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FFICM > MCQ CCMCQs > Flashcards

MCQ CCMCQs Flashcards

1
Q

At what point does sugammadex become a viable reversal agent for vecuronium?

A

Once T2 twitch achieved use 4mg/kg

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2
Q

Reversal dose of sugammadex?

A

16mg.kg

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3
Q

For how long post insertion is high risk for thromosis in BMS and DES?

A

4-6/52 in BMS and up to 12/12 in drug eluting

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4
Q

What is the 1 year rate of thrombosis in DES?

A

DES arebetter in the first year 0-3% vs 5-10% but over the longer term DES are worse with 0.6% blocking per year

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5
Q

How long do you anticoagulate BMS?

A

4-6/52 with DAPT thenaspirin for life

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6
Q

If surgery required in first 4/52 with BMS what do you do about DAPT?

A

Needs to be bridged by Tirofiban or heparin

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7
Q

What are the risks of DAPT and surgery?

A

50% increase in bleeding but not mortality

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8
Q

Biocompatible stents like the Genous R-Stent still needs anticoagulation. More or less than DES and BMS?

A

Less- only need 10 days clopidogrel then life long aspirin

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9
Q

How often do you get CICO?

A

0-2/10000

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10
Q

Below what diameter of tube do you need to jet ventilate?

A

2mm

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11
Q

What does a quinine overdose look like?

A

Low QTc , blindness, VF resistant to cardioversion, hypoglycaemia. CVVH of no use

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12
Q

Maximum score for HIIT score?

A

8

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13
Q

Where is the basilar in relation to the brainstem?

A

anterior

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14
Q

Which is the largest cerebellar artery?

A

post inf cerebellar

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15
Q

What cell mediaed graft vs host?

A

T cells

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16
Q

What drugs are used in GVHD prophylaxis?

A

Calcineurin inhibitors eg ciclosporin or tacrolimus

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17
Q

What is the mortality associated with transfusion related GVHD?

A

almost 100%

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18
Q

Defn anaemia in men and women?

A

M<130

F<120

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19
Q

In HITT type II what is the typical pattern seen with plt?

A

Immune mediated falls 30-50% in 5-10 days after starting heparin

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20
Q

Is HITT more common in M or W?

A

W

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21
Q

What is the immune process of HITT?

A

A complex between heparin antigen and plt factor 4 (PF4) and the patient develops IgG ab resulting in consumptive coagulopathy

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22
Q

How long after HITT diagnosed do you continue anticoag to prevent thrombosis?

A

14 days (fondaparinux, danaparoid or argatroban)

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23
Q

Emergency cricothryoidotomy is performed through which structure?

A

Cricothyroid ligament

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24
Q

What is a standard ECG x and y axis?

A

x-25mm/s

y- 1mV/cm

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25
Q

Which is the most sensitive lead for detecting ischaemia on ECG?

A

V5 apparently

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26
Q

What sensitivity does a 5 lead ECG have for detecting inf or ant ischaemia?

A

90%

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27
Q

Normal cardiac axis?

A

-30 to +90

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28
Q

Define aortic dissection

A

Either an intimal tear or intra-murral haematoma

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29
Q

When and who get aortic dissections?

A

Male 50-70

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30
Q

How many classes of aortic dissection does the European Soc of Cardiology classification have?

A 
5
1- classic intimal flap
2-intra-mural haematoma
3- subtle only bulge at tear site
4- atherosclerotic ulcer with haematoma
5- iatrogenic/trauma
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31
Q

Is there a survival benefit to monophasic vs biphasic defibs?

A

No though the first shock efficacy for biphasic is 86-98% whereas only 54-91% in monophasic

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32
Q

When does IABP inflate electrically and mech?

A

On middle T wave electrically or on dichrotic notch

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33
Q

When does IABP deflate?

A

Just before sstole- peak of R wave or just before upstroke on art line

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34
Q

When is NAC useful apart from in paracetamol OD?

A

In any ALF when early hepatic enceph showing (grade I/II evidence)

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35
Q

In ALF what bleeding risk does ICP monitoring have?

A

4-20% though I wonder if that’s becase we put them in rather than neurosurgeons

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36
Q

ALF is characterised by high CO state and low SVR, what contributes to the low SVR?

A

High NO production and cGMP

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37
Q

What is the mortality risk of variceal bleed?

A

8% immediately and 20% within 6/52

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38
Q

Define portal HTN

A

Pressure gradient >5mmHg. At gradients >10mmHg blood flow through portal system is redirected to lower pressure areas

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39
Q

Once Sengstaken Blakemore tube removed how many rebleed?

A

50%

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40
Q

How far do you put the SBlakemore tube in?

A

55cm

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41
Q

O’Grady ALF system has hyperacute, acute and subacute, what are their time defn?

A

Hyper <1/52
Acute <1/12
Subacute <3/12

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42
Q

What is the Bernuau system for ALF?

A

Fulminant 1-2/52 from jaundice to enceph and subfulminant 2+ weeks from jaundice to enceph

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43
Q

What are the phases of Ethylene glycol toxicity?

A

Three stages:
1- 30-60min intoxication and excitiation (seizure)
2- 12-18 hrs CV signs- dysrhyhmias and cardaic failure, profound metab acidosis
3- 2-3 days renal failure and RTA due to Ca deposits.
There can be a fourth phase 5-20 days limb weakness and CN palsies and sensory disturbance

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44
Q

Causes of HAGMA>

A 
CAT MUDPILES
CO, CN, congen HF
Aminoglycosides
Theophylline and Toluene(glue sniffing)
Methanol
Uraeua
DKA,alcohol and starvation ketosis
Paracetamol/paraldehyde
Iron, Isoniazid, inborn errors of metab
Lactic acidosis
Ethelyene glycol
Salicylates
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45
Q

Causes NAGMA>

A 
USED PART
Urinary diversion
Small bowel fistula
Extra Cl
Diarrhoea
Pancreatic fistula
Addisons
RTA
Tenoovir/Topiramate
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46
Q

What are the toxic metabolites of ethylene glycol?

A

Glycoaldehyde, glycolate (35%), formate oxalate (2.3%) benzoic acid and others
Oxalate binds with Ca and causes hypoCa

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47
Q

What is Fomepizole? Loading dose? When stop?

A

An alcohol dehydrogenase inhibitor, 15mg/kg loading, stop when eythlene glycol <20mg/dl

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48
Q

In SBP what % of cultures are +ve and what are the most common pathogens?

A

60% positive with E.Coli, Step and enterococcal species being most common

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49
Q

When are prophylactic abx used in SBP?

A

If had one prev SBP should have prophylaxis

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50
Q

What is the 1 year risk of HRS if cirrhotic with ascites?

A

18%

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51
Q

Define Wenicke’s enceph

A

Nystagmus, Opthalmoplegia, ataxia and confusion secondary thiamine def

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52
Q

What is the role of Infliximab in liver failure?

A

In ALD TNF-alpha is raised (inflix lowers TNFa) but trials showed it increased mortailty

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53
Q

What TNF-alpha lowering drug is useful in ALD?

A

Pentoxyphylline is associated with recued HRS and is useful in alcoholic hepatitis when steroid contraindicated

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54
Q

What is baseline O2 delivery requirement?

A

300ml/min

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55
Q

Normal CI?

A

2.8-4.2 L/min/m2

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56
Q

Normal SVRI?

A

1760-2600 dynes.sec/cm5/M2

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57
Q

Normal PVR?

A

<250dynes.sec/cm5 (PVR=80*MPAP-PAOP/CO)

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58
Q

Normal SVI?

A

Stroke vol index= CI/HR *1000

35-47ml/m”/beat

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59
Q

When is high risk time for liver transplant? What is 1 and 5 year survival?

A

first 3 months is when most deaths occur
1yr 79%
5yr 72%

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60
Q

How do liver transplants in ALF and chronic liver failure compare?

A

Acute failures do worse initially but after 1 year this reverses and the acute failures havea better long erm survival

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61
Q

How is paracetamol broken down?

A

Mostly by glucoronidation and a small amount by cytochome p450 to NAPQI which itself is conjugate by glutathione to form cysteine and mercapturic acid

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62
Q

What 4 and 15 hr levels of paracetamol require immediate treatment?

A

At 4 hrs 100mg/L

15mg/L at 15hrs

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63
Q

When is NAC continued after the first 16hr treatment>

A

If ALT x2 or 2x upper limit of normal or INR>1.3

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64
Q

Triad of seretonin syndrome?

A

Neuromusc excitability - Termor, stiffness, hyperpyrexia
Autonomic disturbance- mydriasis, tachycardia, flushing, hypertheria
Mental changes- headache, agitiation, coma

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65
Q

A cannabis OD in child presents as?

A

Dilated pupils, hypotonia and hyporeflexia

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66
Q

What is the FOUR score?

A 
Can be used instead of GCS in the intubated patient, the V component is replaced by G (grimmace) with similar 1-5 scores
1- nothign
2- Mild grimmace
3- vigoroud grimace
4- responds to touch
5- normal facial movements
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67
Q

Why is DVT 3x likely in spincal cord injury?

A

Everything dilates reuslting in venous pooling and relative stasis

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68
Q

Steroids in spinal cord injury- discuss

A

NASCIS II and III (national acute spinal cord inj studies) showed improvement in motor and sensory score if methylpred within 8 hrs but the methodology has been questioned and NASCIS III has increased rate severe sepsis and pneumonia so no recommendation and is at the discretion of treating doctor

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69
Q

Where is a lumbar drain placed?

A

Into the subarachnoid space

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70
Q

What is found on nerve conduction studies in CC polyneurophathy?

