (20-40%) HTN (5-25%) Glomerular inc IgA neph (10-20%) Idiopathic (5-20%) Intersitial disease (5-15%) Rare- Renal art stenosis, Polycystic kidneys, vaculitis combined represent <5%
8
Q
What’s the definition of CKD?
A
A disruption of renal function or structure for >3months
9
Q
What % of patients with CKD end up with end-stage CKD?
A
1%
10
Q
What, in addition to eGFR, is a marker of prognosis in CKD? What are the cut offs?
A
Albuminuria
A1 <30, A2 30-300, A3 >300
11
Q
What efficiency do HME filters work?
A
70%
12
Q
Wha efficiency of humidification are cold and warm water baths in the circuit?
A
30% and 90%
13
Q
What efficiency do ultrasonic nebulizers have in terms of generating circuit humidity?
A
100%
14
Q
Why are ultrasonic humidifiers not commonly used in circuit humidification?
A
Can be too efficient and deposit water droplets into the alveoli, for that reason we use it for meds instead
15
Q
What is gas in small bowel and rectum only suggestive of?
A
Large bowel obstruction
16
Q
Gas and fluid levels in small bowel means what?
A
Can be normal or suggest ileus but not necessarily an obstruction
17
Q
Can Thiopentone cause bronchospasm?
A
Yes and laryngospasm
18
Q
Which muscle relaxant has the least histamine release associated with it?
A
Vecuronium
19
Q
At what level does the coeliac trunk arise?
A
T12
20
Q
What are the first branches of the coeliac trunk?
A
L gastric, common hepatic and splenic art
21
Q
What does the coeliac trunk supply?
A
Greater curvature of stomach, liver, gallbladder, spleen, pancreas
22
Q
Where does the portal vein collateralise with the systemic venous network?
A
Oesophgeal, rectal, paraumbilica and a few small connections with colic and retroperitoneal veins
23
Q
How does the IMA drain?
A
In health via the superior rectal, sigmoidal and L colic veins into the inferior mesenteric vein which then joins the splenic vein
24
Q
What is first line treatment for Aspergillosis?
A
Voriconazole. Posaconazole is a resue therapy
25
What is the classic CT sign of Aspergillus infection?
The Halo sign which is a nodule surrounded by ground glass
26
What are the classes of anti-fungals?
```
Cell membrane
Triazoles- Fluconazole, Voriconazole etc
Imidazoles- Ketoconazole
Polyenes- Amphoterecin (liposomal preparations fewer side effects and have surpassed deoxycholate preparations)
Allylamines- Terbinafine
```
Cell wall
Echinocandins- Caspo, Andiulafungin
Intracellular
Griseofulvin, Flucytosine
27
What are the site of action of antifungals?
Cell membrane (azoles), Cell wall (fungins), Intracelluar (Griseofulvin, Flucytosine)
28
If Voriconazole is contraindicated in Aspergilosis what is the next treatment choice?
Amphorecin B
29
What is the treatment of cryoptococcus meningitis?
2/52 Amphoterecin and Flucytosine followed by 8/52 fluconazole
30
Causes of pre-hepatic jaundice?
Haemolysis, haematoma absorption
Crigler-Najjar syndrome
Gilberts syndrome
Jaundice of newborn
31
Cause of hepatic jaundice
Cirrhosis, steatohepatitis, genetic-haemochromatosis, alpha 1, Wilsons,
From mets, autoimmune hepatitis, PBC, infection HAV HBV etc, liver abscess, heart failure and backpressure, toxins, HELLP
32
Drugs that cause hepato-toxicity
Hepatocellular- amidoarone, HAART, halothane, NSAIDs, PPI, rifamipicin, SSRI, paracetamol, TPN
Mixed- phenytoin, enalapril, amitriptyline
Cholestasis- steroids, TCA, erythromycin
33
What equation is used to calculate cardiac output from transpulmonay indicator dilution?
Stewart-Hamilton
34
How does oesophageal doppler measure cardiac output?
Measures descending aorta flow velocity and uses either measured or normogram data of aortic diameter to estimate volume. The proportion of cardiac output going to descending aorta is a large source of error
35
What is Fick's principle?
blood to an organ can be calculated by dividing the amount of a substance taken up by the organ per unit time (A:V concentration difference).
36
Give a practical example of Fick's principle in calculating cardiac output
The O2 update from lungs divided by the difference between mixed venous and arterial O2
37
What is the indirect Fick method
Uses CO2 instead of O2. The difference between arterial and venous CO2
38
What is the Penaz technique for cardiac output estimation>
A cuff with LED is put on finger. The cuff goes up and down to keep the light going through the finger and hitting the photosensor constant. The pressure changes correspond to the pressure waveform of arterial pulsation. From there through multiple assumptions CO can be calculated
39
What is first line treatments for non-high risk PE?
LMWH or Fondaparinux
40
When are LMWH and Fondaparinux not first line for non-high risk PE? What is the treatment?
If (ESC)creatinine clearance <30->UFH
| (NICE) eGFR<30 then use UFH or dose adjusted LMWH with Xa levels
41
When can Rivaroxiban be used in PE?
Can be used as initial treatment in those with non-high risk PE by both NICE and ESC guidelines
42
What are symptoms of total Ant circulation stroke? What is the definition of partial Ant circ stroke?
Unilateral weakness +/- sensory defecit
Homonymous hemianopia
Higher cerebral dysfn (dysphasia, visuospatial disorder)
PACS is 2 of 3 of above
43
What are the signs of posterior circulation stroke POCS?
LOC, isolated homonymous hemianopia, cerebellar symptoms, brainstem signs
44
What are the cerebellar signs?
Ataxia, dysphagia, dysphonia, nystagmus
45
Lacuna infarcts (LACS) present how?
A subcortica stroke due to small vessel disease- unilateral weakness, pure sensory stroke or ataxic hemiparesis
46
How does malignant MCA infarct present and progress?
severe hemiparetic stroke with oedema within 24-48 hours causing raised ICP
47
How does carotid artery dissection usually present
Young people after trauma, headache and neck pain, Horner's syndrome and CN palsies
48
What are the groups of pulmonary hypertension set out by Dana Point classification in 2008
6 groups
Group 1- PAH- idiopathic, congenital or disease related
1'- secondary pulm venous hypertension (occlusive disease)
2- secondary L heart failure
3- secondary chronic hypoxia or chronic lung disease
4- secondary chronic thromboemobolic disease
5- unknown or secondary multiple mechanisms (haem, vasculitic, metabolic)
49
What did the TRICC study look at and find?
'Transfusion req in CC' tested transfusion trigger 70 (aim 70-90) vs 100g/dl (aim 100-120) with non-sig trend to reduced 30day mort in restrictive arm. Those <55 and with APACHEII <20 were statistically sig reductions subgroups.
And increase in MI and pulm oedema in liberal arm
50
What is the evidence for keeping Hb>100 in ACS?
one pilot study (carson, brooks et al 2013 Am heart J)
51
What did the TRISS study find?
70 vs 90g/dl trigger for transfusion in septic shock. Found same as TRICC there was no difference in 90day mortality
52
In traumatic bleeding how do you decide if you use O neg or wait for cross match?
If having transient response to fluid await crossmatch if no response switch to o-neg
53
How is hyperK and hyperPO4 caused in tumour lysis?
Cell lysis
54
How does HypoCa occur in tumour lysis?
Binds with free PO4 and deposits calcium phosphate in tissues
55
Why do you get hyperuricaemia in tumour lysis?
Cell breakdown releases nucleic acids which convert into uric acid
56
How does renal failure occur in tumour lysis syndrome?
Multifactorial but ppt of uric acid and CaPO4 in renal tubules are major contributors
57
How prevent tumour lysis?
Fluid and hopefully pre-treat with rasburicase/allopurinol
58
How treat established tumour lysis?
Correct hyperK and consider phosphate binders for PO4. RRT if needed by standard defn, Ca corrected cautiously as can worsen renal failure through CaPO4 deposition
59
Defn mild c.diff infection and treatment
No WBC, <3 stool/day-> PO metronidazole 10-14/7
60
Defn moderate c.diff and treatment
WBC 10-15 and 3-5 stool/day
| Metronidazole 10-14/7
61
Dfn severe c.diff and treatments
WBC>15, AKI (50% up from baseline), T >38.5, severe colitis
PO vanc 125mg QDS 10-14/7 if low risk
Fidaxomicin if frail or receiving abx otherwise
62
Defn and treatment for life-threat c diff
shock, partial/complete ileus, toxic megacolon, CT evidence of severe disease
PO vanc 500mg QDS 10-14/7 and IV metronidazole TDS
63
What are inclusion criteria for ECMO?
Murray score >/=3, >/=2.5 and deteriorating quickly, uncomp resp acidosis pH<7.2 or bronchopleural fistula
64
Exclusion criteria for ECMO?
High vent support >7/7 inc PIP >30 FiO2>0.8
Sig co-morbidity
Contra-indication to anticoag
65
How do you calcualte the Murray score?
The score for each of the below components divided by the number of components
Score 0-4 for:
CXR quadrants involved (0=0, 4=4)
Compliance (Vt/Pplat-PEEP) (0=>80, 60-79, 40-59, 20-39,4=<20)
PEEP- 5=0, 6-8, 9-11, 12-14, 4->14)
PF ratio- >40=0, 30-40, 23.3-30, 13.3-23.3, < 13.2=4
66
What are predictors of difficult to BVM?
```
M- mask seal-beard etc
O- obesity/obstruction
A- age>55
N -No teeth
S- sleep apnoea/stiff lungs
```
67
How many attempts at intubation should be tried before proceding to LMA in RSI?
3
68
What are subtypes of COPD and how do they manifest?
Chronic bronchitis and empysematous change. The former are at risk of CO2 retension, pulm HTN and sleep apnoea.
THe latter have high work of breathing and hyperinflation
69
Berlin criteria for ARDS?
Within a week of known trigger or start of resp symptoms
Bilateral infiltrates in 2 or more quadrants
Not fully explained by another cause
70
Definition of mild, mod and severe ARDS?
PEEP 5 or more
Mild- PF 200-300 (26.7-40kPa)
Mod- 100-200 (13.4-26.6)
Severe <100 (<13.3)
71
Causes of ARDS
Direct (inside lung) and indirect (outside lung)
72
What cells produce stomach acid?
Parietal cells make HCl
73
What do Chief cells produce in stomach?
Pepsinogen which is activated to pepsin a proteolytic by acid conditions
74
What hormones promote acid environment in stomach>
gastrin, histamine and parasymp system
75
What hormonoes inibit acid production in stomach?
Somatostatin, PGE2, PPI/H2 blocker, anti-muscurinics
76
How does pyloric stenosis result in hypoK?
As the body wants H+ it exchanges K+ for H+ in distal tubule
77
What is in hospital mort for first SBP and 1 year mort?
1st presentation 20%, 1 year mort 30-90% depending on where on the journey the patient is. SBP should be a trigger for liver transplant consideration
78
What bacteria cause SBP?
E.coli (40%)
also klebsiella
Less likely G+ve cocci like strep and enterococcus
79
Definition of cardiogenic shock
inadequate tissue perfusion secondary cardiac dysfn
| BP<90mmHg, pulm oedema, signs imparied perfusion
80
Haemodynamic definition of cardiogenic shock
CI<2.2l/min/m2, wedge pressure >18mmHg
81
What drug is a good choice in shock secondary AMI?
Levosimendan (inc availablity of intracelluar Ca) is an inotrope that doesn't increase myocardial O2 demand but in practice NA and Dobutamine are commonly use.
82
What did IABP-SHOCK-II trial show?
no improvement in 12 month mort with use of IABP in patients undergoing early re-vascularisation so IABP not used
83
Signs of life threatening asthma?
reduced resp effort, silent chest, arrhythmia, reduced GCS, hypoxia, normal PaCO2, hypotension, PEF<33%
84
Signs of severe asthma?
PEF 33-50%, HR >110, RR >25, unable to speak in sentences
85
What is the RR reduction of failure and of complications in USS CVC insertion vs landmark?
Failure 86% reduction with 41% reduction in first pass success (IJV)
Complications 57% reduction (90% reduction in subclavian complications!)
86
Descending from diaphragm what are the main arterial outlets from aorta in abdomen?
```
Phrenic artery
Coeliac trunk
Supra-renal art
SMA and renal arteries
Gonadal
IMA
Iliacs
```
87
What are the branches of the coeliac trunk
on L splenic art and coming off at about 1o'clock the L gastric artery
on R common hepatic which gives off gastroduodenal (greater curve and joins splenic) and right gastric which joins the L gastric and supplies the lesser curve. R common hepatic then becomes the hepatic proper
88
What study demonstrated non-inferiority of Rivaroxiban and Warfarin/LMWH
EINSTEIN-PE
89
What score is used to assess risk of bleeding from anticoagulation as OP? What are it's constituents?
HAS-BLED
HTN, renal disease (Cr>200), Liver disease (TB x2 and ALTx3), stroke, major bleeding or concern, labile INR, >65, anti-plt/NSAID, alcohol >8 'drinks'/wk
90
what is NICE guideline for IVC filters?
Not recommeneded unless confirmed PE and anticoag is contra-indicated. Should be removed as soon as anti-coag starts
91
If PE diagnosed, anticoag given and dyspnoea/functional limation persists at 3-6/12 what pathway should be followed?