A

Both motor and sensory conduction is reduced

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71
Q

What is seen on EMG in critical illness myopathy?

A

See fibrillations. In contrast see denervationin MND

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72
Q

Compression of what structure causes Cushing’s response in about 1/3 cases?

A

Tonsillar herniation compresses the midbrain

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73
Q

What does a normal ICP trace look like

A

Like an art line trace

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74
Q

What is P1 P2 and P3 in ICP waveform?

A

P1 - percussion wave from arterial pressure transmitted from choroid plexus to ventricle
P2-Tidal wave due to brain compliance
P3- Is dichrotic wave due to AV closure

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75
Q

What happens to P1,2 and 3 in raised ICP?

A

P2>P1 and wave becomes broader

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76
Q

What are Lundberg A waves (aka plateau waves)

A

vasogenic waves seen in critical perfusion and are always pathological…seems they are just high ICP with normal poor compliance waveform

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77
Q

What did the POISE study find?

A

Decease in non-fatal MI when BB given pre-op in pts with IHD for non-cardiac surgery but all cause mort increased with inc brady, hypotension and strokes though data fraud has made this area rather murky (not the POISE study guys!)

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78
Q

How does mannitol help in ICP rise?

A

Plasma expansion reduing viscocity. Also is a fluid bolus initially inc CO and compensatory vasoconstriction resulting in lower ICP though an intact BBB is required. Peak effect at 30-45min and lasts about 6 hrs

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79
Q

Mannitol dose for raised ICP?

A

0.25-1g/kg over 20min repeated 1-2 times after 4-8hrs

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80
Q

What % patients remember pain in ICU?

A

70%

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81
Q

What level of thiopentone would exclude brainstem testing?

A

> 5mg/L

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82
Q

What is minimum core temp in brainstem testing?

A

> 34C (brainstem relfexes lost at 28C)

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83
Q

What is the range of Na allowed in brainstem testing?

A

> 115, <160 (Large range!)

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84
Q

What is an acceptable PO4 in brainstem testing?

A

0.5-3mmol/L

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85
Q

What frequencies are used in USS and echo?

A

USS >20kHz, echo 2-10MHz

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86
Q

area definition of severe AS?

A

0.6-0.8cm2 (and mean pressure gradient of 40-50)

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87
Q

What is the most prev organisms causing meningitis in a child up to 3/12? It has been sign modified by vaccination

A

Men B

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88
Q

How do you differentiate between croup and trachiitis?

A

Trachiitis doesnt respond to croup treatments and progresses requiring intubation. It is caused by S aureus and H influenzae type B

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89
Q

What organism classically causes epiglotitis?

A

H. influ B

4Ds- drooling, dysphagia, dysphonia, dyspnoea

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90
Q

What is the causative organism in croup?

A

Parainfluenza virus

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91
Q

What is the dose of HFNO in kids?

A

Well tolerated and used in RSV use 2L/kg/min

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92
Q

What correlated directly with decline of CD4 function in HIV infection?

A

HIV RNA levels (viral load) correlated with rate of decline of t-helper cells and progression to AIDS

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93
Q

How is AIDS defined?

A

AIDS defining illness or CD4 <200cells/microl

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94
Q

What is Zidovudine?

A

Nucleoside analgue reverse transcriptase inhibitor for HIV treatment

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95
Q

What is Enfuvirtide an example of?

A

a fusion inhibitor which prevents HIV binding with cell membrane

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96
Q

What are the side effects of NRTI nucleoside reverse transcriptase inhibitors?

A

Lamivudine, zidovudine etc cause lactic acidosis, hepatomeg and statosis. Stop the drug

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97
Q

The HIV drug NNRTs (non-nucleoside reverse transcriptase inhibitors) are effective against what HIV?

A

HIV 1 only

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98
Q

Pulmonary manifestations of RA?

A

Parenchymal- ILD, diffuse alveolar damage, organising pneumonia
Pleural disease- Effusion, ptx, trapped lung
Airway- cricoartenoid arthritis, cronschiecasis, obliterative bronchiolitis
Nodules- Rheum nodules or Caplan syndrome
Vascular- PHTN or vasculitis
other- infection malig, VTE

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99
Q

What drugs used in RA are toxic to lungs?

A

Pretty much all of them

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100
Q

What fibres sense temp?

A

A-delta and C fibres

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101
Q

How does temp affect iron and in turn what does that do?

A

High temp decreases iron which reduces bacterial growth

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102
Q

What is the initial dose of Dantrolene?

A

2.5mg/kg

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103
Q

What happens to cerebral blood flow with reducing temp?

A

Flow reduced by 7% with each degree C dropped postulated to be due to lower CO and higher viscocity

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104
Q

What is the second leading cause of non-accidental death in UK after RTA?

A

Drowning

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105
Q

Does aspiration often or rarely occur in drowning?

A

It was thought that 20% had laryngeal spasm with so called dry drowning but now we think most people aspirate

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106
Q

Is salt water vs fresh water bettwer or worse in drowning?

A

No difference

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107
Q

What makes normal Hb?

A

2 alpha and 2beta chains (HbF 2 alpha, 2 gamma)

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108
Q

What is the abnormality in sickle cell disease?

A

Glutamic acid is replaced by valine in the 6th amino acid position

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109
Q

How is porphyria inherited?

A

Auto dom

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110
Q

How long into a paeds resus should IO be used if no IV in?

A

90s

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111
Q

Kings college criteria, what in addition to INR>6.5 and Cr >300 is require to fulful criteria?

A

Grade III or IV enceph

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112
Q

What lactate at 4 and 12 hrs form part of the modified Kings Criteria?

A

> 3.5 at 4 hr or >3 after 12 hrs maximum treatment

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113
Q

Where does a pelvic binder of any sort encircle?

A

Level of greater trochanters

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114
Q

What % trauma patients have a c-spine injury and what % of those are unstable/

A

12% have injury and 14% are unstable (1.7% of all traumas have unstble c-spine injury)

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115
Q

Whatare the rates of c-spine injury without radiological abnormality in adults and kids?

A

Adults is rare
Kids 10-20% (!)
commonest cause of c-spine injury is vertebral subluxation

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116
Q

When can ANOVA be used?

A

If parametric data with more than two groupd

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117
Q

Define standard error of mean

A

SD/ square root of n and is an indication of how well the mean of a sample represents the true mean

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118
Q

What is alpha error (and beta)

A

alpha is prob of positive finding in study being wrong

Beta is proab of neg finding being wrong

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119
Q

What did the BALTI-2 trial find?

A

B2 agonists increased mortality in ARDS

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120
Q

What did the PROSEVA trial find?

A

Proning improves ARDS mortality by 50%(!)

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121
Q

What is the Paul Bert effect?

A

CNS toxicity of O2 if delivered at >3atm

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122
Q

What pressures are associated with barotrauma?

A

PIP>45 and Plat >35 (or less, more recent research makes one wonder inf these figures are too liberal)

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123
Q

What is the difference between intra and extracellular pH?

A

Intracellular pH is about 0.6 lower than extracellular

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124
Q

Where is the compensatory mechanism of hyperventilation due to low pH arise?

A

Chemoreceptors in aorta and carotid body

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125
Q

How do you check that there is only one source of acidosis going on?

A

Calc AG then delta ratio

Delta = AG-normal AG/HCO3 -normal HCO3-

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126
Q

How does methanol poisoning present on blood gases etc?

A

Initially has a high osmolar gap, then as its metabolised it causes a HAGMA

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127
Q

What can cause a HAGMA and high osmolar gap?

A

Methanol and Ethylene glycol

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128
Q

Normal osmolar gap?

A

<10

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129
Q

How do you correct AG for albumin?

A

Observed anion gap + 0.25(normal alb-measured alb)

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130
Q

Paracetamol OD can cause a HAGMA, what is the uneasured anion?

A

5-oxoproline

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131
Q

What is leukocyte larceny?

A

Its where someone has leukaemia for example and the WBC use all the O2 before an ABG is analysed therefore having a low PaO2 when it may be higher in practice

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132
Q

What is urine Na in SIADH?

A

> 20

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133
Q

What do hyaline casts and finely granular casts on urine examination mean?

A

Pre-renal azoteaemia

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134
Q

What urine findings would make you wonder about ATN?

A

Tubular epithelial cells and granular casts

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135
Q

How is fractional extraction of Na calculated?

A

FENa= ([urine Na xPlasma Cr]/[plasma Nax urine Cr])x 100

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136
Q

What does a FENa <1% and >2% suggest?

A

<1% pre-renal azotemia

>2%parenchymal renal disease of urine obstruction

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137
Q

Where is TRH made and what is its function?

A

Made in the paraventricular nucleus of hypothalamus and stimulates TSH release and prolactin from ant pit

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138
Q

Where does T3 come from?

A

80% from T4 convesion and 20% from direct thyroid secretion

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139
Q

Where in the body is T4 converted to T3?

A

liver and kidney

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140
Q

How does Enalapril alter renal blood flow?

A

Increases renal blood flow but GFR remains unchanged

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141
Q

Can paracetamol act as a nephrotoxic?

A

Yes in those who are glutathione deplete presents as an ATN

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142
Q

Is acyclovir a nephrotoxic?

A

yes

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143
Q

What drugs elevate digoxin levels?

A

Verapamil, erythromycin, diltiazem, tetracyclines

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144
Q

What happens to K in dig toxicity?

A

Elevated. Initial K correlates with outcome

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145
Q

Standard dig toxic ECG of downard slope ST and TWI is most likely found when?

A

Initially. Proper toxicity can have any rhythm

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146
Q

Indications for Digibind?