ESC PE guidelines suggest TTE for anyone with symptoms or those at high risk of CTEPH. Probability of pulm HTN is then rated low, medium,high. If intermediate do BNP, CPET and consider if risk for CTEPH high any one requires VQ scan and if defect for pulm HTN specialist work up
92
What are risk factors for CTEPH
T4 replacement, malignancy, prev or recurrent VTE, anti-phos, infected pacemaker, splenectomy, non-O blood groups
93
Head and neck (usually extra-cranial) dissections account for 20% of all strokes between 20-45. What are the risk factors?
Classically think of trauma but also chest infectinos, smoking, HTN, OCP but also Ehler's-Danlos, high homocysteine levels and alpha 1 def.
94
How do extra-cranial internal carotid artery dissections present?
the commonest type of head/neck dissection 2.5% of all first strokes.
Classic triad:
1. Pain on side of head, face, neck
2. partial Horner's
3.followed in hours/days later by cerebral/retinal ischaemia (intimal tear causes clot and emobolism)
95
Why is the vertebral artery most likely to dissect in trauma?
Most mobile of arteries and likely to go at C1/2
96
Whats the evidence for treating carotid/vertebral artery dissection with antiplt/warfarin to prevent embolic events?
None, no RCT. A trend toward more events in aspirin only but not significant. Who knows whats best
97
What are the components of the APACHE II score?
```
A-Age
B- RR, FiO2
C- HR, MAP
D- GCS
E- Temp
Bloods- WBC pH, Na, K, Cr, AKI (clnical judgement), hct
```
98
what are the qSOFA criteria?
GCS <15, RR>/=22, SBP <100
2 or more= 10% hosp mort
99
Definition of sepsis?
Life threatening organ dysfunction caused by disregulated host response to infection
100
How is organ dysfunction defined in sepsis 3 defn?
EIther 2 or more points on qSOFA
101
How is septic shock defined in sepsis 3?
pressor to maintain map 65, lactate >2 and not hypovolaemic
102
What did the ALBIOS study find?
ALBIOS comapred albumin 20% and crystalloid with crystalloid alone. No mortality benefit for aiming albumin >30 but was safe.
103
What subset is ALBIOS knowns for?
In a post-hoc subset analysis there was a significant mortality benefit to those with septic shock. That was the same for sepis-2 and sepsis 3 criteria
104
What did CESAR looks at?
Is ECMO safe, efficacious and cost-effective cf standard practice?
105
Findings and limitations of CESAR?
Single centre really, sig cross-over and poor followup data. Only recommendation is Murray>3 or pH<7.2 despite optimum vent (lung protective) should be referred to ECMO centre
106
According to DAS, how many intubation attempts?
3, changing something with each attempt, +1 from a more qualified person
107
What interventions after Loraz and phenytoin in status epilepticus?
Propofol induction
Then Midaz 0.1-0.2mg/kg bolus followed by 0.05-0.5mg/kg/hr
Then Thio
108
Define status epilepticus and refractory status
Status is seizure for over 30min despite mx or multiple seizures within 30min without recovery
REfractory 30-90min
109
What is the management of status epilepticus in children?
Loraz 0.1mg/kg
Phenyoin 20mg.kg over 20min
Can give Praldehyde 0.8mg.kg if required
110
Why do cirrhotic patients hold onto (or not excrete enough) Na?
Splanchnic arterial vasodilatation from portal htn causes a decrease in effective arterial blood volume with activation of the sympathetic system and up-regulation of RAAS.
111
What does a SAAG >11 g/L mean in terms of ascites?
97% accuracy of saying it is due to portal HTN
112
Why measure total protein in ascitic tap?
If <15g/L at high risk of SBP and may benefit from prophylactic abx
113
With development of ascites there is a 40% 1 year mortality. What are the predictive factors that would mean poor prognosis?
HypoNa, low BP, inc Creatinine, low urine Na (note only creatinine in MELD and none in CPugh)
114
What diuretics for ascites?
First presentation Spiro 100->400mg then Furosemide. If recurrent give 100 Sprio, 40 furosemide and increase both stepwise over 7 days
115
What is the cutoff for positive neutrophil count for SBP?
250cells/mm3 though it is more specific at 500
116
What are the common organisms to cause SBP>
Culture +ve in only 40%
| E.coli, strep and enterococci most likely
117
What is bacterascites?
When WBC <250 but positive culture. If other signs/symptoms treat otherwise re-sample
118
What's first line abx for SBP according to EASL 2010 guideline?
cepholasporin- mostly cefotaxime though Taz is what I have seen used
119
When may albumin be useful in SBP?
HRS in 30% with abx only, but reduces to 10% if 1.5g/kg on day 1 and 1g/kg on day 3 if TB at baseline >68 and Cr >88. Not a great study so A2 guideline
120
Define hepatorenal syndrome
occurrence of renal failure in a patient with advanced liver diseas in the abscence of a cause for renal failure
121
Criteria for HRS diagnosis?
```
Cirrhosis with ascites
Cr >133
no shock, no hypovolaemia
Albumin 1g/kg/day for 2 days tried
No nephrotxics
NO renal parenchymal disease
```
122
What are the four factors that contribute to HRS?
1. Splanchnic arterial dilatation
2. Sympathetic nervous and RAAS activation causing shift of renal auto-regulation curve and more susceptible to MAP changes
3. Impaired cardiac fn secondary cirrhotic cardiomyopathy which cannot respond to 1.
4. increased synthesis of vasoactive substances such as thromboxane A2 and endothelin 1
123
Definition of neutropenic sepsis?
<0.5 neuts and fever >38 or signs/symptoms
124
Symptoms hyperK
>6.5 muscle weakness, malaise, nausea, parasthesia
125
What causes the characteristic changes on ECG for HyperK?
hyperpolarisation of excitable membranes
126
What is the earliest and most sensitive change to ECG in hyperK?
What other abnormalities eventually with same?
Tented T-waves (T>R)
| Eventually wider and flat P and QRS lengthens
127
When do you see J waves on ECG?
hypothermia
128
What is the Marshall score and what is it used for?
Pancreatitis
| PF ratio, Cr, BP and pH
129
What % of pancreatitis is severe and of those what % get ARDS?
15-20% develop severe panc
| Of those 33% get ARDS and account for 60% of early deaths
130
What is thought to be the mechanism of ARDS in pancreastitis?
SIRS and neutrophilic activation and release of pancreatic protelytic enzymes (elastase) which then damages lung microvasc and cause third space losses in lungs
131
What is Well's score for PE?
Signs of DVT (3), Alternative diag lesslikely than PE (3), Tachy (1.5),immobile >3days or surgery within 4/52 (1.5), prev VTE (1.5), Haemoptysis (1), Active cancer (1)
Therefore most emphasis on clinical exam and what clincian thinks
Score >4 ->CTPA
132
Well's score for DVT?
All of equal weight (1) except last one (-2):
Reason for it -Ca, recent immonilisation and surgery within 3/12, had it before
signs of it- localised calf ternderness, swelling of whole leg >3cm, pitting oedema in symptomatic leg, varicose veins,
Dont' think they have it - an alternative diagnosis is at least as likely
Score >2 for USS within 4 hours
133
If DVT suspected using Well's score and USS is negative what are the next steps? If the test is positive what then>
DVT -ve on USS but Well's high then do D-dimer. If positive repeat scan in 1/52
134
When should local thrombolysis be offered to someone with a ilio-femoral DVT?
If they've had it for less than 2 weeks and are low risk of bleeding with at leat 1 year of life expectancy.
135
When would you use heparin in DIC?
For thrombotic complications usually chroni
136
What are the transfusion thresholds in DIC for plt and FFP
If bleeding correct plt if <50, if not replace when <20. If overtly bleeding correction with FFP appropriate
137
What is the triad of DIC?
Fibrin deposion, plt aggregation and microvasc occlusion
138
What bacteria are more likely to cause DIC?
G-ve and those that produce endo-toxins
139
What are non-infective causes of DIC?
trauma, burns, long-bone fractures, obstetric complictations (eclampsia, amniotic embolus), malignancy, transplant rejection
140
What is the mechanism of DIC?
Thought to feature one or more pro-coagulant factor such as intra-cellular contents, endoxtoin, tissue factor or lipopolysaccharide
141
What is the key to treat DIC?
Treat the cause
142
What heparin is used in DIC if microvascular clots predominate?
LMWH rather than UFH
143
What is dose of Thiopentone?
1-5mg/kg
144
Which causes more hypotension Thiopentone or Propofol?
Propofol
145
What are the classes of lactataemia?
Type A and B
146
What is the cause of type A lactataemia?
increased production due to lack of O2 for whatever reason (hypoperfusion, severe anaeamia, exercise, CO poisoning)
147
What are the causes of type B lactataemia? What are the subcategories?
Non- hypoperfusion
B1- underlying disease such as phaeo, leukaemia, organ failures, pancreatitis, short bowel
B2- drugs (Beta agonists, arenaline, alcohol, bacterial endotoxins, paracetamol)
B3 - inborn errors of metabolism
148
Lactate is produced from glycolysis, what can that sometimes cause a lactataemia?
Endogeous of exog catecholaemines increase glyolysis, along with sepsis and trauma/burns so more lactate is made
149
Lactate is also made anaerobically from pyruvate. What states increase pyruvate concentrations therefore pre-disposing to lactate formation?
Thiamine deficiency, critical illness, malignancy esp lymphoma and leukaemia
150
Where is lacate metabolised?
Largely 70% liver but also anywhere with mitochondira. Renal is only 5% but can go up when lactaemia is present.
151
How does phentolamine work?
Predom alpha 1 receptors
152
How does methyldopa exert its cardiovascular effects?
Alpha 2 receptors reducing SVR
153
How does increasing alpha 2 receptor agnoism affect SVR?
Reduces NA production
154
List some Alpha 1 receptor blockers
phentolamine, phenoxybenzamine, prazocin
155
List some alpha 2 blockers
methyldopa and clonidine
156
What drugs work by increasing locally produced nitric oxide?
GTN, ISMN causes direct relaxation of smooth muscle tone
157
How to Beta blockers work?
act on G-protein coupled adrenoreceptors which competitively inhibiting cell membrance receptor which in turn reduces cAMP and reduction of intracellular Ca therefore reduces contractility.
158
What is the acute treatment for thombotic stroke once thrombolysis complete? When should statins be started?
Aspirin 300mg for 2/52
No statin in acute phase
(PPI only if previous dyspepsia wiht aspriin)
159
What is the BODE index and how is each part scored?
Used in mortality prediction in COPD
B-BMI <21 (1),
O- obstructive FEV1 >65% (0), 50-64% (1), 36-49% (2), <35% (3)
D- Dyspnoea MMRC dyspnoea scale dysp on walking on flat (1), stops after 100yds/ few min (2), housebound on dressing (3)
E- 6min ET- >350m (0), 250-349 (1), 150-249 (2), < 149 (3)
160
What is the mortality associated with acute TTP?
10% though another card says 50% which seems more plausible
161
What is the cause of primary TTP?
related to enzyme deficiency in breakdown pathway for large von Willibrand factor multimers leading to plt aggregationand microvas coag
162
Causes of acquired TTP?
idiopathic (autoimmune), malig, HIV, preg, drugs (immunosuppressants, antiplt agents)
163
What are the forms of MAHA?
TTP, HUS, DIC, HELLP
164
Classic presentaion of TTP
Fever, neuro symptoms, renal failure (with MAHA and thrombocytopenai)
165
Treatment of TTP?
Plasma exchange but can use steroids, stop when normalised bloods. Plt treatment avoided unless life threatening bleed.
166
If plasma exchange and steroids are already in use for TTP what else can be added in extremis?
Rituximab (steroid sparing and as adjunct)
167
What does SDD (selective decontamination of the digestive tract) target?
15 most common pathogens on ICU:
MSSA, s.pneumonia, H. influenzae, maroxella, e.coli, candida all normal flora. And abdnormal flora Klebsiella, Enterobacter, Citrobacter, Serratia, Proteus, Morganella, Pseudomonas, Acinetobacter, MRSA
168
What is SDD (selecgive decontam digestive tract)
The idea from 80s is to prevent overgrowth of 15 common pathogens and has been shown to reduce infections in ICU (means infections are overgrowth of flora). Cost and resistance means its not really used.
169
What is the SDD protocol?
4/7 PO cefotaxime 100mg/kg/day! And PO tobramycin, amphotericin B, polymyxin and Vancomycin
170
What are the CSF variables normally?
Open pressure <20, clear, glucose 2/3 blood, protein 35mg/dl, WCC 0-3, no cells predominate
171
What are the CSF variables seen in viral meningitis?
Normal/high open pressure, clear, normal glucose, 50-100mg/dl protein, 5-1000 WCC lymphocytes
172
What are the CSF variables in bacterial meningitis?
Opening pressure high, cloudy, low glucose, >100 protein, 100-50K WCC mostly neurophils
173
What does fungal meningitis look like on CSF?
Very high opening pressure, clear or cloudy, low-normal glucose with 20-50 protein, 0-1000 WCC mostly lymphoctes
174
What does a TB CSF sample come back with from lab?
High opening pressure, yellow colour, very low glucose, 100-500 protein and 25-500 WCC mostly lyphocytes
175
How does TB meningitis usually present?