A

Arrest due to dig or >12ng/ml serum level

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147
Q

What are the connections between the ventricles and thrid ventricle and the third and fourth ventricle?

A

Vent->3rd foramen of Munro

3rd-4th-> aqueduct of sylvius

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148
Q

What are the electrolytes in CSF that are different to plasma?

A

HighCl and low K

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149
Q

What happens to Ca in therapeutic hypothermia?

A

Reperfusion injury thought ot be reduced by reducing calcium flux

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150
Q

What groups of HEV are there?

A

Two genotypes 1 (water bourne) and 2(faeco-oral) infect humans. Genotypes 3 and 4 come from pigs and are accidental carriers.

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151
Q

HEV may masquerade as DILI. Which genotype is worst for hepatitis in preg women?

A

Genotype 1

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152
Q

What is the complication rate in cricothyroidotomies?

A

20%

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153
Q

Where is CSF produced?

A

Choroid plexus in lateral and 3rd ventricles

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154
Q

What is a normal rate of production of CSF?

A

0.4ml/min (576ml/day)

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155
Q

What is the volume of CSF around the spinal cord?

A

35ml

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156
Q

If a normal ICP and you remove CSF what happens to ICP?

A

Under normal circumstances, taking a bit of fluid has no effect on ICP

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157
Q

What % of those with neut sepsis need ICU?

A

5%

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158
Q

What is defn of neut sepsis?

A

Neut <0.5 and T>38 or other signs of infection

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159
Q

What blood abnormalities in DIC?

A

Thrombocytopenia, hypofibrinogenaemia, high fibrin degredation products, long APTT and PT and TCT

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160
Q

What does chronic DIC look like?

A

compenstaed state with increased turnover of haemostatic components eg malignancy

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161
Q

How does type 1 DIC present on TEG initially?

A

hypercoagulable state with decreased R time and K time and inc MA.
Type II DIC can prsent with long R time

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162
Q

Did TTM trial find a difference in harm between 33 and 36C?

A

No

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163
Q

What does hypothermia do to insulin?

A

Inc resistance

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164
Q

What happens to myocardial contraction with hypothermia?

A

It increases but some pts do get dysfn

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165
Q

What is Rasburicase mechanism?

A

urate oxidase catalyst and oxidises uric acid to allantoin

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166
Q

Define MAP

A

DBP + 1/3(SBP-DBP)

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167
Q

What are the most common cardiac abnormalities?

A

ASD 17%
VSD 14%
ToF 11%
Coarc 10%

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168
Q

What is the relative rates of DU and PU bleeds?

A

PU 35-85%

DU 8-15%

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169
Q

What does the Rockall score predict?

A

Re-intervention and mortality postOGD

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170
Q

What does the glasgow Blatchford score?

A

Predicts outcome of someone in need of OGD for bleed and if have a score of 0-2 can be managed as OP

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171
Q

Is CT required for diagnosis of pancreatitis?

A

No, scan should only be if there’s uncertainty

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172
Q

Cardiac transmural pressure is the difference between intravascular and extravascular pressure. In the heart what does this approximate to given the pericardial pressure is usually zero?

A

End diastolic pressure

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173
Q

What does global end diastolic volume index mean and what is a normal value?

A

GEDVI represents the blood in the heart chambres and is normally 650-800ml

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174
Q

What is intra-throacic blood volume index?

A

It is the amount of blood in the thorax. Can be calculated from GEDVI (ITBVI=GEDVI x1.25)

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175
Q

What is Reye’s syndrome?

A

abrupt failure of mitochondria of unknown cause. Associated with acute viral prodrome followed by encephalopathy which progress to hepatic and metabolic decompensation. Aspirin in kids

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176
Q

What can hapen in the extremes of HELLP and the liver?

A

Sinusoidal obstruction can result in hepatic necrois, infarction, haemorrahge and rupture (1:40-250k)

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177
Q

Can alpha1 def cause heptaic failure in children?

A

Yes

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178
Q

What happens to serum Cu and ceruloplasmin in Wilson’s?

A

Low

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179
Q

What chelates Cu?

A

Penicillamine

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180
Q

What is Budd-Chiari?

A

Hepatic vein is occluded by thrombus or tumour

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181
Q

What sort of virus is HBV, HCV and HEV?

A

HBV- DNA

HC/EV- RNA

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182
Q

What % of HBV causes persistent infection?

A

5%

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183
Q

What is the first marker of HBV infection?

A

HBsAg (if persists >6/12 likely chronic infection)

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184
Q

What does interferon alpha and Lamivudine do to HBV?

A

Int alpha is immunmodulatory impairing HBV replication

Lamivudine directly blocks HBV replication targeting reverse transcriptase

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185
Q

Who with HBV have the highest risk of HCC?

A

100x more common in HBV patient. Those with HBsAg- and HBeAg +ve most at risk

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186
Q

What does a TIPS connet?

A

Tract between hepatic vein and intra-hepatic segment of portal vein

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187
Q

TIPS can occlude, what rate of stenosis at 2 years?

A

40%

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188
Q

If encephalopathy post TIPS how manage?

A

15% can be managed with drugs but the rest need the TIPS narrowed or occluded

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189
Q

Does HCV cause ALF?

A

Only 1% of cases get acute hepatic failure

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190
Q

What does Ribavirin do in HCV?

A

Used synergistically with int alpha

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191
Q

What do Boceprevir or Telaprevir do to HCV?

A

inhib NS3/4A enzyme with stops HCV polyprotein cleaving during replication

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192
Q

What is standard HCV treatment?

A

Boceprevir or Telaprevir in combo with peginterferon and Ribavirin for HCV 1. Can cause anaemia

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193
Q

How is a LiDCO setup?

A

Li transpulmonary dilutiono f 150mM Li into venous circ. An ex-vivo electrode attached to a peripheral art line draws a concentration time graph

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194
Q

What is the LiDCO calibration eqn?

A

CO=Li dose x 60/area under conc-time graph x (1-packed cell vol)

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195
Q

How measure intra-abdo pressures?

A

Foley cath in bladder zeroed at iliac crest in mid axillary line inflated with no more than 25ml saline. Measurement 30-60s after fluid instilled at end exp

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196
Q

How much caffeine in can coke? Tea? Red Bull?

A

Coke 30-40mg
Tea- 20-60mg
Coffee- 60-180mg
Red Bull 80mg

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197
Q

Fatal dose of caffeine?

A

150-200mg/kg about 5-10g

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198
Q 
What occurs if you have a radiation dose of 
0.5-1.5Gy
>1.5Gy
3-5
>10-20
A

0.5-1.5- N+V fatigue
>1.5- people start dying
3-5- 50% death rate with 60 days
10-20- dead in 2 weeks

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199
Q

Does a lead apron reduce expousre to zero?

A

Yes apparently though I’m not sold

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200
Q

What radiation exposure causes skin burns?

A

> 3 Gy

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201
Q

What is the cancer risk for adults having a CXR and CT?

A

CXR- 1:1,000,000

CT- 1:2000-1:2500(!)

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202
Q

Normal ICP?

A

7-15mmHg

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203
Q

How much does cerebral blood flow increase for 1mmHg rise in CO2?

A

3-4%

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204
Q

What is an EEG energy output?

A

between 20-200microV

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205
Q

What EEG is seen in status myoclonus?

A

sharp repetitive spikes or triphasic waves at about 1Hz

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206
Q

What is the Naloxone dose allowed in heroin OD?

A

0.4-2mg

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207
Q

What does botulism look like?

A

Afebrile descending symmetrical flaccid paralysis of motor and autonomic nerves

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208
Q

What is the 1 year mortality of critical ilness weaknes?

A

65%!

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209
Q

What measures of power may indicate need for mechanical vent eg in GBS?

A

VC <15ml/kg or <1L or reduced by 50% from baseline
negative insp flow <30cmH2O and exp force < 40.
Nocturnal desats

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210
Q

If arrest due to amitriptyline what do?

A

Prolonged resus at least 1 hr

intralipid 1.5ml/kg over 1min plus infusion if bicarb ineffective.

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211
Q

Dose of glucagon if needing for hypotension?

A

5-10mg with infusion at 50-150microg/hr

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212
Q

How do phosphodiesterases exert their effect?

A

Prevent breakdown of cAMP and cGMP therefore increase contractility, chronotropy, dromotropy and reduce SVR

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213
Q

How much of carotid blood flow goes into the MCA?

A

75-80%

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214
Q

What is the Lindegaard ratio and what is the upper limit of normal?

A

MCA to ipsilateral carotid flow velocity in TCD. > 3 or over 120cm//s is suggestive of vasospams

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215
Q

Define death

A

An irreversible loss of consciousness and irreversible capacity to breathe (no legal definition of death in the uk)

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216
Q

No heart sounds or respiration is used to declare death but what other measures are acceptable in hospital?

A

asystole, no art line trace or standstill on echo

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217
Q

How long should someone be observed if you are confirming death

A

5min-no pulse, no heart sounds.

After 5min of that check no pupil reflex, no corneal reflex and no movement to supraorbital pressure

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218
Q

Whats a FEEL echo?

A

a focused echo in emergency life support- basically a subcostal view which is achieved in the 10s pulse check and reviewed for tamponade, thrombus or hypovolaemia, severe ventricular dysfunction and new RWMA

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219
Q

In a spont breathing patient what sort of IVC collapsibility would you expect?

A

about 50% given neg pressure allowing greather inflow of blood to thorax in inspiration. Therefore collapsibility loss in spont breathing means high RA pressure

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220
Q

How are pericardial effusions classified?