Insidious course over weeks, similar story to acute meningitis, chronic headache, low grade fever
176
What viruses commonly cause meningitis?
enterovirus, HSV, chicken pox, HIV, mumps
177
What organisms cause meningitis <3months of age?
G B strep, E.Coli, Listeria, Neiserria, S. pneumonia, S. aureus
178
What organisms cause meningitis in children?
Neiserria, H. influ, s. pneumonia
179
What organisms cuase meningitis in adults?
S. pneumonia, N meningitidis, s.auraus, Listeria (>65), Klebiella
180
What organisms more likely to cause meningitis post trauma and in neurosurgical settings?
Aerobic G-ve eg E.coli
181
What is the incidence of N.meningitidis, s.pnuemonia, s.aureus causing meningitis?
22% N.men
18% S.pneumoina
10% S. Aureus
5% both E.coli and GBS
182
What are the complications and the incidence of complications in ECMO?
Major bleed 41%, Death 40%, sign infection 30%, circuit clot 19%, lower limb iscahemia 17% oxygenator failure 15%, compartment syndrome 10%, stroke 9%,DVT, 8%, LL amputation 5%, ICH 2%, air embolus 2%, major vessel rupture 2%
183
When would you do a pleural fluid amylase?
Pancreatic or oesophageal pathology
184
Causes of exudative pleural effusion
Malig, pneumina, TB, PE, autoimmune such as RA, asbestosis, pancreatitis
185
When would you do a pleural fluid pH?
If suspect inection/empyema
186
When is glucose a useful test of pleural fluid?
If RA suspected (usually young men early in disease) would be low
187
When is CT warranted in pleural effusion?
CT with pleural enhancement should be done before drainage in all complicated infective and undiagnosed exudative effusions
188
What are the four main categories of indication for PPM?
Brady 2 nodal dysfn
Avoidance or treatment of arrhythmia (overdirve eg)
CV optimisation
Specific conditions like heart transplant
189
What % population have a PFO?
20-30%
190
What is the sensitivity of TTE and TOE for IE?
TTE 50%, TOE 90-100%
191
Which heart chamber is usually affected first in pericardial effusion?
RA filling
192
What two wavelengths of light are used in pulse oximetry?
660 (deoxy) and 940nm (oxy)
193
What are the findings in TURP syndrome?
Hyponatraemia from fluid absorption and glycine toxicity, most people absob 1L during procedure
194
TURP syndrome is caused by irrigation fluid, why is the fluid so hypotonic?
Electrolytes would make it conduct the diathermy current
195
What is the loading and infusion rate of aminophylline in asthma?
5mg/kg over 20min then 0.5mg/kg/hr
196
What is the frequency of a persistent left SVC?
0.5% of population, higher in those with cardiac defects where it can be 1:5
197
Where do persistent L SVC usually drain?
Coronary sinus usually but can go straight into LA
198
The commonest cause of nec fasciitis? And other causes?
Group A strep (60%) (and group B, S. aureus and coliforms such as Klebsiella, Enterobacter and E.coli
199
Why is Clindamycin included in first line regimen for nec fasc?
It has an additional benefit over penetrance that it reduces the production of strep super-antigen
200
What are the treatment priorities as listed in the guideline for anaphylaxis?
1. Remove trigger
2. IM adrenalin
3. High flow O2
4. IV fluid challenge
201
```
Give afferent and efferent CN for the following reflex
1. pupillary light
2. corneal
3. oculovestibular
4. Gag
5. Cough
6 Motor response to pain
```
1. II and III
2. V and VII
3. VIII, III IV and VI
4. IX and X
5. X and X
6. V abd VII
202
If only one ear is available for the oculovestibular reflex can the test be conducted?
Yes
203
What is the starting CO2 in an apnoea test for brainstem testing?
>6 or >6.5 if a chronic retainer
204
What must happen to CO2 and pH in apnoea brainstem death test for it to be failed by a dead patient?
pH <7.4 and pCO2 >0.5kPa cf start
205
What are the points of the Glasgow-Imrie score?
```
PANCREAS
pO2<7.9
Age>55
Neut>15
Ca <2
Renal Ur >16
Enzyme LDH >600
ALb <32
Sugar >10
```
PPV 79%
The transition point is between score 3 and 4
206
What are the types of acute pancreatitis?
Necrotising and intersitial oedematous
207
What is required for diagnosis of pancreatitis?
Two of
| 1. typical history and pain, 2. Amylase at least 3x normal, 3. characteristic findings on CT/MRI
208
In what situation is the amylase likely to be less than 3x normal in someone who has pancreatitis?
If they are are a delayed presentation
209
What percentage of people with acute pancreatitis have necrotising pancreatitis?
5-10%
210
Is there a link between the extent of pancreatic necrosis and the probability of it becoming infected?
No
211
What gives the most reliably early indicator of mortality in pancreatitis?
Persistent organ failures, not the presence of absence of local complications of the pancreatitis itself
212
What is the modified Marshall score and when is it used?
Pancreatitis, can be done daily
PF ratio, renal function and BP off inotropes, score 2 or more means persistent organ failure which confers a mortality risk
213
Define pancreatic pseudocyst
A walled off collection outside the body of the pancreas only can be called such 4 weeks after initial symptoms
214
What is CARS?
Compesnatory anti-inflam response syndrome (can increase risk of infection apparently)
215
Should pancreatitics be NBM
No unless good reason, start feed within 72 hrs, anecdotal to give NJ as better tolerated
216
What are the three underlying pathological causes of pancreatitis and some examples of each?
1. Ductal dysfunction- GS, malig, post ERCP (alcohol)
2. Acinar injury - trauma, ischaemia, drugs (alcohol)
3. Defective intracellular transport- hyperCa, hypertrigs (alcohol)
217
What is the sequence of events leading to pancreastitis?
Acinar cell damage leads to early conversion of trysinogen to trypsin and local digestion
218
There are three phenotypes of DIC what are they and what is the underlying pathophysiology?
You can have high fibrinolysis (bleeding) or high thrombosis (clots). The former usually seen in malignancy particularly haematological and results in bleeding, the latter in sepsis (and results in organ failure due to microvascular thombi). If however you have both you get massive bleeding and a consumptive picture. You can have a little bit of either which is termed pre-DIC
219
What does Pre-DIC look like and is it worth treating
Difficult to identify but it is worth treating
220
What is the scoring system for DIC and what values are included?
ISTH overt-DIC
| Plt count, D-dimer, PT and Klauss
221
When is heparin given in DIC?
When microvessel thrombosis dominates, not when someone is bleeding. Small RCT favours LMWH with Xa measurements
222
What should be done with VTE prophylaxis in DIC?
Cont it
223
GIven DIC is partly microvessel thombi can you give TXA?
Yes if the bleeding/major bleeding phenotype
224
What is the untreated mortality of TTP?
90%, even with treatment the mortality is still 50%, half of which in the first 24hrs of presentation
225
TTP can be congenital and acquired, what does ADAMTS13 do that makes its absence pathognomonic?
ADAMTS13 cleaves ultra large vWF, if it's absent then the ultra large structure causes massive shear forces and major platelet activation and aggregation in all organ systems
226
What is the pentad of TTP symptoms and signs? What are its short comings?
Thrombocytopenia, MAHA, neuro symptoms, renal impairment and fever. 35 % of people don't have neuro features at presentation and fever and renal impairment are variable.
227
If you are convinced you have TTP but early need for RRT what may be the alternative diagnosis?
Unusual for TTP to need RRT straight away, consider HUS
228
Whats issue with not being able to use pupillary reflexes in brainstem death testing?
Its the only mid-brain nerves we test
229
Apart from pentad of signs and symptoms of TTP what other issue can the patient have?
Abdo pain from mesenteric ischaemia
230
What is seen on blood film in TTP?
Schistocytes
231
Why test troponin in TTP work up?
Sinister sign of coronary occlusion and is a leading cause of early death
232
What can cause a false positive ADAMTS13 result?
Activity usually low <40% but >5% in uraemia, sepsis, post op, pregnancy
233
What viruses do you look for in TTP workup?
Autoimmine screen and also HIV, HAV, HBV and HCV
234
When is TTP particularly difficult to diagnose?
Post-partum, 25% of all TTP is pregnancy related. Seems to be more neuro involvement and less renal cf HUS
235
Which drugs should be avoided in TTP because they may be the cause or ppt another attack?
Quinine and oestrogen containing OCP
236
Which cell type of malignancy is most associated with TTP
adenoca
237
What is treatment for diarrhoea +ve HUS and diarrhoea -ve
D+ve is supportive +/- RRT secondary verotoxin
| D-ve is similar to TTP and is treated with PEX and eculizumab
238
What dose of steroid would you give alongside PEX in TTP?
1g Methylpred BD for 3/7 or 1mg/kg/d pred
239
When is Rituximab considered in TTP?
If neuro symptoms on admission
240
What is the tira of HUS?
MAHA, thrombocytopenia and renal failure
241
Do you need a PPM if you have a sinus pause during sleep test for OSA?
No it is usually reversible as long as no symptoms
242
Which AV blocks require PPM?
3rd degree and any second degree with symptoms even if the bradycardia is iatrogenic because of meds needed for something else.
Also any AV block that has a pause >3s even without symptoms or any escape rate <40 even if asymptomatic
243
If you have 2nd or 3rd degree HB with AF when would you insert PPM?
If you have a pause of 5 or more seconds
244
What about a PPM if AV block only present during exercise?
Yes, PPM needed as long as there is no inducible ischaemia
245
What is pacemaker syndrome?
No universal definition but is the loss of improvement in symptoms due to the pacemaker. Used to be single wires cause AV dissassociation and retrograde flow. Now can happen if threshold for capture changes (usually in A lead as we would notice if the V lead stopped doing its thing). This leads to the same thing, AV dissassociation
246
Is PPM needed in 1st degree HB?
Not usually but if PR>0.3s then yes
247
If you have a bundle branch block is PPM indicated?
No unless the bundle branch block is alternating the caveat being that you must also be asymptomatic. If symptoms for any weirdness then PPM should be considered
248
If you're post MI and have a transient 3rd or 2nd degree block what should be done?
As EP study may be needed + PPM or simply a PPM
249
Carotid sinus becomes more sensitive with age and may ppt syncope, when would PPM be advised?
When pause >3s or sig bradycardia from spont carotid pressure or on tilt table
250
When would you use overdrive pacing?
When someone has SVT or VT that is demonstrably terminated by overdriving after ablation and drugs have failed
251
When is cardiac resynch therapy indicated?
Someone who is NYHA III or IV with LVEF<35% and QRS>0.12s and SR (class I), and AF (class II recommendation). CRT with or without defib is equal though with defib may be better we don't know. If you're putting in a PPM for something else and the above applies by NYHA I or II CRT should be considered
252
When is PPM useful in HOCM?
If given with a small AV delay the LVOT gradient is reduced (most useful if grad >30mmHg at rest or>50 on exercise) and even when pacing removed it persisted meaning remodelling may have occurred. That said subsequent RCT showed ++ placebo effect and no objective correlation
253
What are the class I indications for ICDs
Anyone who survives a VF or VT arrest/instability if no completely reversible cause
Structural heart disease if VT even if stable
VT on ESP but unexplained symptoms
LVEF<35% with MI after40 days if NYHA IIor III or <30% and NYHA I
Non ischaemic DCM with EF<35% and NYHA II or III
254
What are the main differences between child and adult airways?
Children- narrowest point immediately below vocal cords and is most open in the neutral rather than head tilt position. Children have larger tongues and nasal passages are smaller
255
If you are a lone resus responder to an arrested child what should you do? Why is that different to adults?
Check for signs of life if safe, then give five rescue breaths and check for life again. If not then do 1min CPR before going to get help.
Adults you should go for help before CPR because you need a defib
256
What drugs are most likely to cause long QTc?
Anti-dysrhythmics class Ia and III are most likely. Sotalol (and quinidine) causes Torsades in 2-4% of patients receiving it. Amiod does prolong QTc but TdP is unlikely
257
Amiodarone causes long QT as often as Sotalol (2-4%) why do we use Amiodarone and not really Sotalol?
Sotalol degenerates into TdP, Amiodarone less so
258
Give some drugs commonly used in ICU that cause long QTc
```
TCA and SSR
Cipro, Erythro (etc), metronidazole,co-trimox
Haloperidol
Ondansetron
Dexmetatomidine
```
259
What size molecules down haemodialysis filter?
Small molecules
260
What size molecules does haemofiltration filter?
Medium and large molecules using convection
261
What are the characteristics of drugs that are more easily cleared by RRT?
```
Vol dist <1l/kg
Low protein binding
High water solubility
up to 40kDa (only 500Da by dialysis)
low endogenous clearance (<4ml/min/kg)
extraction ratio exceeds endogenous elimination
```
262
What common toxins can be cleared by RRT?
```
Salicylates
Li
Theophy/Aminoph
Alcohols
Ethylene glycol
Some BB (sotalol, atenolol)
Anticonvulsants (cabemaz, phenytoin, Na val)
Abx- most B lactams, aminoglycosides and metronidazole
metformin
MTX
paraquat and mushroom toxin
```
263
What is a common definition of major trauma?
ISS>15
264
What is the estimated blood loss for each class of haemorrhagic shock?
Class 1-4
1. <750ml (<15%)
2. 750-1500 (15-30%)
3. 1500-2000 (30-40%)
4. >2l (>40%)
265
How does HR vary in haemorrhagic shock for each class (in general)?
Class:
1. <100bopm
2. 100-120
3. 120-140
4. >140
266
What classes of haemorrhagic shock generally have hypotension?
Class 3 or 4
267
What RR would you expect in each class of haemorrhagic shock?
Class 1 normal
2 20-30
3 30-40 and class 4 >40
268
What are the main risk factors for a significant (>2g Hb drop with transfusion requirement) in ICU stress ulcers
```
48hrs ventilated for resp failure (OR 15.6)
Coagulopathy (OR 4.3)
Other causes are:
head injury
spinal trauma and polytrauma
Major >35% burn
renal/hepatic failure
severe sepsis/shock
Organ transplant
Steroids
Previous ulcer
```
269
What are the strong inhibitors of cytochrome p450 with regards to warfarin?
Fluconzole
270
In SAH what BP should you aim for?
BP<160
271
What is the advantage of coiling SAH over clipping?
If both technically possible then coiling increases the rate of independent survivors by at least 7 years!
272
Should TXA be used in SAH if coiling is delayed?
Yes but side effects outweigh benefits if started after 48hrs or if cont for more than 72hr
273
How does Nimodipine reduce neurological deficit in SAH>
Vasospasm is no reduced, the effect is through another unknown mechanism
274
Phenytoin not recommended as prophylaxis in SAH but what duration of non-phenytoin agent is allowed?
3-7 days
275
How do you calculate a child's weight based on age between ages 1-5(APLS calculation) What weight would you expect for a 4 year old?
weight= (2xage)+8
| Therefore 16kg
276
How do you calculate weight when 1-12 months?
| and 6-12 years?
1-12 months 0.5*age in months +4 kg
6-12 3*age +7
277
What is the simple weight for age calculation the resus council advocates?
(age+4) x2
278
What defib energy is used in children?
4J/kg
279
how calculate ETT size in children?
| And insertion length?
age/4 +4
| Length (age/2) +12
280
What bolus of crystaloid is given in trauma and non-trauma in children?
trauma 10ml/kg
| non-trauma 20ml/kg
281
What is the dose of adrenalin for children?
10microg/kg
282
What dose of Fentayl used in children
1-5microg/kg
283
Which blood group is considered the universal receipient?
AB patients as they have no ABO antibodies
284
Patients who are Rh + can have Rh -ve blood but who should preferably not?
Women of child bearing age
285
If you are blood group B which blood types can you receive?
O and B
286
What are Duke's major criteria for IE?
Major and minor
| Major- positive blood culture typically causing IE (HACEK) from two sources 12 hours apart, positive TTE
287
What constitutes a positive TTE for IE?
Oscillating mass on a valve without an alternative anatomical explanation or abscess seen
New partial dehiscence of prosthetic valve
New regurg
288
What are the minor Duke's criteria for IE?
Heart condition or IVDU that makes it likely
Fever >38
vasc phenom- Janeway, pulm infarcts/mycotic, splinters
Immunological- GN, Osler's, Roth spot
micro or TTE not fulfilling major criteria but fit
289
When is proning useful in ARDS?
When PF<150
290
How long should someone be proned if it is deemed a useful intervention?
16-18hrs
291
Which pathologies are more likely to benefit from prone positioning?
Those with dependent consolidation and diffuse alveolar collapse. Fibrotic conditions are less likely to respond
292
What are reported complications of prone positioning?
Airway- loss, obstruction
loss of CVC etc
Hypoxia and haemodynamic instablity esp on turning
Facial oedema and pressure injuries/nerve injuries
Retinal/corneal damage
293
According to KDIGO guidelines what are the referral criteria to renal?
AKI, GFR<30, ACR>300mg, red cell casts, CKD +HTN on 4 agents, Persistent K+ abnormalities, recurrent nephrolithiasis, hereditary kidney disease, >5 reduction GFR per year
294
Define CKD
GFR<60 for >3/12 +/- ACR >30mg/g, histological/structural abnormalities or tubular disorders that cause electrolyte imbalance
295
What affects amount of fluid removed in PD? And the number of larger molecule?
Fluid removal depends on electrolytes in PD fluid
| The dwell time dicates how many large molecules are removed
296
Complications of PD?
Over or under hydration
Raised abdo pressure- hernias,orthopnoea
Also adhesions, sclerosis and peritonitis
297
What is the mortality of peritonitis secondary PD? How is it defined?
```
Mort 3.5-10%
Two of
signs/symptoms
WBC >100 per ml of effluent with >50% neuts after 2 hour dwell
Positive dwell culture
```
298
What organisms cause peritonitis in PertonealD?
coag neg staph (30%)
gram -ve
S.aureus
299
What are the constituents of post-cardiac- arrest syndrome?
Anoxic brain injury- worsened by hypotension, pyrexia, hyperglycaemia
Arrest related myocardial dysfn- all patients regardless of underlying cause
Reperfusion injury/ischaemia- SIRs immune pathways activate and adrenal suppression. Vasoregulation is lost and microcirculation clots. Un-coupling of oxidative phosphorilation
300
Which electrolyte contributes most to resting membrane potential
K+
Every cell membrane has a potential of about 70mV
K+ has the greatest intra-cellular concentration and the greatest permeability at rest
301
What is the intra-cellular concentration of Na, K, Mg, Cl, HCO3-
```
Na 15
K 150
Mg 0.5
Cl 10
HCO 15
```
302
What are the risk factors for getting contrastinduced AKI?
CKD, DM, HTN, heart failure, age, volume deplete, use of nephrotoxics, recent contrast
303
What treatments reduce contrast-induced AKI?
IV hydration Na2HCO3 or 0.9% NaCl is most evidence based +/- NAC PO (not IV because of anaphylaxis risk) and use of iso or low osmolar contrast
weak evidence for theophylline but given side effects not recommended in the guideline
304
What is the process of deciding if someone should go to a MTC?
If they have any of the pre-hospital trauma triage tool outcomes and the MTC is within 45min
305
What is on the pre-hospital trauma triage tool?
Abnormal physiology- low GCS, RR high/low, BP <90
Anatomical- penetrating, chest injury with abnormal physiology, bone(pelvis/ >1 long bone, open skull, crush
Mechanism- fall >6m Ad, >3m Child, car (intrusion, ejection, death of other), vs ped/bike (>20mph, thrown over vehicle), motorbike >20mph, burns.
Those likely to bleed
306
How does the ISS score?? Over which score should mean MTC involvement?
1->75
| Over 8 should be MTC and major trauma >15, mod 9->15
307
What is the triad of DKA?
Ketone >3mmol/l (2+ ketostick)
Gluc >11 or known DM
Bicarb <15 +/- pH <7.3
308
What are the high risk groups in DKA?
<25yrs, elderly, preg, heart/renal failure
309
When and at what rate is 10% glucose added in DKA?
When gluc <14 start 10% glucose at 125ml/hr
310
What is the dose of the fixed rate insulin used in DKA?
0.1units/kg/hr up to 15units
311
What are the recommended correction rates for blood abnormalities in DKA?
Ketone dec by 0.5mml/l/hr
Bicarb inc by 3mmol/hr
Glucose dec 3mmol/hr
312
If the recommended correction rates for blood abnormalities in DKA aren't met what do you do?
Increase the fixed rate insuline by 1 unit/hr
313
What factors predict severe disease in DKA?
```
pH<7.1
HCO3 <5
Ketone >6
K <3.5 on admission
GCS <12
O2 <92%
SBP <90
HR >100, <60
AGap >16
```
314
Which NMBD is most likely to cause histamine release?
Atracurium
315
What happens in CO poisoning?
CO with high affinity causes left shift of dissociation curve further impairing O2 offloading. CO also competitively impairs mitochondrial enzymes impairing O2 utilisation
316
What % CO poisonining is symptomatic and likely to cause coma?
<10% ok
10-50% headache, visual disturbance etc
>50% coma
317
What is the half life of CO? And if 100% O2 given to patient?
6 hours, 90min if 100% O2
318
If child comes in in status already on phenytoin at home and have had lorazepam what is the next drug?
Phenobarbitol 20mg/kg (the thio)
319
Why do femoral lines have the highest infection rate?
The density of skin flora is highest there. The caveat being that in children there is no greater risk of infection at the femoral site and more recent research has suggested the rates aren't higher
320
How often should clear and gause type CVC coverings be changed and with what?
use chlorhex every 7 (clear) or 2 days gause)
321
What is the minimum frequency for changing caps and administration sets for CVCs?
72 hours minimum, any more will cause infection
322
How often should giving sets that contain blood/lipids be changed?
Every24 hrs
323
Are sututres advised or not for CVC placement?
Teh recommendation from the guidelines is to use a securing device but the risk of CVC falling out should be balanced
324
What conditions have raised Hb transfusion targets and what are the individual targets?
Ischaemic stroke (>90), TBI (90), SAH (80-100), ACS (80-90), early stages severe sepsis with evidence of tissue hypoxia (90-100)
325
What are the components of CHA2DS2VASc score? When is anticoagulation advised?
CCF, HTN, Age (65 (1)-74 (2)), DM, vasc disease (2 for stroke/TIA/VTE), female
Anticoag advised when one risk factor in addition to gender (>1 men, >2 women)
326
What are the factors in HAS-BLED the
HTN (>160), renal dysfn, liver disease, prev stroke, prev or maj bleeding, unstable INR, Age >65, NSAIDs/anti-plt, EtOh/drugs
327
What do the scores for HASBLED mean in terms of bleeding?
score 0 is 1% risk over 1 year, score 1 its 3.5%, score 3 6%, score 5 9%
328
Who is at risk of dying from asthma attacks?
prev ventilation, recent admission or recurrent admissions, heavy use B2 agonists, emotional/MH/ learning difficulties
329
What is the evidence behind using Mg in acute severe asthma?
Reduces intubation rate and improves lung function
330
What are the final line agents in acute severe asthma?
Aminophylline, montelukast, abx, heliox, nebulised furosemide- none recommended but have been studied. Case reports of Ketamine, inhaled anaesthetic
331
What are the three most common reaons people with HIV come to ICU?
Resp failure (30-40%), sepsis (15-20%), then very low numbers for neuro, cardiac or GI disease
332
What is the leading cause of resp failure in those with immunocompromise secondary HIV
PCP but also bacterial pneumonia and COPD are increasingly seen
333
What causes PCP?
An atypical fungus, thought to lie dormant in 20% of people
334
What CD4 count is required to see PCP usually?
<200
335
What are the typical CXR findings of PCP?
Up to 25% are normal but classically bilateral perihilar interstitial infiltrates that becomes more diffuse as the disease progresses
336
What is the first and second line treatement for PCP?
Co-trimoxazole +/- steroid (if hypoxic pO2 <9.2 on air) and second line dapsone and others
337
What is the steroid dose for PCP?
Pred 40mg BD for 5/7
338
When should HAART be started/restarted in PCP? Why not straight away?
Immune reconstitution syndrome could be fatal. Restart after 2/52
339
Can FAST be used to exclude haemorrhage in trauma?
No, whilst its PPV is good, its NPV is poor
340
When is a peritonealtap or lavage recommended in trauma (not that you would do it)
If there is a negative or equivocal FAST scan as there is a lower false positive for a tap so that would be first
341
What is first line for candidaemia in non-neutropenic patients?
Either fluconazole or echinocandin (caspo/Anidula)
342
What is the treatment for a candidaemia in a neutropenic patient?
Caspo/Anidulafungin
343
If you get a candidaemia what should be done with indwelling lines?
If not neutropenic it is the likely source and should be removed.
If neutropenic could have another source but consideration should be given to its removal
344
What investigatios are required in candidaemia?
Echo, Ophtal review (though less important), and USS renal for fungal balls (though would expect +ve urine cultures) which is more often seen in children.
345
Define AKI
An abrupt (within 48hrs), reduction in kidney fn with absolute increase in Cr >26.4 micromol/L or >50% increase or <0.5ml/kg/hr for 6 hrs urine output
346
What are the commonest causes of AKI in ICU?
Sepsis, major surgery, low CO, hypovolaemia/renal hypoperfusion, medications
347
What are the concentrations of NA, Cl, K Ca, Mg, acetate, bicarb, lactate and glucose in haemodialysis fluid?
Na 136-140, Cl 99-110, K 0-4, Ca 2.5, Mg 0.5-1, Acetate 2.5-5, bicarb 27-39, lactate 0, glucose 11
348
What is the cut off for using RRT for toxin removal?
If the removal can be increased by 30% or more then it is usually recommended
349
What are the classic toxins that are easily dialysed?
Li, Ethylene glycol, salicylate, paracetamol, ethanol, methanol, theophylline, carbamazepine
350
What is metabolised by CYP1A2?
Theophylline and Haloperidol
351
What drug inhibits CYP1A2 and may potentiate haloperidol and theophylline?
Ciprofloxacin
352
What drugs are metabolised by CYP2C9
Warfarin, phenytoin, voriconazole
353
What inhibits CYP2C9 and therefore potentiates warfarin, phenytoin and voriconazole?
Metronidazole, amiodarone
354
What does CYP2D6 metabolise?
Codeine, tramadol, haloperidol, metoprolol
355
What inhibits CYP2D6 and therefore potentiates codeine, tramadol, haloperidol and metoprolo?