A

Small, moderate and large (<0.5cm, 0.5-2cm and >2cm)

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221
Q

Over what altitude is gas expansion an issue for air-evacuation?

A

2000m, so rarely a problem as helicopters don’t usually go that high.

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222
Q

How much O2 do youn eed for a transfer?

A

2x transport time x ((MV xFiO2) + driving gas)

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223
Q

What does helicopter vibration do to the body?

A

blurred vision, nausea, fatigue but also messes up abaility to autoregulate esp in burns pts. Can also lead to wound fracture with associated pain/ deterioration

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224
Q

Febrile convulsions common betwen 6/12 and 5 yrs, are they usually short or long?

A

Can be prolonged

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225
Q

Doses of benzos in kids?

A

Loraz- 0.1mg/kg
Diaz 0.5
midaz 0.5

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226
Q

Dose paraldehyde kids?

A

0.8ml/kg PR

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227
Q

Dose Phenytoin kids

A

18mg/kg

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228
Q

Can osteonecrosis occur in HAART and HIV?

A

Yes in advanced disease

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229
Q

What are some metabolic effects of HAART?

A

fat redistribution, insulin resistance, dyslipidaemia

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230
Q

What are NRTIs, Stavudine in particular, known to cause

A

Lipodystrophy syndrome

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231
Q

What HAART drugs can cause SJS?

A

Nevirapine (NRTI) and protease inhibitors

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232
Q

What sort of virus is flu?

A

RNA

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233
Q

What surface proteins describe different flu strains?

A

Neurominidase(9), Haemagluttanin (16) and glycoproteins,

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234
Q

What is the role of haemagglutanin in flu?

A

attachment of virus to host resp epithelium

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235
Q

Can vasculitis, sarcoid, deymatomyositis and PMR cause a CK rise

A

Yes all autoimmune or rheum disorders can

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236
Q

Can hyer and hypo tyroid cause raised CK?

A

Yes both

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237
Q

Haemorrhagic fever has how many subtypes?

A

5- arena-, bunya-, filo-, flavi and rhabdoviruses

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238
Q

How is haemorrhagicfever transmitted?

A

blood-blood contact or body fluids though mucus membranes/broken skin

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239
Q

What s thetreatment of Lassa fever (memeber of arenaviruses)?

A

Ribavirin with weak evidene

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240
Q

What is etanercepts action? (same as infliximab)

A

TNF alpha inhibitor

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241
Q

If someone taking biologic agent come in with meningitis wht bacteriamay be the cause?

A

All the normal ones but also rarer things like listeriosis

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242
Q

Where do you get Listeria from?

A

eating contaminated food get fever and diarrhoea

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243
Q

What is the dose of Oseltamivir?

A

75mg BD PO for 5/7 (or 150mg BD for 10/7 in severe infection)

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244
Q

How does Clostridium Botulinum affect the body?

A

Creates a neurotoxin that acts on the pre-synaptic terminal of the neuromuscular junction preventing acetylcholine release

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245
Q

How is clostridium botulinum spread?

A

Person to person trasnmission does not occur. Get it from food/soil and home-made canned foods

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246
Q

The anti-toxin for botulinum toxin is immunoglobulin fragments. Can it be given in pregnancy and paeds?

A

Yes

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247
Q

What does Sarin do?

A

Inhib anticholinesterase (like organophosphate) leading to cholinergic crisis- miosis, rhinorrhiti,bronchospasm, weakness, resp arrest

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248
Q

What is the treatment for Sarin?

A

Atropine antagonises the muscarinic effects (and pralidoxime reactivates anticholinesterases at nicotinic sites

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249
Q

When is a lateral tilt used in pregnancy ALS?

A

15-30 degrees if known to be above 20/40 or you can see they are pregnant. If no tilt manually displace

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250
Q

How many more failed intubations are there in obstetrics?

A

about 8x

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251
Q

In maternal arrest, how long for skin incision and how long for delivery?

A

4min skin, 5min delivery

Delivery within 10min improved maternal outcome

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252
Q

In amniotic fluid embolus what happens to SVR and PVR?

A

Increased markedly (according to book but Clark in 1995 suggested its more like anaphylaxis)

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253
Q

If you find foetal material on maternal post-mortem can you conclude amniotic fluid embolus?

A

No, get some materialin normal labour

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254
Q

While waiting for liver what is the 1year mortaliy?

A

Those on thelist who didn’t get a liver had a 12% 1 year mort

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255
Q

In the anhepatic phase of liver transplant what happens to the LY30 and 60 (measures of % decrease of clot amplitude at 30 and 60min):

A

May see fibrinolysis in the patients including immediately post reperfusion

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256
Q

Circumstances of arrest is associated but not definitely causative of poor outcome. What is the PAR score?

A

Prognosis after resus uses seven variables and scores between -2 and 18 invented in Sheffield. Anything over 5 is terrible

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257
Q

Evaluating prognosis at 72 hrs in arrest patients is contentious wh?

A

one small study showed some who had absent corneal reflex or pupillary reflex on day 3 and myoclonic status regained awareness

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258
Q

Dose of oxytocin in emergency?

A

Slow push 5units, (rapdi 10 has killed people)

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259
Q

Define primary and secondary PPH

A

Primary within 24hrs

Secondary 24hr to 6/52

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260
Q

What usually causes PPH?

A

Uterine atony

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261
Q

Cell salavage in pregnacy?

A

Can be used but theoretically risk of foetal cells and amniotic fluid infusion

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262
Q

Virchow’s triad of bleeding (hypothermia, consumption products and acidosis) are known to worsen bleeding in trauma, what else?

A

activation of fibrinolytic pathway and tissue injury related generation of thrombin-thrombomodulin complexes (which convert thrombin from a coagulant to and anticoagulant)

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263
Q

trauma associated severe haemorrhage score uses what parameters?

A

SBP, Hb, intra-abdo fluid, complex long bone or pelvic fracure, HR, BE and gender

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264
Q

Dose of TXA in CRASH2?

A

1g then 1g over 8 hrs

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265
Q

Use of factor VIIa in trauma?

A

Has been shown to reduce transfusion requirements but no mortality benefit

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266
Q

Define a widened mediastinum

A

> 8cm

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267
Q

What % of trauma deaths are due to thoracic injury?

A

25%

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268
Q

Can diarrhoea cause a hyperchloraemic acidosis?

A

Yes, because you lose Na meaning Cl is relatively high

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269
Q

Maximum warm ischaemic time for liver, lung, kidney, pancreas?

A

Liver- 30min
Lung- 60min and time to re-inflation critical.
panc 30mni
kidney 120min but can be extended to 4hrs if deemed viable

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270
Q

Before DCD should coroner be informed if no concerns?

A

Yes, all DCDs should be discussed

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271
Q

Burn injury surface area can be simplified using what?

A

Wallace rule of 9s

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272
Q

What is the Parkland forumula?

A

4ml x weight x %burn= volume in first 24hrs with first half given over 8hrs then the rst over 16

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273
Q

What trace elements have evidence for them in burns?

A

Zn, Cu and Selenium decrease rates of infection, imp wound healing and dec LoS. Use of glutamate also reduces infec and length of stay however REDOXS study shows it may harm if patient also has sepsis and MOF

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274
Q

Would acidificationo f urine be useful in burn?

A

No, alkalinisation would be if you had haemoglobinuria and or myoglobinuriea though no level 1-3 evidence

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275
Q

In rhabdo what happens to albumin and calcium

A

hypoalb due to proteinuria

hyperca can be a late complication due to vit D release from damaged muscle but classically low ca

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276
Q

Treatment of myoedema coma?

A

Give T4 and some places also T3 though there is concern about cardiotoxicity of T3 in elderly. ALso 100mg hydrocort QDS because adrenal reserve may be low

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277
Q

In myoedemea coma what happens to vasoactive?

A

May be ineffective or cause arrhythmia, drug metab ay be decreased (dig for example)

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278
Q

OSCILLATE and OSCAR studies?

A

OSCILLATE was 548pts and showed mortality high in HFOV (48 vs 35%) but OSCAR around same time showed 41% each (more muscle relaxants for both HFOV groups)

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279
Q

How do B2 agonists lower K+?

A

cAMP dependent Na/K pumps is promoted

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280
Q

Maximum K infusion rate via CVC?

A

40mmol

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281
Q

How much more Ca in calcium chloride vs gluconate?

A

3x 6.8mmol vs 2.325

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282
Q

How is calcium stored in the body?

A

40% protein bound, 47% ionised and 13% complexed with citrate, sulphate and phosphate

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283
Q

What is Chvostek’s sign?

Trousseau’s sign?

A

Chvostek-Twitch of facial muscle when tapping facial nerve

Trousseau- carpopedal spasm following inflating blood pressure cuff for >3min

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284
Q

How is Ca corrected for albumin?

A

0.02mmol/L for each g below 40g/L albumin

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285
Q

Where is calcitonin secreted?

A

Parafolicular cells of thyroid

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286
Q

How do allopurinol and rasburicase differ?

A

Allopurinol decreases formation of uric acid where rasburicase promotes its breakdown

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287
Q

What did the CALORIES study find?

A

No difference in outcome or infection in enteral vs TPN but no advantage of TPN

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288
Q

What did EDEN study find?

A

1000 pts with acute lung injury got small amount of feed or full enteral feed. No difference

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289
Q

Selinium in septic patients?

A

May be of use from meta-analysis in 2013

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290
Q

What was the MELD score initially developed for?

A

Survival after TIPS

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291
Q

Lots of cardiac workup before liver transplant. Sometimes get HF post transplant why?

A

Relvatievly higher SVR can unmask cardiac dysfn

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292
Q

What sort of fever would you expct in thyroid storm?

A

> 38.8

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293
Q

Apart from high T4/T3 and no TSH what else would you see in thyroid storm on bloods?

A

high ALT, hyperCa, Hypergly and leucocytosis

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294
Q

What drugs for thyroid storm?

A

Propranolol- 60-80mg 4 hrly
Esmolol B1 selective as the absolute number of B1 receptors are markedly increased
and hydrocortisone coutner intuitively

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295
Q

In thyroid storm should you use meds that inhibit T4 secretion or those that reduce its synthesis?

A

Both sodium iodide inhibits release and propylthiouracil decreases synthesis

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296
Q

Contents Hartmans

A

Na 131, K 5, Cl 111, Ca 2, lactate 29

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297
Q

Advantage of Int care deliurum screening checlist over CAM-ICU?

A

CAM-ICU gives a dichotomous assessment at a certain point in time, ICDSC observes over time

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298
Q

What eqn is used to predict calorie requirement?

A

Harris-Benedict

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299
Q

Daily Ca requirement?

A

0.1mmo/kg/day

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300
Q

How many variables in APACHE II?

A

12

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301
Q

Over what time period is APACHE calculated?

A

from worst measure in first 24hrs

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302
Q

Can APACHE II be used in kids?

A

No

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303
Q

RDA vit C?

A

700-900microg

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304
Q

Can Mg be used as a tocolytic?

A

yes

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305
Q

Where is Clichy criteria for liver transplant used?

A

Northern Europe-interestingly uses age, enceph, coagulopathy and factor V levels- Kings is better it would seem

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306
Q

How is pyruvate converted to lactic acid?

A

By lactate dehydrogenase

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307
Q

What does research suggest we aim for in terms of lactate reduction in septic shock/

A

If lactate >3 decreasing by 20% over 2 hours period is associated with a reduction in mortality

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308
Q

When is there good evidence for RBC transfusion>

A

Post renal liver and cardiac transplant

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309
Q

Define TRALI

A

new acute lung injury characterised by acute dyspnoea with hypoxia and bilateral pulmonary infiltrates with non-cardiogenic pulm oedema within 6 hrs of transfusion

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310
Q

What stratgergies have been employed to reduce TRALI?

A

leucocyte deplete, men only, pooled (to dilute ab) and screening for people with anti-leucocyte antigen antibodies

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311
Q

over what time frame does a necrosed pancreas organise a wall?

A

After 4 weeks

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312
Q

If you have pancreatic necrosis, do infections make the systemic effects worseor better?

A

systemic effects and MOF are no different in steril vs infected necrosis

313
Q

If you have pancreatic necrosis is surgery or endoscopic drainage superior?

A

Endoscopic drainage due to less morbidity and cost

314
Q

If adenosine contraindictaed what drug and dose?

A

Verapamil, 2.5-5mg

315
Q

If in third degree HB and awaiting temp pacing wire, what drugs can be used to get your through?

A

Atropine and glyco but also isopren and adren

316
Q

When should verapamil be avoided in VT?

A

VT with severe LV failure

317
Q

What sort of HME filters bacteria?

A

Hydrophobic

318
Q

Whatrelative humidity can nose achieve?

A

80%

319
Q

With chest drain insertion should prophylactic abx be used?

A

Yes, less chance of empyema and all infections

320
Q

What level of suction should be applied to a chest drain?

A

Book says 10-20cmH2O

321
Q

Why is ketamine contra in preg?

A

Increases uterine pressure and cause foetal asphyxia, most evident in third trimester

322
Q

Does sux cross the placenta? Is its action prolonged?

A

No, relative reduction in plasma cholinesterases means it last longer

323
Q

What are category A and B biological weapons?

A

A- easy to distribute- anthra, smallpox, botulism

B- moderately easy- Q fever, Typhus

324
Q

What sort of bacterium is Antrax

A

Bascillus

325
Q

How treat Antrax?

A

60 day post exposure prophylaxis, penicillin is effective in natural variety but with genetic engineering there are concerns over resistance

326
Q

what is the incubation for Anthrax?

A

2-60days

327
Q

Survival of Anthrax?

A

10-15% naturally, 55%with treatment

328
Q

Most common cause of VAP?

A

Aerobic gram -ve (E.Coli, Klebsiella, Proteus)

329
Q

How long after fondaparinux can you put in an epidural?

A

42 hrs for removal, 36 hrs for insertion

330
Q

Define TEG R value

A

Time from initiation to fibrin formation (15-30mm) Prolonged in anticoag use and haemophillia

331
Q

Define TEG K value

A

Time measured from end of R time (clot formation starts) until amplitude of 20mm (normal 6-12mm). Prolonged in antiplt

332
Q

What is a normal MA in TEG?

A

50-60mm

333
Q

What is a normal LY30?

A

<7.5% degredation at 30min

334
Q

What is alpha-angle in TEG?

A

measures the acceleration of fibrin buildup and cross-linkage.

335
Q

Is NIV allowed in bowel obstruction?

A

Book says no because risk of aspiration…is this true in large bowel obstruction without nausea too??

336
Q

What % of phaeos are malig?

A

10%

337
Q

What are lab findings in phaeo?

A

Hypergly, hyperCa and erythrocytosis

338
Q

Why is beta bloackade only started after 2 days of alpha blockade in phaeo?

A

Unopposed alpha may give rise to a hypertensive crisis

339
Q

What tumours in MEN I?

A

Pituitary, parathyroid and pancreas

340
Q

MEN IIa and IIb?

A

2A- Para, medullary thyroid, phaeo

2B- Mucosal neuroma, marfanoid habitus, meduallry thyroid, phaeo

341
Q

Addison’s causes distributive shock with low SVR, what is Waterhouse-Friderichsen syndrome?

A

adrenal gland failuredue to bleeding into glands seen in meningococcaemia

342
Q

What deficiency does acute steroid withdrawal cause?

A

Acte glucocorticoid def

343
Q

If Addisons and want to do a short synacthen later what drug can you use?

A

Dex

344
Q

What is a rare finding in Addison’s?

A

1/3 have hyperCa

345
Q

Which Candida have natural resistance to fluconazole?

A

Krusei and glabrata, though the latter is dose dep resistance

346
Q

Risk of AAA rupture follows the law of LaPlace, what is the annual risk of ruputre for a 6-7cm and 5.5cm?

A

6-7cm 6.6%

5.5cm 0.5-1%

347
Q

Blood products are first line in AAA rupture. How does GI haemorrhage occur?

A

Can rupture into the duodenum or colon in their retroperitoneal portions

348
Q

How many umbilical veins are there?

A

One (two arteries)

349
Q

What is the umbilical vein sats?

A

80%

350
Q

What % of blood in foetal circulation enters the RV?

A

1/3

351
Q

What did PAC-man find?

A

PAC- no evidence harm or benefit but the FACCT trial showed no mort benefit but more complications with PAC

352
Q

How is the AUCon thermodilution related to CO?

A

it is inversely related, if low CO the area is large because it takes more time to warm up the thermistor with blood again

353
Q

How does Ticagrelor work?

A

ADP receptor blocker

354
Q

How long after STEMI do you have to get PCI according to the guidelines?

A

90min if in a PCI hospital

120min if in a non-PCI hospital

355
Q

What anticoagulant is best given in PCI lab in addition to aspirin and ticag?

A

Bivalirudin is preferred over heparin with a mortality benefit seen

356
Q

Dose of Bivalirudin?

A

0.75mcg/kg IV with infusion 1.75mcg/kg/hr for 4 hrs with reduced doses of 0.25mcg/kg/hr from 4-12hrs.
Fondaparinux is not given due to potential harm in the Oasis 6 trial

357
Q

What do if PCI not available in 120min?

A

Fibrinolysis within 12 hrs

358
Q

When is fibrinolysis considered to have failed in ACS?

A

If there is on-going inschaemia, evidence of re-occlusion or <50% ST resolution at 60min…if occurs PCI.

359
Q

What is dumping syndrome

A

post obesity surg carbs are dumped into small bowel 15min to 2hrs after meal leading to sweating, dizziness, tachy, nausea, diarrhoea. Common after Roux-en-Y

360
Q

What are the preservatives in RBC and how long can they be stored?

A

SAGM- saline, adenine, glucose, mannitol-35 days

ACPD- adenine, citrate, phosphate and dextrose- 42days

361
Q

What temp are plt stored at and how long before bacterial contamination a concern?

A

20-24C 5 days

362
Q

How do you ABO match platelets?

A

Compatible are preferable but incompatible can be used in emergency as the plasma content is so small

363
Q

What temp is FFP and Cryo stored at?

A

FFP -20

Cryo -30

364
Q

How do you ABO match FFP?

A

Must be used immediately after thawing and must be ABO matched. Contains clotting factors, fibrinogen and plasma proteins

365
Q

How many donors for one cryo?

A

1

366
Q

How is cryo made?

A

Precipitate from FFP

367
Q

How long can you store cryo?

A

12/12

368
Q

Cryo needs to be ABO compat, what does it contain?

A

High levels factor VIII and fibrinogen

369
Q

What does the posterior column transmit?

A

Fine touch, vibration and proprioception and two-point discrimination

370
Q

What is transmitted in the spinothalamic tract?

A

Pain and temp in the lateral column

371
Q

What attache to the coccyx at the end of the spinal cord?

A

Filum terminale

372
Q

What is the arteria radicularis magna? Where does it arise and what does it supply?

A

Artery of Adamkiewicz

Arises from L post intercostal artery supplying the lower two thirds of the spinal cord via ant spinal art

373
Q

How can protamine cause RV failure?