Fluoxetine, Amiodarone
356
CYP3A4 is the big one in terms of p450s in ICU, what does it metabolise?
Fentanyl, clarith, eryth, warfarin, carbamaz, haloperidol, midaz, amlod, diltiazem, verapamil, statins, hydrocort, methyl pred, anti-retrovirals
357
What drugs inhibit and therefore potentiate drugs metablised by CYP3A4?
clari, flucon, amlod, amiodarone
358
What is the big inducer of enzymes p450 and therefore reduce efficacy od drugs?
Rifampicin, carbamazepine, phenytoin
359
What did the ISAT trial look at? How many patients and outcome?
Coil vs clips in SAH, 1k in each group followup at 2/12 and 12/12
23.7% vs 30.6% dead at one year in favour of coiling
360
What are the causes of intra-renal AKI?
Intrinsic renovascular - HTN, small vessel vasculitis, TTP/HUS
Glomerular disease- Goodpastures, post infectious GN etc
Tubulointerstitial- ATN (sepsis, contrast rhabdo, pro-longed pre-renal hypotension) or AIN (drugs)
361
What is the effect of ACEi and ARB on renal glormerualr afferent and efferent?
The efferent arteriole is preferentially afeced by these drugs. The inhibition of angiotensin II means the efferent arteriole dilates, this reduces the pressure at the glomerulus meaning GFR is reduced
362
How do NSAIDs affect kideny?
Prostoglandins vasodilate the afferent arteriole, NSAID inhibits this effect
363
How do Tacrolimus and cyclosporin affect the kidney
They constrict afferent and efferent arteriole through unknown mechanism
364
What drugs causses ATN classically?
Aminoglycosides
365
What drugs cause AIN?
Beta-lactam, co-trimoxazole, NSAIDs, vancomycin
366
What drugs cause crystallopathies in the kidney?
Aciclovir, cipro, MTX
367
Where is Renin secreted?
The juxtaglomerular cells in the afferent arteriole
368
How do you differentite between an AKI and ATN?
Fractional excretion of Na (excreted/filtered)
369
How does FE Na differentiate between AKI and ATN
Low in AKI, high in ATN (<1% pre-renal), >2% ATN not useful if diuretics used but can use FE urea in that situation
370
Where is acid excreted in kidney?
Distal tubule largely
371
What viruses are affected by aciclovir?
HSV and VZV
372
What disease is Ritonavir used for?
HIV
373
Ganciclovir is used in which condition?
CMV
374
What are the three drugs that affect influenza?
Influenza A, B and C. Flu A is the one that causes the problems
We have Oseltamivir, Zanamivir and amantadine (amantadine not recommended) The other two are equally effective so it comes down to cost
375
What are level 2 (moderatesly strong) recommendation for TBI?
Keep BP>90, ICP<20, but CPP>70 is bad, mannitol in emergency but hypertonic may be as effective with fewer side effects. Avoid pCO2 <3.3 prophylactically, barbiturates as last resort, prophylactic AEDs to reduce O2 demand during seizure
376
What is the only level 1 (strongest) recommendation regarding TBI?
Avoid steroids as increases mortality
377
What are the level 3 (weakest) recommendations for TBI?
SpO2 <90% avoided, CPP<50 is bad, can use hyperventilation to control ICP in first 24 hours
378
What is the evidence for therapeutic hypothermia in TBI>
Mixed data for prophylactic use but probably a role in rescue of a high ICP....doesn't make much sense to me though...
379
What are the two most likely causative organisms in IE?
S.Aureus (40%)
| Strep 33% (S. Bovis 10%)
380
What are the two main risk factors for developing IE?
Cardiac damage- valve replace or rheumatic fever etc and bacteraemia (dentition, IVDU, in-dwelling something, chronic infection)
381
What is first line abx for IE with a native valve?
Co-amox and Gent (Vanc Gent and Cipro for pen allergic)
382
What is the first line abx for IE in prosthetic valve?
Vanc, Gent, Rifampicin
383
What is the ARDSnet formula for predicted body weight given height?
Male - 50 + 0.91(height (cm) -152.4)
| Female = 45.5 + 0.91(height-152.4)
384
In a spinal injury what are the pre-requisites for the commencement of weaning?
FiO2 <0.4, lung compliance >50ml/cmH2O and VC >150ml, no pain awake and co-operative
385
What would be the biggest factor affecting clearance of a drug that is 98% protein bound and has a high hepatic extraction ratio?
Liver blood flow.
If low extraction ratio and high protein binding then clearance is dependent on protein binding
If low extraction and protein binding then hepatic enzyme fn predominates
386
What are the concerns about using bicarb in a met acidosis and when is it appropriate to use it?
Worry is that it makes breathing harder due to CO2 produced but also makes intra-cellular acidosis worse. If there acidosis is due to bicarb loss/non-production however then replacement is reasonable.
On balance pH<7.1 would mean bicarb is likely of use
387
What are the causes of a NAGMA?
Renal- RTA I, II, IV, carbonic anhydrase inhibitors or aldosterone antagonists
Extra-renal- TPN, Cl rich fluid, GI loss, Ileal conduit
388
How does an ileal conduit cause a metabolic acidosis/
Te urea is degraded but bacteria and the resultant NH3 and H+ are absorbed.
389
What does the area under the receiver operator curve of 0.5 mean?
Means the test, if positive (or neg in this case) has a 50:50 chance of being a true positive or a false positive
390
Where should an IABP be placed, what % of aortic diameter should it occlude and when does in inflate/deflate?
2-3cm distal to L subclav, 80-90% occlude aorta when up.
Inflate either on middle of T wave/dicrotic notch and deflates at start of R wave/ just before pressure comes up for systole
391
How does IABP improve CO?
reduced after load with reduced LVEDP and therefore LV wall tension therefore improving CO
392
When have IABPs traditionally been used?
In cardiogenic shock post MI
393
What did the IABP-SHOCK II trial study and show?
600ptsin cardiogenic shock post MI who were going for early revascularisation. No change in 30 day mortality or 12 month mortality.
394
What is the triad of acute liver failure?
Jaundice, coagulopathy and encephalopathy
395
What is the definition of hyperacute, acute and subacute disease in acute liver failure>
hyper <7days
acute 1-4 weeks
subacute- 4-12 (some say 6/12)
396
What are the commonest causes of liver failure?
70% is paracetamol overdose and presents as hyperacute
397
What are the Kings criteria for liver transplant if from paracetamol OD?
```
pH<7.3 with adeuqate resus
or lactate >3
or all of:
PT>100s
Cr >300
G3-4 enceph
```
398
What are the Kings criteria for liver transplant in non-paracetamol OD?
```
PT>100s or
any three of
age <10, >40
PT>50
Bili >300
enceph >7 days after jaundice
Unfavourable dises- non-HAV/HBV, DILI
```
399
What does a FIBTEM look for in ROTEM?
Estimates the effect of fibrinogen by activating cytochalasin D which is a platelet inhibitor
400
Whats the difference between TEG and ROTEM?
In TEG the cup rotates and the wire is dipped in. As the clot forms the wire moves more and more.
In ROTEM the wire moves and as the clot forms slowly starts to move the cup.
401
What is the clotting time and clotting formation time and alpha angle in TEG/ROTEM?
Clotting time is the time it takes for a clot to start to form.
Alpha angle is the rate at which the clot forms and the time it takes for the alpha angle to get to zero (clot formed) is the clot formation time
402
What does a HEPTEM and a FIBTEM measure?
HEPTEM- Heparinase
| FIBTEM- removes plt fn and only looks at fibrinogen
403
What are the signs of hyperoxia?
mild neuro signs, seizure (>2.8atm) but at normal pressures depends on time of exposure. Acute tracheobronchitis is earliest followed by starnal pain, coug and thick secretions, later diffuse alveolar damage
404
What are the potential benefits of hyperoxia in hyperbaric setting (not seen outside of this setting)
inc periphe VR, suppression of inflamatory process, anti-microbial effect esp on anerobic organisms, enhanced tissue repair
405
When does alveolar damage start if FiO2>0.5?
after about 48hrs
406
Why may surgery precipitate a thyroid storm and how would it manifest?
Stress response from infection/trauma causes additional thyroid hormone to be released.
Manifests as pyrexia, tachycardia and HYPOtension. Hypertension is possible but only sometimes. Usually go into AF and get diarrhoea
407
How do you treat a thyroid storm?
Correct fluid loss, and glucose
Carbimazole (reduces T3/T4 production), propylthiouracil (reduces converstion of T3/T4 peripherally) and Propranolol for sympathetic effects.
May need active cooling and Dantrolene 1mg/Kg may be useful
408
What other medications should you be careful of in thyroid storm?
Mostly protein bound so anything that competes with that eg aspirin will make things worse
409
What dose of propranolol do you give in thyroid storm and repeat every how many min?
1-2mg bolus every 10-15min
410
Why use propranolol in preference to other BB in thyroid storm?
It also prevents peripheral conversion of T4 to T3
411
What is the evidence for NIV in ECOPD?
Halves mortality with NNT 10
412
When should NIV be offered in exac COPD?
If after starting standard therapy remain acidotic and pCO2>6 after 1 hr
413
What are the contr-indictions for NIV?
Coma or moribund, ++ secretions, vomting, undrained PTX, UGI surgery, facial trauma burns
414
If unsure where the gastric balloon is on a Sengstaken tube what do?
50ml air or contrast and XR to see where it is
415
At what OG distance would you expect the GOJ?
about 38-40cm
416
What weight should be applied to a Sengstaken tube>
either 500 or 1000ml bag
417
How do you inflate the oesophgeal balloon in Sengstaken
If present inflate with air until 35-40mmHg reached, this should be deflated every 2few hours to check if bleeding on going. The risk is necrosis
418
What is the Goldman RIsk Index used for?
For cardiac complications from non-cardiac surgery
419
Define NYHA classification
NYHA 1 -normal
2- mild impairment
3- comfortable only at rest
4- symptoms all time
420
According to surviving sepsis, in septic shock how much fluid should someone get before you admit defeat and start pressors?
30ml/kg
421
Who should get an ICP monitor?
Those with a chance of survival, GCS<9 and CT proven TBI
422
When shouldan ICP monitor be placed if CT head normal?
If two of age>40, BP<90,abdnormal posturing
423
What drugs can cause acute pancreatitis?
Na Valproate, metronidazole, steroids, cisplatin, furosemide, azathioprine, NSAID, statins
424
If someone has secondary PTX for >72 hrs where should they be referred?
Surgeons for a pleurectomy
425
What is the cutoff for large/ small pneumothorax?
>2cm at level of hilum would be large
426
In PTX the surgical options are a open pleuretomy and a VATS led pleurectomy, what are the recurrence rates for each?
1% open, 5% VATS
| Medical pleurodesis in those not fit for surgery but inferior to both
427
Why do we use prasugrel and ticagrelor in preference to clopidogrel?
More potent and more reliable that clopidogrel
428
When can you not use Ticagrelor?
Haem stroke in past, mod hepatic dysfn
429
What is the alveolar gas eqn?
P(alveolar)O2=FiO2(P(atm)-P(H2O))-p(blood)CO2/RQ
Where at 37C and normal diet reduces to
PAO2= FiO2(101-6.25)- PaCO2/0.8
=FiO2(94.75)-1.2*PaCO2
430
How is respiratory quotient defined?
Vol CO2 released/Vol O2 absorbed during respiration of a particular food
431
What are the two tests for capacity?
Test if there is a disturbance of mind/brain and if so does it impair their ability to make the specific decision?
432
When can a lasting power of attorney speak as the patient on medical matters?
If the ability to make life-sustaining treatment decisions has been specifically noted within the agreement
433
What are the markers of decompensated liver cirrhosis?
ascites, varceal bleeds, encephalopathy, jaundice
434
What is the median survivl for a compensated cirrhotic liver disease patient and one who has decompensated?
12 years median if compensated, 2 years if decompensated. 5-7% decompensate per year
435
What is the best score to use in prognosis of hepatic cirrhosis?
Child-Pugh
436
What is the AUROC (sensitivity) for APACHE III, IV, ICNARC 2007, SAPSII and MPMIIo?
```
III- 0.9
IV - 0.88
ICNARC - 0.87
SAPSII- 0.86
MPMIIo- 0.82
```
437
What is the best measure of deterioration in neuromuscular disease like GBS?
Vital capacity
438
What is thought of as a good volume that predicts the need for intubation in GBS or similar with regards FVC?
15-20ml/kg or reduction of 30% from baseline
439
Why is vasopressin thought superior to NA in the DBD patient?
ICS guidelines state less likely to cause pulmonary HTN and metabolic acidosis.Not sure if I'm sold.
440
What is the usual history of hypercalcaemia?
Short history of renal, neuro and abdo symptoms
441
What % patients get delayed ischaemic injury in SAH?
60%
442
Vasospasm causes delayed ischaemia in SAH mostly between days 4 and 14. Occurs in 70% but only half have signs (does that mean we undertreat?) How can trans-cranial doppler be used to diagnose?
Flow velocity >120cm/s or ratio >3 between MCA and ICA
443
What % of patients get hydrocephalus post SAH?
20-30%
444
How do you differentiate between CSW and SIADH?