A

the proamine heparin complexes stimulate complement and produce thromboxane which leads to high PVR (bit of stretch if you ask me)

374
Q

Is albumin a good marker of liver synthetic fn?

A

Not acutely but chronically yes

375
Q

ALT is more liver specific than AST, why?

A

AST in skeletal muscle and myocardium along with others.

AST up in renal/bowel infarction, pancreatitis and hypothyroid

376
Q

What do raised ammonia levels imply?

A

reduced liver synthetic fn

377
Q

INR goes up in liver disease and is a good measure of synthetic dysfn (when no vit K def), what factor is most affected?

A

VII low levels

378
Q

Official dose range of NA?

A

0.1-2microg/kg/min

379
Q

Where does NA mostly act?

A

alpha 1 in vascular smooth muscle promoting vasoconstriction, at high doses get beta effects

380
Q

What % of NA is metabolised in lung?

A

25% (adrenaline and dopamine no)

381
Q

What did the VASST study find>

A

low dose vasopressin did not reduce mortality

382
Q

How many strokes are haemorrhagic?

A

10-30%

383
Q

ICH may expand by up to 33% in the first hours, when do you treat BP?

A

If >180/105 but is risk/benefit, BP>90 to prevent infarction due to pressure effects

384
Q

Urine acid or alkalinisation in aspirin OD?

A

Alkalinisation to between 7.5 and 8.5

385
Q

Why may aspirin OD look like a NAGMA?

A

The salicylate acid is mistaken for chloride by the ABG machine and therefore you calculate a NAGMA

386
Q

What is a bezoar?

A

a mass trapped in the GI tract (drug mule)

387
Q

What is the target pH in aspirin OD?

A

7.5-7.6 which should be rememered when ventilating! oOtherwise the profound acid can be deadly

388
Q

In pregnancy plasma expands by how much?

A

45%

389
Q

If a term preg woman lies flat what happens to IVC and SV?

A

in 90% IVC will be completely occluded

CV dec by 30%

390
Q

How much is CO inreased in third trimester?

A

50%

391
Q

How much does FRC reduce at term?

A

20% or more when supine

392
Q

What happens in hypovolaemia in hearttransplant?

A

Delayed response due to denervation

393
Q

Can you use adenosine in heart transplant?

A

No, has an exaggerated response

394
Q

What views in FAST scan?

A

Subcostal, right upper quad, LUQ, suprapubic

395
Q

What volumes can FAST find?

A

100-250ml minimumm

396
Q

What is Pendelluft effect?

A

Exchange of gas betwen adjacnet lung units due to their differing time constants. Insp fast filling fill first, exp opposite

397
Q

What is the principle mechanism of gas transport in the terminal airways?

A

Molecular diffusion

398
Q

Can ECMO be used in DCD?

A

yes

399
Q

Can normal saline cause abdo discomford?

A

Apparently…how the hell you work that out I dont know

400
Q

Where is K stored in body?

A

98% intracelular in particular skeletal muscle

401
Q

What % potassium absorbed by body is ultimately excreted by kidney?

A

90%

402
Q

The Na/K pump transporthow many of each cation?

A

2K for 3Na

403
Q

How much hospital AKI is due to contrast?

A

About 12.5%

404
Q

Is fluid loading or bicarb more useful in protecting against contrast neph?

A

bicarb is better

405
Q

theophylline has been proposed as a way to prevent contrast neph, by what mechanism?

A

Inhibition of adenoseine A1 receptor which mediates afferent renal vasoconstriction

406
Q

What does the trochlear nerve innervate?

A

IV SO4 superior oblique

407
Q

What nerve for muscles of mastication?

A

Trigeminal

408
Q

Where does the abducent arise? Where does it classically get compressed?

A

Lower pons (VI), if ICA aneurysm get palsy

409
Q

How does tongue get its sensation?

A

post 1/3 glossopharyngeal, ant 2/3 facial nerve

410
Q

AF affects about 1.5-2% pop. By how much does it increase stroke risk?

A

5x and 3x risk of HF

411
Q

What is Vernakalant and when should it be used and not used?

A

It is superior to amiodarone in cardioverting AF in stable patients but should be avoided in HF, hypotension, ACS, severe AS and prolonged QTc

412
Q

When is dronedarone given?

A

maintains SR in those with PAF but should be avoided in mod/severe HF and avoided in mild HF if an alternative exists

413
Q

How does acute acalculous cholecystitis occur?

A

uncommon but secondary opportunistic infection, iscahemia and hypoperfusion and also in immunocomp

414
Q

When does acute acalc cholecystitis occur?

A

Men post trauma or surgery

415
Q

Who should get USS monitoring for acute acalc cholecystitis?

A

Trauma pt with ISS>12 who are tachy and getting blood

416
Q

What are non trauma causes of acute acalc cholecystitis?

A

Vasculitidies can cause it inc antiphosphlipid syndrome (give anticoag rather than cholecystectomy) others like SLE and Henoch-Schonlein purpura may need steroid

417
Q

What is mort of acute acalc chole without treatment?

A

50-85%

418
Q

Is RRT any good for diltiazem and metformin OD?

A

Diltiazem too large , relatively ineffecive

Metformin very soluble and readily removed by RRT. Start if severe lactic acidosis

419
Q

What is the upper limit of normal FTc in anaesthetised pt and why higher than normal?

A

400ms due to low SVR under GA

420
Q

What is FTc

A

Forward flow in aorta corrected for HR

421
Q

Initial antiplt in ichaemic stroke?

A 
aspirin 300mg (held for 24hr if throbolysed), and clopidogrel. DAPT superior to asp alonein preventing further stroke in first 90 days without inc risk of bleeding
This seems incorect- only aspirin in the guideline
422
Q

Why are statins not given immeditely post stroke?

A

Higher levels of haemorrhagic transformation reported so start at 48hrs

423
Q

If you knock out the artery of Adamkiewicz what happens?

A

motor impairment with extensive bilateral paralysis plus loss of pain and temp with preservation of post column (position, vibration and touch) aka ant cord syndrome

424
Q

What is Conus Medullaris syndrome?

A

Injury at T12/L1 with damage to lumbar and sacral cord leads to extensive paralysis in legs

425
Q

How does central cord syndrome present?

A

UL>LL and bladder dysfn

426
Q

How does Brown-Sequard present?

A

Ipsilateral motor and prop, contra pain and temp equal ‘loss’ on both sides

427
Q

How are starch based fluids made?

A

Hydrolysed maize

428
Q

With albumin as 1, what is the relative rate of anaphylactoid reactions to HES, dextran and gelatin?

A

HES-4.5
Dextran -2.3
Gelatin 12.4

429
Q

Why is starch not recommenede in ICU?

A

MAy lead to higher need for RRT and death

430
Q

What side effect of starch do 13% people get?

A

Itch

431
Q

What % of post liver resection pts have a major complication( bleeding, liver dysfn, resp failure, sepsis, infection)

A

30%

Seems high to me

432
Q

Liver resection pts kept dry but what may make them even more deplete?

A

Self limiting ascites in first 48hrs which may be helped by HAS in immediate post op

433
Q

When can paracetamol be used post liver resection?

A

Usually avoided immediately post op but once LFTs normal can be used

434
Q

What does hypoPO4 mean in liver resection pt?

A

PO4 rapidly consumed in liver regeneration via high ATP production so can be low when regenerating

435
Q

Is PTX frequent in VILI?

A

Apparently so

436
Q

What is thought to be the initial mechanism in barotrauma?

A

Development of extra-alveolar air due to perivascular alveoli disruption

437
Q

What cytokines are important in lung biotrauma?

A

TNF Il 6 and 8

438
Q

How many grades of encephalopathy are there?

A

5 with grade 0 being normal ! FFS

439
Q

What levels of ammonia are associated with cerebral oedema?

A

> 200g/dl

440
Q

Is Rifaximin NICE approved?

A

No

441
Q

What current flow across chest is needed to induce VF?

A

100mA

442
Q

What radiation exposure is needed to alter blood counts?

A

1Gy

443
Q

MH is auto dom or recessive?

A

Auto dom

444
Q

What receptors are involved in MH?

A

dihydropyridine receptor and ryanodine receptor (Ca efflux) on SR

445
Q

Dose of Dantrolene for MH?

A

2.5mg/kg up to 10mg/kg

446
Q 
Normal CSF
osmo
specific grav
gluc
Cl
Protein?
A 
280mOsm/kg
1.005
1.5-4
Cl 120-130 HCO3 25-30
Pro 0.15-0.3g/L
447
Q

What are the boundaries of the thoracic inlet?

A

1st T vertebra, manubrium and first rib and costal cartilage

448
Q

What separates the subclavian vein and artery?

A

Scalenus anterior

449
Q

What goes through thoracic inlet?

A

Trache oesoph, large vasc trunks, vagi, thoracic duct, phrenics, cervical sympathetic chain

450
Q

Where is the cricothyroid cartliage?

A

Between thyroid cartilage and cricoid cartilage

451
Q

What is the space overlying the cricothyroid muscles that allows access to the cricothyroid membrane?

A

9mm

452
Q

Is the cricothyroid avascular?

A

Not completeley, have branches from sup thyroid

453
Q

Are bypass and RRT acceptable to jehovah witnesses?

A

Yes as is EPO, VIIa and Fe and TXA

454
Q

Indications for RRT?

A 
AEIOU
acidosis
electrolyte (usually K)
Ingestion of toxins (ffs)
overload
uraemia with complications
455
Q

What physical principle does haemofiltration use?

A

Convection for small and middle size molecules

456
Q

What physical principle does haeodialysis use?

A

diffusion

457
Q

Where is the mutaton in Sickle cell disease?

A

Chrom 11 causing amino acid substitution i beta globin subunit

458
Q

What causes thalassaemia?

A

Defective synthesis of alpha and beta globin subunits

459
Q

Does vit K def result in prolonged bleeding time?

A

No

460
Q

Does aspirin and uraemia lengthen APTT/PT?

A

No only bleeding time

461
Q

What is the M:F ration in IE?

A

2:1

462
Q

What species should be considered in culture negative IE?

A

Coxiella burnetti, Legionella, Brucella, Bartonella, Chlamydia

463
Q

What, using Duke is confirmed IE

A

2x major
1 major, 3 minor
5minor

464
Q

Cure rate of abx in IE?

A

50% the remaining require surgery

465
Q

Define HRS

A

Cr >133micromol/L in cirrhosis and ascites where no other diagnosis found

466
Q

What is the pathophysiology of HRS?

A

Protal htn starts off resulting in NO overproduction, then get RAAS and sympathetic upreg with water and Na retention. Renal autoreg altered making it more sensitive to MAP changes. As cirrhosis worsens more systemic dilatation occurs resultingin further renal constriction and fuctional renal failure

467
Q

Which of type I and II HRS is worse?

A

type 1 (cr>221)- occurs in 2 weeks usually secondary bacterial infection that decomp liver.

468
Q

When should surgery for AS be considered?

A

When symptomatic and those who are not with low risk

469
Q

How is mitral stenosis usually treated?

A

Most with good anatomy have a perc mitral commussurotomy

470
Q

How long after bioprosthetic AV do you take aspirin?

A

3 months

471
Q

In hypertesnive crisis how muc do you lower BP?

A

10-20%

472
Q

GTN dose IV?

A

0.5-20mg/hr

473
Q

SHOT reports divide reactions into what?

A

acute (<24hrs)

Delayed(3-10/7 post)

474
Q

Blood product reaction may be subtle inder GA, what may be the only signs?

A

urticria and hypotension

475
Q

Can Coombs test be used to check for ABO incompatibility (along with others) resulting in haemolysis?

A

Yes

476
Q

What is the risk of bacterial contamination in plt and RBC?

A

Plt 1:2000

RBC 1:500,000

477
Q

Bazzett’s formula is what?

A

QTc=QT/square root RR

478
Q

How does pulmonary fibrosis give a reading for PCWP not close to LVEDP?

A

The venous obstruction

479
Q

How does Mg affect Ca?

A

If low or very high can cause hypoCa

480
Q

Pseudohypoparathyroid is primarily a function of what and what subtypes?

A

PTH resistnace

1a,1b and 2

481
Q

Outline pseudohypoparathyroid 1a,b and 2

A

1a- Albright’s- short 4/5thmetacarpal and round face, ass with TSH resistnace too
1b- same as 1a but normal face/hands
2- normal reponse to PTH but abnorml Ca regulation

482
Q

what can pseudopseudohypoparathyrodism be considered?

A

A variant of Albright 1a pseudohypoparathyroidism, have the short fingers and round faces but normal gland function

483
Q

After NSTEMI how long until angio +/-PCI/

A

72 hrs unless high risk (ongoing pain, arrhyth etc)

484
Q

What is the ARR of PCI in STEMI?

A

3% (8->5% mortality)

485
Q

Ifyou have left main or three vessel disease is CABG or PCI better?

A

CABG

486
Q

Can Neostigmine be used in pseudo-bstruction?

A

Not first line but if conservative measures failed can with cardiac monitoring

487
Q

Is fluid and eletrolyte replacement wiith NG decompression useful in adhesional bowel obstruction?

A

Yes apparently though I think time is the most therapeutic component

488
Q

Is CT helpful pre-laparotomy?

A

If peritonitis CT and USS have limited yield and increase time. CT with contrast however is useuful in finding leaks and collection

489
Q

cellurlar prion protein occurs natually in humans and animals where is the gene located?

A

Chrom 20

490
Q

What happens if there is a mutation in the prion protein gene?

A

Accumulation of abnormal proteins and death ensues

491
Q

What is the scarpic isoform of prion protein

A

Abnormal form which can be innoculated or ingested or acquired from inherited mutation. In converts normal prion protein to abnormal accumulating and is associated with loss of synapses and neuronal death

492
Q

What is the best way to test for prion disease?

A

Tonsillar biopsy 100% sens (bloods 70%)

493
Q

What is the WHO defn of CJD?

A

progressive psych disorder of less than 6/12 with no alternative diagnosis

494
Q

What is the M:F split in gastroparesis?

A

1:4

495
Q

What are risk factors for secondary gastroparesis?

A

T1DM, abdo surgey- vagotomy, fundoplications, bariatric surgery, HypoT4, rheum conditions

496
Q

What scores do albumin get in Child-Pugh?

A

> 35=1
28-35= 2
<28=3

497
Q

What is the 1 year survival for C-P A, B, C cirrhosis?

A

A- (5-6)=100%
B- (7-9) =80%
C-(10-15)=45%

498
Q

Is Child-Pugh better or worse than APACHEII at predicting prognosis of critically ill patients with liver disease?

A

Worse (SOFA is better than CP too)

499
Q

What do people with paraquat poisonoing die from?

A

Fibrosis (O2 during resus probably makes them worse)

500
Q

How does strychnine work?

A

antagonist of glycine->inc muscle toe, twitch, seizures

501
Q

What are the symptoms of organophosphate OD?

A 
DUMBBBELS
Diarrhoea
URination
Miosis
Bronchorrhoea
Bronchoconstriction
Bradycardia (but tachy can also occur)
Emesis
Lcrimaion
Salivation
'everything comes out of you'
502
Q

How does short bowel syndrome cause lactaemia?

A

Raised D-lactate causing type B hyperlact

503
Q

What does baclofen OD look like?

A

Can mimic brainstem death with fixed pupils for days to weeks. Intubation is needed in all but the most minor intrathecal OD

504
Q

What does baclofen toxicity often present with?

A

hypotension and hypothermia with reboudn hypertension, hyperthermia and hallucinations on withrawal

505
Q

Is RRT any good in baclofen OD?

A

yes

506
Q

How does baclofen work?

A

GABA(b) agonist so down regulates everthing

507
Q

Whats the difference between hyperthermia and hyperpyrexia?

A

Hyperthermia is fever, hyperpyrexia is where the set point for temp is raised

508
Q

How does ecstasy give sympathetic over activity?

A

dopamine release

509
Q

NMS results in true hyperpyrexia, how?

A

antagof D2 receptors in hypothalamus and spinal cord. This increases the temp set point and impairs heat dissipating mechanisms

510
Q

Why does bromocriptine sometimes work in NMS?

A

It is a D2 agonist (antipsych are D2 antag)

511
Q

Whats the danger with phenytoin and status?

A

Extravasation can cause nasty burns and necrosis

512
Q

How does keppra work?

A

Nobody knows but its not Na+ cannels, GABA or glutamate. ? works on synaptic vesicle protein 2 influencing Ca signalling

513
Q

What are the 4 mechanisms of diarrhoea?

A

Osmotic, secretory,inflamm and dysmotility

514
Q

Define osmotic and secretory diarrhoa

A

Osmotic- failure of gut to absorb solutes and therefore retain water in lumen (laxatives, bile salt malab, short gut synd)
Secretory- inc sec or reduced absorb of salt/water (endotoxins/laxatives)

515
Q

Define inflamm and dysmotility diarrhoea

A

Inflamm- loss of mucosal integ

dysmotility- fluid/electrolyte stay in SB which then overwhelms the large bowel ability to absorb

516
Q

HSV is most common cause of enceph in developed countries, which one?

A

90% HSV1

10% HSV2 (more immunocomp and kids)

517
Q

Treatment for VZV enceph?

A

Limited evidence but given aciclovir for 14/7 and shot course steroids to reduce inflamm

518
Q

What do 20% of those who are receiving aciclovir get?

A

reversible obstructive neph secondary crystalluria (usually after about 4days)

519
Q

What % enceph is unknown cause and what % VGKC/NMDA ab?

A

50% uknown

8% voltage gated K channel and NMDA ab

520
Q

Define delirium

A

disturbance of consciousness, change in cognition, developed over a short period with fluctuations
or
sudden severe confusion and rapid changes in brain fn that occur with physical/mental illness

521
Q

What % patients ahve hyperactive delirium and hypoactive?

A

2% have hyperactive

522
Q

Lidocaine Vaughan williams class?
Propranolol?
Flecanide?
Verap?

A

Lido- Ib (Na blocker)
Prop- II
Flec Ic
Verap- IV

523
Q

Which is faster midaz or loraz?

A

Midaz (2-5) vs loraz 5-10

524
Q

Half life of midaz and loraz?

A

Loraz 8-15hrs

Midaz- 3-11

525
Q

What are phase 1 reactions?

A

All oxidative

526
Q

Zero order and 1st order kinetics?

A

zero- contatnt amount of drug removed per unit time

1st- amount drug removed prop to concentation

527
Q

Which of alkali vs acid ingestion cause liquefactive necrosis?

A

Alkali

528
Q

Rates of c-spine injury and TBI in paeds?

A

2% c-spine but 75%TBI

529
Q

What agents are approrpiate and in what dose for Paed RSI?

A

Ketamine 1-2mg/kg
Thiopental 2-5mg/kg
Sux 1-2mg/kg
Etomidate 0.3mg/kg

530
Q

What malarial species causes the most deaths?

A

P.Falciparum

531
Q

In P. Falciparum where does infecrion initialy develop?