Two ways clinical difference is volume state (Eu/hyper in SAIDH and hypo in CSW) and oliguria in SIADH and polyuria in CSW
445
Once HypoNa corrected how best to differentiate between CSW and SIADH?
FE of Urate is the best, if >11% post correction then CSW if returns to normal 4-11% then SIADH
446
Which is best, NG or NJ feeding in pancreatitis?
Both equal but obv NG easier to achieve, TPN should be used in those intolerant but is inferior
447
What is a parametric statistical test?
That which is applied to a normal distribution (non-parametric being a skewed distribution)
448
What test is used in qualitative data when<10 data points and >10 data points?
<10 Fisher's exact test
| >10 Chi squared
449
What stats test in quantitative data when parametric and non-parametric?
Parametric (normal dist) Student's T-test
| If non-para- Mann-Whitney U test
450
If you have a parametric and non parametric dataset with quantitative multiple groups which stats test is best?
Paramet- ANOVA
| Non-para Kruskal-Willis
451
If a paired dataset (same people before and after intervetion) what stats test would you use?
Para- paired-t or ANOVA
| non-para- Wilcoxon signed rank
452
What electrode is used to detect CO2 in ABG machine?
Severinghaus
453
What electrode measures the partial pressure of O2 in a liquid?
Clark
454
How is pH measured in ABG machine?
silver/silver chloride electrode within a buffer is referenced against a Calomel electrode
455
How does a CO2 electrode work?
Its a silver/silver chloride electrode protected by bicarb solution. The CO2 diffuses across much like the BBB and changes the pH of a known solution therefore you know the CO2
456
What does a paramagnetic analyzer measure?
Found in ventilators and measures O2
457
In APACHE score what makes up the majority of the score?
65.5% is acute physiology, followed by 16.5% chronic health, 5% age, 9.4% admission source, lengthof stay 2.9% and need for IPPV 0.6%
458
Does Mg have a role in phaeochromocytoma?
Yes, improves stability
459
What did the MAGPIE study find?
Reduced rate of eclampsia with use of Mg in those with severe pre-eclampsia or eclampsia
460
What is the treatment for Eclamptic seizure?
4g over 5min Mg follwed by 1g/hr for 24 hrs. If recurrent seizure give 2-4g additional Mg
461
How does magnesium exert its analgesic effect?
It is an NMDA antagonist
462
Which NMBDs are metabolised by plasma cholinesterases?
Sux and mivacurium (can inc or dec in preg and liver disease)
463
How is atracurium and cis-atra degraded?
Hofmann degredation, therefore limited by temp and pH
464
What about a clinical history confers a poor prognosis on OOHCA?
Factors that increase time to ROSC and initial non-shockable rhythm
465
What are the neurophysiological investigation outcomes that are poor prognosis in OOHCA?
Isoelectric baseline on EEG or burst suppression/refractory status after 72 hrs, absence of SSEP >72 hrs if cooled, >24hrs if not
466
Which biomarker is best (though not good enough to be used in isolation) in OOHCA?
Neurone specific enolase
467
What is the most clear cut sitation in OOHCA on day 3 post rewarming and ensuring nothing else could be causing the problem
M1-2, no pupil/corneal reflex and bilateral absent SSEPs. If not met then repeat after 24hrs
468
If the criteria of M1-2, no pupil/corneal reflex and no SSEPs not met after 72-96hrs in OOHCA what are the other components of poor prognosis?
Two of
myoclonic status <48hrs post ROSC
High NeuroneSpecificEnolase levels 48-72hrs post ROSC
Unreactive malignant EEG
Diffuse anoxic injury on CT <24hrs or on MRI 2-5days
469
If synced DCCV fails in AF with compromise what do you do?
Inc from 100 ->150J and if still noting given 300mg Amio and try again after 15min
470
Which recreational drugs can cause serotonin syndrome?
Ecstacy, cocaine and LSD
471
What is the major differentiating factor between NMS and serotonin syndrome?
Onset- SS usually hours, NMS in days to weeks
472
Which common drugs sshould be avoided when treating serotonin syndome?
Tramadol, fentanyl and ondansetron
473
What serotonin antagonist can be used as last ditch attempt in serotonin syndrome?
Cyproheptadine (only eneteral preparation available)
474
When should a CT head be done within 1 hour of presentation?
```
>1 episode of vomiting
GCS<13
GCS <15 2 hours after injury
Likely skull fracture
Seizure
possible base of skull
focal neurology
```
475
If someone is well after a head injury but takes warfarin how long do you have to do the CT head?
8 hours
476
What complication of heparin confers the greatest risk of death?
type 2 immune mediated thrombocytopenia (HIT-2)
477
What types of HIT are there?
HIT 1 and 2, type 1 is non-immune medated and occurs within a few days and resolves without stopping heparin. Type 2 is immune mediated so takes longer to develop 4-14 days (sooner if previous exposure) and confers the risks known with HIT
478
What is the HIT scoring system?
'4 T's'
Thrombocytopenia- 0 points <30% reduction, 1pt 30-50%, 2 >50%
Time to thrombocytopenia- 0pts <3days no prev exposure, >4 days but uncertain 1 pt, 5-10days 2pts
Thrombosis?- 0pts none, 1pt, suspected, 2pts definite
Other possibility? 0pts definite 1pts maybe, 2pts none
479
Other treatments for anticoagulatoin if HIT develop are what?
Danaparoid (Xa inhib), Fondapariunux. Interestingly, they also cause heparin antibodies but not HITs
480
How do you change the resonant frequency of an arterial BP circuit?
Use a shorter or fatter cannula to change the resonant frequency away from 40Hz
481
Define pre-eclampsia
HTN after 20/40 gestation resolving within 3/12 of delivery with SBP>140 or DBP>90 on two occasionals >4 hrs apart or >160 or >110 on one reading plus one of
>0.3g/24hr urine protein
AKI
liver disease- epigstric pain, liver tenderness, abnorml LFT
Neuro- seizure, visual disurbance
Haem- haemolysis, low plt, DIC
IUGR
482
When is pre-eclampsia severe?
SBP >160, DBP >110
483
Risk factors for pre-eclampsia?
```
prev pre-ec
older mother and mother<20
multiple preg
high BMI
protein C and S deficiency
Facor V leiden
hyperhomocysteinaemia
```
484
What to pre-eclamptics die from?
ICH and pulmonary oedema (seizure)
485
What is the causative organ of pre-eclampsia?
placenta
486
There is an early and late pre-eclamptic phenotype, whilst they are likely to be both present in varying derees within one woman what is the pathophysiology of early pre-eclampsia?
Nobody really knows but oxidative stress of the syncytiotrophoblast (cells that are the blood/placenta interface) is one hallmark. If stressed pro-inflammatory cytokines and free foetal DNA is leaked into the maternal bloodstream. This is due to a blood/demand mismatch through defective remodelling of the placental spiral arteries
487
What is the draw back of irradiated RBC?
Shorter shelf life and more K+, enough to cause death in massive transfusion
488
What are the hunter seretonin toxicity decision rules?
1. if spont clonus then Seretonin syndrome
2 else if inducible clonus and agitiation/sweating->SS
3. Else if occular clonus +agitated/sweat->SS
4. Else if tremor +hyperreflex->SS
5. Else if hypertonic+T>38+ occular/inducible clonus->SS
6. Else not SS
489
What are the crieria for CT within 1 hour at risk of c-spine injury?
```
GCS<13
Has been intubated
plain XR not good enough
Urgency-prior to surgery
Having other areas scanned
Stable patient but >65, dangerous mechanisms of injury, focal peripheral neurology, parasthesia in UL
```
490
What counts as a dangerous mechanism of injury with regards C-spine injury?
Fall >1m
Fall 5 stairs
Axial load to head (RTA, rollover, ejection, off-road accident)
491
What does CONSORT stand for?
consolidation standard of reporting trials
492
What does QUORUM stand for?
Quality of reporting of meta-analyses
493
What does MOOSE stand for?
meta-analysis of observational studies in epidemiology
494
What does SQUIRE stand for?
Standards for quality improvment reporting excellence (of course)
495
What are the top 5 hospital acquired infections?
```
Resp-23%
UTI- 17%
Surgical site infection 16%
Sepsis 10%
GI 9%
```
496
When should fixed rate insulin be given in HHS?
When glucose is not decreasing with fluid resus and ketones still >1
497
When do you change from 0.9% to 0.45% NaCl in HHS?
When blood osmolality stops falling, aim 250-500ml/hr for 12 hours, deficit may be 20L
498
When should HHS be considered for ICU/HDU?
Biochem-Os >350, Na>160, pH<7.1, abnormal K, Cr>200
| Clinical- GCS<12, O2<92%, BP<90, HR abnormal, Urine <0.5ml/kg/hr, hypoT, macrovascular event (stroke,MI)
499
What variables does the MDRD (modification of diet in renal disease) calculation consider when calculating eGFR?
Sex, Cr and ethnicity
500
Define delirium
an acute fluctuating disorder of consciousness and cognition which is reversible
501
What are the risk factors for developing delirium in ICU?
dementia, alcoholism, HTN and severity of illness at admission
502
What are the parts of a CAM ICU screen?
if acute change in last 24 hours
Inattention- Squeeze hand on each A of SAVEAHAART if >2 errors (where squeeze or no squeeze incorrectly is a mistake) then do RASS.
If 0 ask 4 disordered thinking questions
503
What is the mortality associted with fever in neutropenia (without sepsis)
15%
504
What is beta-D-Glucan?
Its a component of fungal cell wall but is quite non-specific
505
Cause false +ve BDGlucan?
surgical gause, GI leak
506
What is Galactomannan
Its part of the cell wall of Aspergillus
507
What is the classic aspergilloma CXR appearance?
Ball with a crescent of air around it
508
Whats does ADAMSTS13 do?
Cleaves ultralarge VWF to normal VWF, if UL VWF is left in the circulation then it causes microthrombi and clot everything off
509
How long do you have to start plasmaexchange if TTP
4 hours idealy but up to 8
510
What is Caplacizumab?
Used in TTP, stops VWF binding with plt and improves plt count quickly. Now approved by NICE
511
Why does plasma more likely cause TRALI?
Anti-leucocyte ab in plasma
512
Why use heparin CVVH in tumour lysis?
The hyperPO4 will ppt with Ca and perhaps cause more problems than is solves
513
Causes of isolated raised APTT?
Lupus anticoag, factor XII, XI, IX, VIII deficiency, Heparin
514
In massive transfusion when should factor VII be considered?
When 10PRBC, 8FFP, 2Plt, 2 Cryo and triangle of bleeding is corrected as much as possible. 10% coronary artery thrombus rate in >65
515
What is FEIBA?
Factor eight inhibitor bypassing activity is the original PCC with II, VII, IX and X but only small amounts of activated components apart from VIIa therefore used in haemophiliacs
516
Why is novoseven used in preference to FEIBA in acute setting?
Half life of FEIBA shorter so chance of re-bleed higher if you don't get the dosing exactly right
517
Why do you not add allopurinol to rasburicase?
It increases LOS and hospitalisation costs
518
What are the main physiological changes of pregnancy?
A- laryngeal oedma
B- splint diaphragm low FRC
C- CO x2 by term, increased circulating volume, aorto-caval compression after 20/40. Placenta 10% of CO
E- pH in stomach lower increasing risk of aspiration, lower oesoph sphincter relaxes
519
What is the best scoring system for predicting maternal outcome if admitted to critical care?
CIPHER, though not used much
520
What are the factors that make up the maternal CIPHER mortality prediction calculation?
Admission following surgery, external transfer, highest T, highest Cr, highest HR, highest RR, highest WBC if mech vent, lowest Hb, lowest plt
521
How is HELLP defined?
Haemolysis- LDH>600, TB >20
Elevated liver enzyme- ALT>70 (AS/GGT>70)
Low plt- <100
522
What are the classes of HELLP?
Class I, II and III
523
Which is the most severe form of HELLP? Class I or III?
Class I is worst with 40-60% morbidity
524
How is class I, II and III HELLP defined?
```
Haemolysis is universal- LDH>600
Liver enzymes- >40 in class III, >70 in the other classes
Platelets seem to be more important, 100-150 in III, 50-100 in II and 0-50 in I
```
525
Are steroids used in HELLP?
Used to be but after Cochrane review have fallen away
526
When is eclamptic seizure most likely to present?
Post partum (usually within 12 hours of delivery) 44%, 38% antenatal and 18% intrapartum. 20% have no diagnossi
527
How do you treat magnesium toxicity in cardiac arrest? Say someone in obsterics with eclampsia?
Stop infusion and give calcium chloride/gluconate
528
What are the two physiological phases of amniotic fluid embolus?
First is vasoactive substances causing massive pulm HTN then later it causes LV failure which puts you at risk of pulm oedema
At the same time the circulating vasoactives cause uterine atony and coag factor consumption leading to massive haemorrhage through DIC
529
What % cases of amniotic fluid embolus lead to seizure?
10-50%
530
What are the risk factors for amniotic fluid embolus?
Older mother, induction of labour, fast labour, operative delivery, abruption, IUfoetal death
531
Whats the triad of symptoms in amniotic fluid embolus?
Not useful at all
| Hypottension, hypoxia, coagulopathy...good luck spotting coagulaopathy!
532
What are the four Ts of primary (<24hr) and secondary (>24hr) post partum haemorrhage?
Tone-atony
Trauma- intruments/delivery itself
Tissue- retained clots/placenta
Thrombin- coagulopathy
533
Whats the defn of major obstetric blood loss?
>1L for RCOG, but other sources suggest 1.5L no real consensus. Point is circulating volume goes up in pregnanc likely for this very reason
534
Can TXA be used in maternal haemorrhage?
Yes, WOMAN trial showed decreased mortality give1g if >500ml vaginal or 1L caesarean delivery
535
What is the dose of syntocinon to improve uterine contractility if there's bleeding?
5 units +5 units + infusion
| Causes hyptension so inject slowly
536
What frequently accompanies peri partum cardiomyopathy?
Most have it before delivery but name persists.
| Thromboembolism
537
What is the outcome for women with peri partum cardiomyopathy?
Half recover, half are left with a problem. 1.5% need mechanical support and 0.5% get transplant
538
What do pregnant mothers die from?
Cardiac disease 2 per100K followed by VTE 1.5/100K, neuro, sepsis, psych, haemorrhage is 0.5 per100K with others between 1.5 and 0.5
539
what is the most common reason for a still pregnant motherto be admitted to ICU?
Resp failure- still get CAP, flu, asthma etc
540
What is the most common reason for admitting a post-partum mother?
Haemorrhage
541
What do you do if a mother is on a Mg infusion and becomes oliguric?
Review the Mg as it may accumulate!
542
What are the risks with a maternal airway?
x8 risk of difficulty, increased risk of aspiration
543
What happens with breathing during pregnancy?
Increased MV secondary larger Vt, RR stable, reduced FRC of course
544
What are the segments of the RUL?
Apical, Ant, post
545
What does the bronchus intermedius divide into?
RLL and RML
546
What are the segments of the RML and RLL?
RML into two-medial and lateral, RLL into five superior and four basal- ant,post, med, lat)
547
What does the L main bronchus divide into?
LUL and LLL
548
What are the segments f the LLL?
Superior and 3 or four basal like RLL, ant, post, lat, medial
549
The LUL bronchus gives of LUL proper and lingula, what are the lobes of the lingula?
Sup and inf
550
What is the time and BP cut off for thrombolysis in stroke?
4.5hrs, BP >185/110 should be treated first (NICE), <180/110 from AHA
551
How long should aspirin be held if thrombolyse for stroke?
24 hrs
552
How does clonidine exert its effect?
Alpha 2 agonist which acts centrally to reduce exogenous NA
553
What is the maximum number of patients one registrar should be responsible for?
8
554
How many patients can a cons ICU be responsible for?
8-15
555
When does the ICS recommend you have one supernumerary nurse?
For every 10 patients
556
According to GPICS 2 how quickly should a consultant be available?
Within 30min
557
What infarct in particular benefits from ACEi?
Anterior ? why
558
What aldosterone antagonistsare recommended post STEMI?
Eplerenone if HF with EF<40% or DM. Spiro does not feature
559
When can verapamil/diltiazem be used post STEMI?
Not initially, useful if BB contraindicated
560
If acute UGIB what drugs do we give?
Blood, FFP etc as needed
Terlipressin-evidence for reduced rebleed and mort
Somatostatin (superior to octreotide) has been used but not common place
Abx- reduce rebleed and mort
561
Is intubating a potentially infectious patient in a side room recommended by epic3?
Yes but with huge caveat that it should not delay intubation if it is required. That essentially means no, unless they are already in one!
562
Which dugs are associated with pleural effusion?
MTX, phenytoin, amiodarone, BB, nitrofurantoin
563
Howwork up a pleural effusion?
BTS 2010 suggest if transudate treat cause, if exudate speak to resp and do a tap.
564
What is electrical alternans?
The axis of the heart changes wit each beat thought to be due to the heart moving within the pericardial fluid in tamponade
565
What are the four types of exravasation injury?
Vasoconstrictor, hyperosmolar (TPN), extreme of pH (amio, phenytoin) and cytotoxic
566
What type of extravasation injury can thiopentone, ketamine and atracurium cause?
All very alkaline so causes ischaemia
567
Which extravasations should you not spread and dilute?
Cytotoxic agents
568
Over what pH range is feeding allowed in NG tube placement?
pH<5.5
569
What can be done to try and get NG aspirate and avoid CXR?
Nurse on one side, move NG in or out by 20cm(!) and give mouth care to stimulate secretions
570
When is peripheral cannula ok for someone with TPN?
If <14 days and no need for central line otherwise
571
When is a tunnelled line for TPN recommended?
After 30 days or expected to need for more than 30 days
572
Which artery supplies the SA and AV node in 60 and 85% of population respectively?
RCA
573
How do you size and length an ETT in a paeds pt?
Size- (age/4)+4
| Length- (age/2)+12
574
What is Parkland's formula and how is the volume calculated adinistered?
Volume=weightx4xsurface area of burn
Half over 8 hours, the rest over 16
Useless in my opinion-need constant review, airway burns need ++ fluid
575
What wavelength is absorbed by CO2?
428nm
576
What are the major and minor risk factors for refeeding syndrome?
BMI<16 major,<18.5 minor
Weight loss over 3-6/12- 15% maj, 10% min
Day without food- 10maj, 5minor
Other- Low Mg, K, PO4 major, EtOh, diuretics, insulin, cehmo minor
577
How do you start feeding someone at risk of re-feeding?
5-10kcal/kg/day slowly increasing to requirement over 7 days
578
What is the evidence for paralysis in ARDS?
```
Study is if PF<150 to give for 48hrs.
If you get to the point where it may be useful, the initial data is in cis-atracurium strictly speaking though is probably a class effect
```
579
In a 16year old what is the most likely causative organism in meningitis?
Neisseria menand strep pneumonia
580
At what ages is Listeria covered for in meningitis?
<3/12 and >50
581
When is dexamethasone given in meningitis? What dose in kids?
0.15mg/kg max 10mg QDS given before or alongside the first dose of abx in all those >3/12 with suspected bacterial meningitis
Evidence in s.pneumonia.
582
If a trauma patient has a positive FAST scan and is unstable do you go to CT?
Group decision but the recommendation is no, go straight to theatre-not sure how you can make a recommendation on this
583
Above what level do you expect autonomic dysreflexia?
Above T6. Worse in higher and complete rather than incomplete transection
584
How does autonomic dysregulation work later on in spinal injury?
Sympathetic stimulus from pain/distended bowel/bladder is un-inhibited causing massive HTN below and vasodilatation above with reflex bradycardia
585
What drugs can be used prophylactically in autonomic dysreg?
Nifedipine and prazosin have been used
586
How do you treat someone with a hypertensive crisis secondary autonoic dysreg?
Sit them up and identify the cause of sympathetic stimulation.
Watch for complications- MI ICH..etc all pressure realted
Used short acting fast onset meds to control if BP>150. Hydralazine, labetalol, nifedipine
587
Why is Foscaranet a second line agent in HSV?
Is active aginst but can be toxic
588
What does Ribavirin treat?
HCV
589
What are the causes of encephalitis?
Can be infective or non-infective. Non-infective is usually autoimmune. Infection likely due to virus but can also be bacteria, fungi or parasite
590
Which HSV causes encephalitis?
Usually HSV 1 90% and HSV 2 10%
591
What does daptomycin and Tigecycline largely cover?
G+ve
592
What are the ESKAPE bacteria, most likely to be problematic in terms of resistance?
Enterobacter, S.aureus, Klebsiella, Acinetobacterm Pseudomonas, Enteroccocus
These also account for more tha 80% of infection in ICU
593
What is the sensitivity of BAL for PJP before and after abx start?
90-98% before and 64% if already had abx. With advent of PCR testing BAL is less required and not first line
594
What is the maintenance fluid requirement for children?
Holliday Segar formula
4ml/kg/hr for first 10kg
then 2 for the second and 1 thereafter
595
Which has the larger volume of distribution, morphine or fentanyl?
Fentanyl 4L/kg but morphine 3.5, Diamorph is 5
596
Define volue of distribution
theroretical volume of plasma into which the drug would dissolve in order to give the plasma concentration achieved by administration of a bolus dose
597
Whatis the mortality associated with GI bleed whilst in hospital when admitted with another condition?
23%
598
What is attrition bias and how do you avoid it?
It is the failure to account for the withdrawals from a research project. To avoid it you do an intention to treat analysis
599
How is performance bias guarded against?
If you think you've had the drug and know what effect it should have you may do other things make sure it works. Blinding helps
600
What is detection bias and how do you guard against it?
If those collecting data know which group is which theymay round up or down as they expect the result to go..blinding
601
If a patient has tachyarrhythmia and fails to respond to three escalating shocks what is the next step?
Amio 300 over 10-20min then try again.
602
What are the contrindications to adenosine?
Ashma or bronchospasm of any cause, 2nd/3rd egree HB, sick sinus with symptomatic bradys (unless PPM)
603
Which drug antagonises adenosine?
Diparydamole
604
By how much should a BB be reduced once eGFR<30?
By 50%
605
What does PCC contain?
II, VII, IX and X
606
What does activated PCC contain?
II, VIIa, IX and X (may be useful in Dabigatran reversal)
607
What colour is sputum in s.pneumonia? H. influenzae?, Klebsiella?
S.pneumnia rust colour
H.inf- green
Kleb- red currant jelly
608
How do you get leptospirosis?
Contaminated water- pigs, cows, bats etc
609
How does leptospirosis cause problems?
You feel ok for 0-3/52 then get spiraemic and feel awful but then the immunogenic phase kicks in and you get a widespread vasculitis and endothelial damage potentially leading to MOF
610
What is a HAP?
Infection that develops >2days after admission or on admission if been admitted to care home or similar for >2 days in last 90 days
611
Risk of death x4 if inhalational burn, what are the mechanisms of inhalational injury?
direct heat, irritation from inhaled particles, biochemical toxicity
612
Why are burns below the vocal cords unusual?
The humidification process in the oropharynx efficiently moves heat to those structures. It's usually inhaled soot in the airways. Unless steam was about for obvious reason
613
What compound is most likely (80%) to be implicated in death due to fire?
CO
Binds Hb
Left shift O2 dissociation curve preventing O2 liberation
Competitive inhibitor of cytochrome oxidase
614
Featrues of severe CO poisoning?
Acute neuro symptoms, coma, MI on ECG, significant acidosis, COHb >30%
615
CO is often present when CN is also therefore picking up CN poisioning is difficult. When should it be suspected?
Lact >7, Elevated anion gap, reduced AV O2 gradient (high SvO2)
616
How treat CN poisoning? How does it work? Dose?
Hydroxycobalamin directly binds HCN to cyanocobalamin which is then renally excreted. Dose 5g over 15min. s/e red gums, urine, can falsely elevate hbCO by 5%
617
How would you treat a post phaeo patient with hypotension?
Alpha agonism may be ineffective because phenoxybenzamine will linger. THerefore NA and Phyenl and metaraminol may be ineffective. Could give Vasopressin
618
What apart from hypotension is a post op complication of removing a phaeochromocytoma?
hypoglycaemia because eh lack of cortisol reduces the amount of glycogenolysis
619
What is the accepted reference point for BP?
The RA
620
What is an ideal BP cuff size?
20% larger than the diameter of the arm
621
Which Korotkoff sound is systolic and diastolic?
1st systolic
| 5th- which is loss of 4th sound
622
What are daily nutritional needs (kcal, water, protein)
30kcal/kg/d
30ml/kg water/day
1g/kg protein
623
No gold standard definition of VAP but what are the constituents of any system?
Clinical
Micro
Radiological
624
What is the VAP care bundle and what does it consist of?
```
2007 and updated in 2010
Daily sedation hold
Bed head up
ulcer prophylaxis
oral hygiene with antiseptics
Sub glottic aspiration
cuff monitoring
```
625
How do you correct Na for glucose?
Corr[Na]= measured[Na]+2.4*(gluc-5.5)
626
What is a primary spont pneumothorax and a secondary?
Primary is anyone F+W<50
| Anyone >50 is assmed to have lung disease and is secondary
627
How treat primary spont PTX?
Small assymptomatic <2cm can be aspirated or just left
628
How treat a symptomatic spont PTX?
drain, seldinger
629
How des furosemide help in HF?
Transient but helpful venodilatation and also the diuresis
630
When should dobuatmine be considered?
If signs of hypoperfsuion or SBP<85
631
Define heart failure
Syndrome of typical symptoms and signs caused by structural or functional cardiac abnormalities resulting in reduced cardaic output and/or elevated intra-cardiac pressures
632
Define HFmrEF (mid-range)
Have symptoms +/- signs, LVEF 40-49%, high BNP, LVH of LA enlargement, diastolic dysnfn
633
Define HFrEF (reduced)
Symptoms +/- signs with EF<40%
634
Define HFpEF (preserved)
Symptoms +/ signs with EF>50%, raised BNP, LVH/LA enlarge and diastolic dysnfn
635
Which causes of HF should prompt genetic counselling?
HCM, DCM, arrhythmogenic RV cardiomyop
636
What are the most specific signs of HF?
Raised JVP, Hapatojug reflex, S3, lateral displacement of apex
637
What is the NPV of BNP for HF in non-acute and acute settings?
PPV?
94-98% NPV
acute PPV 67%
so good rule out test
Not good in renal failure, obese AF and high age
638
In what order do you add drugs for HF?
ACEi +BB and if still signs/symptoms HF add spiro/eplerenone
639
In HF when would you add Ivabradine and ARNI?
If have ACE, BB and mineralocortocoid anatag and still symptomatic with EF<35%, then swap the ACEi for ARNI and if SR>70 add ivabradine.
640
When is CRT considered in HF?
IF ACEi, BB, spiro/eplerenone and HR<70 and considered for ARNI and QRS >130ms resync is considered
641
What does ARNI stand for?
Angiotensin receptor neprilysin inhibitor
642
How does an ARNI work?
The neprilysin inhibition slows degredation of BNP (and bradykinin) therefore allowing it to exert its diuretic and natriuretic properties for longer. In addition it has myocardial relaxation and anti-remodelling charateristics. The AR bit selectively targets the AT1 receptor and in addn to ARB more generally also reduces myocardial hypertrophy
643
Can ACEi and ARB be used together?
Yes but only in HF patients who are on BB and can't tolerate sprio/eplerenone and then only under strict supervision
644
Who should be considered for CRT?
If QRS>130ms and EF<35% and on optimum medical management
If RV paced and deteriorating despite optimum meds
If HFrEF and need pacing for anything else go for CRT
645
How treat exac HFpEF/HFmrEF
No real evidence, BB seem to not work for AF i these patients. Give diuretics
646
What is the flow chart for angina treatment?
BB first, add Ivabradine or instead of BB if BB not tolerated if HR>70. Add nitrate/amlodipine/ nicorandil. Can attempted revascularisation
647
What angina treatments should not be used together?
Nicorandil and nitrate because of lack of additional efficacy
648
What are teh causes of acute HF?
```
'CHAMP'
Coronary syndrome
HTN emergency
Arrhythmia
Mechanical
PE
```
649
What did the DOSE study find?
furosemide at home dose or 2.5 times the previous oral dose intermittently or cont infusion. Trend toward higher Cr in high dose. No difference in primary end point which was subjective. Secondary end points were stat sig- fluid loss, weight loss, congestion free etc. Therefore higher dose either bolus or cont are recommended. Guidelines suggest home dose and uptitrate
650
What is the complication of IVIG?
Sterile meningitis
651
What is given to patients in subsequent pregnancies if they get HELLP or PET?
Aspirin 150mg
652
What is the dose range for GTN infusion?
0.1-0.8mcg/kg/min
653
Dose range for dobutamine?
2-20mcg/kg/min
654
How much Na and gluc in 0.18%NaCl with 4% glucose?
Na=31mmol
| Gluc- 40g
655
What BIS number do you aim for to ensure anaesthesia?
40-60
656
What structures do you pass through to get an LP?
Skin, sub cut, supra-spinatusligament, interspinous liganment, ligamentum flavum, extra dural, dura mater, arachnoid mater
657
Where does the line connecting the iliac crests cut the spine?
L3/4
658
What is the standard error of the mean?
It is the SD/square root of the sample size
659
What contribution do albumin and PO4 have to anion gap?
AG= Na+K-HCO3-Cl but also -0.2(alb)+1.5PO4
This means alb contributes 2-8
PO4 contrubutes 0.5-1.5 so low albumin could squeeze you into a falsely low AG
660
Unusual causes of HAGMA?
urea acid cycle inherited disorders, salicylates which impair oxidative phosphorylation, glycols, pyroglutamic acid (paracetamol and fluclox), CN, formaldehyde
661
When can pyroglutamic acid cause an acidosis?
Glutathione plays important role. When depleted like in malnut, preg, sepsis, paracetamol use levels of pyroglutamic acid rise. Fluclox inhib 5-oxoprolinase to further prevent breakdown.->give NAC and stop ppt drugs
662
What causes right shift of oxygen dissociation curve?
high T, low pH, high pCO2
663
Causes of left shift oxy dissociation curve?
low T, high pH,
664
What is the p50 for myoglobin?
0.4kPa! Myoglobin always get the oxygen
665
What is the context sensitive half life of the following drugs at steady state?
Fentanyl
Thiopentone
Propofol
Fent at 12 hours is 300min
Thio is 100min
Prop<50min
666
What are the risks from art line?
20% transient occlusion
14% bleeding/haematoma
infection1%
667
According to surviving sepsis, which order should management me instigated in someone who needs everything?
1hr bundle -lacate, BCx2 before abx and abx within 1hr, if hypotension give 30ml/kg fluid and cont whilst still fluid responsive and give vasopressors if MAP>65 (pressors in less than 1 hr?)
668
What is in the surviving sepsis 6 hour bundle?
It as the followingbut now no longer exists Vasopressors for MAP>65, CVC if lact initially >4 or septic shock and measure CVP and ScvO2 and on going lactate
669
In surviving sepsis guidelines the aims are to achieve normality: MAP 65, CVP 8-12, U/O >0.5ml/kg/hr but what ScvO2 and SvO2 are they aiming for?
ScvO2 70% and SvO2 65%- hands up who knows how to reliably control these variables.... now defunct
670
What did the ProCESS and ARISE trial show?
Showed that measuring CVP and ScvO2 in sepsis does not confer a survival benefit but it's still in the guidelines
671
If eclamptic seizure lasts >5min after Mg what do you do?
Give loraz as usual but if still refractory think that something else is going on ?ICH
Next would be intubation and propofol or keppra. Avoid phenytoin
672
In SAH where are the aneurysms usually found?
```
30-35% ACOM
30-35% ICA/PCOM
20% MCA
5% bifurcation of basilar
8% posterior circ
```
673
What is the difference between HELLP and acute fatty liver of pregnancy?
HELLP has LDH rise and AFLP are generally unwell
674
Intrahepatic cholestasis of pregnancy can occur in third trimester with intractable itch and nausea. What danger does it pose to the child?
Fetal complications including death but no long term impact on mother
675
How does hypoPO4 present?
Refeeding/rhabdo/ haem anaemia usually, global weakness (inc ocular causing diplopia), resp muscle weakness (classically tachypnoea and resp alkalosis), confused,coma
676
What hormone controls phosphate?
PTH, if high PO4, PTH high to increase renal losses
677
How does reintroducing carbohydrate to diet after starvation cause hypoPO4?
Insulin activtes Na/K ATPase pumps and proteins are again made intracellularly. Both of these proceses shift PO4, K and Mg as co-factors into cells making serum conc fall.
678
Nec fasc can be divided into three types based on the causative organism. What is are they?
Type 1- polymicrobial- mixture of G+ve and -ve, aerobic and anaerobic
Type 2- G+ve monobacerial classically strep pyogenese, S. aureus (in particular MRSA)
Type 3- Gas gangrene- Clostridium perfringens
679
Give an example of nec fasc abx treatment
Mero, Clindamycin and Vanc/Linez. (Hyper baric O2 and IVIG (neutralise exotoxins) in small number of cases)
680
How is warm ischaemic time defined in organ transplantation>
Time that has passed since BP<50 for 2 min until organ is cooled in theatre
SpO2 <70% has been in the guideline previously and can still make up the definition along with other factors
681
What is the allowed warm ischaemic time for liver, pancreas, lungs, kidney?
Liver <20min (up to 30min allowed)
Panc 30min
Lung 60min
Kidney 120min
682
What is the investigation of choice in dissection?
ECG gated CT, TOE obviously usefl but not as sens/specific as CT
683
When TEVAR placed a concern is the spinal arteries, if a patient develops neuro symptoms how do you treat it?
Increase MAP but obviously not tht high given the indication for the procedure. A lumbar drain can improve spinal perfusion pressure
684
What are the two main aortic dissection classification systems?
Stanford (Type A and B)
| DeBakey (Type I, II, III where II=A III=B and I is everything)
685
What proportion of dissections are type A and B?
A=70-80%, B 20-25%
686
What are the three pathophysiological findings in aortic dissection
Atherosclerotic ulcer leading to tear
disruption of vasavasorum causing haematoma
de novo tear
687
What is meningococcus? What is pneumococcus?
Neisseria meningitidis is meningococcus wheras bacteria like strep pneumoniae is pnuemococcus (90 types of pneumococcus)
688
Are steroids usedul in meningocococcal meningitis?
No, N. Meningitidis is not the indication, pneumococcal is.
689
How do steroids help in meningitis in adults?
They must be given before the first dose of abx as they work by reducing inflammation to cell lysis that is induced by abx treatment
690
How is steroid treatment for paediatric meningitis different to adults?
There is some evidence that H.Influenzae along with pneumococcal meningitis respond favourably to steroid
691
What are the stages of abdominal hypertension?
Grade 1 12-15mmHg
2 16-20
3 21-25
4 >25
692
What is the definition of iof abdominal compartment syndrome?
abdo htn >20mmHg with organ dysnfn
693
How is abdominal HTN treated?
Each factor that plays a role has a primary, secondary and tertiary management plan
694
How is abdominal pressure measured?
Catheter in bladder with 25ml saline, supine with no abdo muscle movement zeroed at the mid-axillary line
695
How are intra-luminal contents modified in abdo HTN?
Step 1 NG/rectal tube and start pro-kinetics
step 2 reduce feed and give enemas
step 3 colonoscopic decompression and stop feed
4. decompressive lapartotomy
696
In abdo HTNwhat are the steps of removing intra-abdo SoL? (what a term!)
Abdo USS to see if there is one
CT to characterise
then drain if possible or surgery if not possible
697
How is abdo wall compliance improved in a step wise appraoch to abdo HTN?
step 1 - analgesia and sedation, remove dressings that may be restrictive
2 consider reverse Trendelenbory position, head up 20 degrees
3. Muscle relaxant
698
How is fluid optimised in abdominal HTN?
1. Avoid excess fluid (good one), aim zero balance by D3
2. Resus with hypertonic fluid, diuretics
3. CRRT
699
What abdominal perfusion pressure do you aim for in abdominal HTN?
APP>60
700
If intra-arterial injection of a medication what are the first steps? What are the next steps possible?
Flush with saline to dilute the drug. Thio is the classic one where crystals block small arterioles. Give analgesia to reduce sympathetic response and further vasoconstriction, keep limb warm but elevated. Heparin useful if ischaemia
701
When is a stellate ganglionblock used?
I'm sure in other cases but also if pt has intra-art injection of a drug that has caused ischaemia. The block makes limb lose sympathetic innervation dilating the vessels
702
How long should UFH, LMWH, aspirin and clopidogrel be stopped before doing an LP or epidural?
UFH 4 hrs
LMWH- 12 hrs for prophylactic, 24 for therap
Clopid/Prsugrel-7 days
Aspirin-no effect
703
What is the mortality beenfit of treating T2RF 2 COPD with NIV?
50% reduction in mortality with NNT 10
704
When should NIV be considered in AECOPD?
pH <7.35 pCO2 >6 after 1 hr of medical mx
705
How often should a trahe inner tube be changed?
Every 8 hours in non-ventilated pts. In ventilated pts the risk of derecruitment etc needs to be weighed
706
What cuff pressure should be aimed for in trache?
Check every 8 hours and should be 20-25cmH2O
707
Trauma resus centres on permissive hypotension and low volume blood product resus, when is this not appropriate?
If TBI/spinal injury aim MAP 80
| If not though can aim SBP 80-90
708
What did CRASH1 show?
Steroids are not good for head injuries an should be avoided
709
What did CRASH2 show?
TXA reduced death NNT 68, its safe so has been incorporated into practice
710
What did CRASH 3 show?
No reduction in death at 28days to those with TBI and getting TXA within 3 hrs but in mild-mod group there was a tiny reduction in mortality...on balance if in that group it causes no harm so give it
711
Beta blocker overdose can be treated with glucagon but what two blockers should you be most worried about?
Propranolol causes Na blockade which widens QRS, this an be treated with bicarb
Sotalol causes K efflux blockade which can cause Torsades
712
What abdnormalities would you see in BB overdose?
bradycardia and hypotension, AV block
bronchospasm
Hypoglycaemia and hyperK
comas seizures
713
What are the antidotes to BB overdose? How do they work?
Glucagon 50mcg/kg up to 10mg then 2-10mg/hr is traditional but is inferior to high dose insulin euglycaemic therapy. Glucagon is a positive inotrope by a non-catecholaime mechanism, it also counters the B3 effects and subsequent hypoglycaemia
Consider intralipid
714
How is high dose insulin euglycaemic therapy given in BB and CCB overdose?
Given 50ml 50% glucose with 1unit/Kg insulin short acting initially then titrated to effect
715
What are the admitting criteria for a burns centre? Burns unit? Burns fascility?
Centre- BSA>25% + airway burn or >40% if not ( if >25% should be discussed with burns centre)
Unit- Any BSA>10% should be d/w burns unit also if it is non-blanching, circumferential or to face/feet/hand/perineum/gentials
Facilities- More than 2% but <10% discuss if chemical or electrical burn
716
What are the interventions suggested by KDIGO in those ith stage 1 AKI?
Avoid nephrotoxics, adequate volume status, maintain perfusion pressure with vasopressors if required, use of functional haemodynamic monitoring should be considered. Normal glucose. Non-invasive work up for the cause
717
What are the recommendations for Stage 2 AKI?
All drugs reviewed and adjustments made. RRT/ICU needed?
718
What are the KDIGO stage 3 AKI recommendations?
Avoid subclavian lines