A

Liver then RBC (incubation 9-14 days)

532
Q

Whatis gold standard for malaria diagnossi?

A

Thick and thin blood films

533
Q

TB causes 3million deaths annually, how oes primary and secondary TB present?

A

Primary asymp usualy. Over 90% of TB is secondary in non-HIV group

534
Q

How does Botulism present?

A

Acute descending motor paralysis (cranial resp and autonomic nerves0

535
Q

What does botulinum toxin do?

A

Bloacks acetylcholine release fro presynapse

536
Q

How is botulinium toxin tested for?

A

ELISA and electrochemicaluminecent test or tissue culture

537
Q

How does tetanus cause its effects?

A

Inhibits presynaptic GABA

538
Q

Treatment for tetanus?

A

Metronidazole to kill clostridium tetani, immunoglobulin sedation, muscle relaxants, benzos and management of autonomic dysfn

539
Q

C. diff is what sortof bacteria?

A

G+ve anaerobic bacillus

540
Q

What do c.diff enterotoxin A and cytotoxin B target>

A

Rho proteins are target within colonic cells leading to diarrhoea

541
Q

Where may the future issues be in drug resistnace?

A

G -vebascilli as no new drugs for years

542
Q

What has VRE evolved?

A

mutated penicillin binding protein

543
Q

In addition to b-lactams what else are ESBLs usually resistant to?

A

Aminoglycosides and quinolones

544
Q

in preg what happens to clotting factors?

A

Increase except XI and XIII

545
Q

What happens to platelet function in preg?

A

Remains normal, there is a relative low count given plasma expansion

546
Q

Risk of VTE in preg? And post partum?

A

10x throughout and 25x post partum

547
Q

Is thrombolysis allowed in pregnancy?

A

Yes

548
Q

What is Mendelson’s syndrome?

A

Aspiration pneumonitis

549
Q

What are the common casues of infectionin preg?

A

Chorioamnionitis, post partum endometritis, UTI, pyelo, septic abortions

550
Q

How long should empiric abx be used for according to surviving sepsis?

A

3-5 days

551
Q

Glucocorticoids synthesised where>

A

zona fasiculata or cortex

552
Q

Where are
aldosterone
androgen sex hormones and catecholamines secreted?

A

Aldost-zona glomerulosis
sex-zona reticularis
catecholamines- adrenal medulla

553
Q

Where is glucagon made?how does it act?

A

Alpha cells in islet of Langerhans, opposes insulin via second messenger cAMP

554
Q

What size ETT for neonate at term?

A

3.5mm

555
Q

What do you assess in neonatal resus?

A

colour, tone, RR, HR

556
Q

Without antiviral prophylaxis what rate of CMV infection post solid organ trans?

A

23-85%

557
Q

What are predictors of re-admission to ICU post discharge with liver transplant?

A

Abnormal XR on dc,high CVP, tachyponoea, age, abnormal pre transplant synthetic fn, abnormal bili, large intra op product requirement, renal dysfn.
Commonest cause is overload and infection

558
Q

How many ant and post spinal arteries?

A

Two post, one ant

559
Q

What % of spinal column fractures lead to cord injury?

A

14%

560
Q

In spinal cord injury what % develop VTE and PE?

A

90% VTE, 10% PE

561
Q

How good is ciclosporin’s PO availability?

A

Uncertain gut absorption and bioavailability is poor

562
Q

What sort of anion gap acidosis does acetazolamide cause?

A

NAGMA

563
Q

What tests can be used in non-parametric data?

A

Mann-Whitney U tests, Wilcoxon matched pairs and Spearman’s rank co-efficients

564
Q

Well’s criteria for PE?

A 
HR>100
Immobilisation
PrevDVT/PE (1.5)
Clinically evident DVT
other dianosis less likely than PE (3)
haemoptysis
Malig
6or more 87.4% chance of PE, <2 only 3.4%
565
Q

What is the maximum time an inner tube should be in a trache without cleaning?

A

7-14 days…I’d be amazed if anyone has ever reached that

566
Q

What is the upper limit of pressure for hyperinflation physio techniques?

A

40cmH2O

567
Q

Sedation slows mucocillary clearance,whenuse cough assist?

A

When pt has exp muscle weakness

568
Q

What is Bartter’s sndrome?

A

Inherited defect in thick ascnding limb, K loss and high aldosteronewith normotension. If low HCO3 could be an RTA

569
Q

Whatis the Fowler method utilised for?

A

Measureanatomical dead space

570
Q

Howcan resp drive be measured?

A

airway pressure 0.1s after occluding airway against insp effort

571
Q

Where’s calcium found in body?

A

> 98% in bones

572
Q

ECG changes in hyperCa?

A

wide T wave, short QT

573
Q

What does secondary hyperparathyroidism look like?

A

appropriate hyperPTH due to low Ca so normally have normal Ca but canbe hyper or hypo

574
Q

What do thiazides do to Ca?

A

HyperCa

575
Q

What are recognised treatments for hyperCa?

A

Mithramycin, steroids, calcitonin, bisphos

576
Q

incidence of prop infusion synd?

A

1.1%

577
Q

What ppt the metb acidosis in PRIS?

A

Renal failure and lactic acidosis

578
Q

What ECG changes in PRIS?

A

Brugada-like changes also AT, bradys, BBB and eventually asystole

579
Q

Risk factors for PRIS?

A

head injury, sepsis, high catecholamines and glucocort levels, low carbs:lipid ratio and inborn errors

580
Q

2g Mg is how many mmol?

A

8

581
Q

What can cause hypoMg?

A

diuretics, ACEi, aminoglyc, amphotericin, cyclsporin, cisplatin

582
Q

ECG findinds inhyperMg?

A

long PR, QRS and QT

583
Q

What is the Ostrosky-Zeichner rule used for?

A

Had a high negative predictive value of those who will not develop invasive candida

584
Q

normal daily GFR?

A

180L

585
Q

5mg pred = ?hydrocort

A

20mg

586
Q

Prednisolone is equal to prednisone in potency but how much methypred =5mg Pred?

A

4mg

587
Q

Dex and Betamethasone have the same conversion from pred, 5mg pred =?

A

0.75mg

588
Q

GI bleed in HIV, mostly HIV or something else?

A

70% lower GI bleed is HIV related eg CMV colitis.

589
Q

Most common causative organism in HIV meningitis

A

cryptococcus neoformans

590
Q

If have cANCA and PR3 ANCA what is 99% likely?

A

GPA

591
Q

If you have CF what ANCA are you likely to have?

A

cANCA with MPO -ve

592
Q

What drugs can cause ANCA vasculitis?

A

minocycline, hydralazine and propythiouracil

593
Q

what is the calorific value of propofol?

A

1kcal/ml

594
Q

What are the effects of adrenalin?

A

Beta at low dose, alpha at high

595
Q

What Ig is responsible for anaphylaxis?

A

IgE though in some it may be IgG

596
Q

How does adrenalin help in anaphylaxis?

A

It increases cAMP in leukocytes and mast cells therefore inhibiting further histamine release and improves cardiac contractility and SVR and bronchial smooth muscle tone.

597
Q

Risk factor for latex allergy?

A

Healthcare worker, strawberry/kiwi allergy and spina bifida

598
Q

60% of all anaphylaxis is from muscle relaxants, which is the most likely to cause anaphylaxis?

A

Sux

599
Q

What WBC abnormalities are diagnostic of sepsis?

A

> 12, <4 or normal count with >10% immature forms

600
Q

What mixed venous sats would suggest sepsis?

A

> 70% due to microvascular shunt

601
Q

If someone has drowned how many rescue breaths?

A

5

602
Q

In drowning what immersion time indicated prolonged asphyxia?

A

10min

603
Q

If inadvert intra art thio what do?

A

Leave catheter and run 0.9% NaCl through it and assess. Injury mechanism unclear but may be endothetial inflam, crystal formation, thrombus, high osmolarity, lipid solubility, direct cytotox or vasospasm

604
Q

How many panels are there on a CPET?

A

9 panels (2,3,5 CV, 1,4,7 vent and 6,8,9 VQ)

605
Q

What does peak VO2 correlate with although under the control of the pt at testing

A

Cardiopulm complications after oesophgectomy and AAA

606
Q

Define anaerobic threshold

A

The point at which the rate of increase of CO2 exceeds the rate of increase of VO2

607
Q

What should happen to a patient with an AT<11ml/kg/min?

A

Admit ICU post op

608
Q

In TURP syndrome what fluid is used?

A

glycine 1.5%, mannitor5% or sorbitol 3.5%

All are non-conductive and non-haemolytic

609
Q

Where does the RCA arise?

A

anterior aortic sinus or right coronoary sinus

610
Q

Wheredoes the LCA arise?

A

Posterior aortic sinus dividing into LAD and circ

611
Q

Which cardiac veins drain into the LA via the coronary sinus?

A

All of them except the anterior cardiac veins which directly flow into the LA

612
Q

What is the PDA a branch of? And the anterior ventricular art?

A

PDA is a branch of RCA, ADA is from LCA

613
Q

What determines coronary art dominance? Which is more prevelent? What happens whenthe unusual setup occurs?

A

PDA, R dom in 80%

If not the PDA arises from the LCx

614
Q

What types of hypoxia are there?

A

Hypoxic, anaemic, stagnant, histotoxic

615
Q

What are the causes of hypoxic, anaemic, stagnant and histotoxic hypoxia?

A

Hypoxic- low O2 eg VQ mismatch of high altitude
Anaemic- anaemia, blood loss, CO poisoning
Stagnant- HF, Shock, ischaemia
Histotoxic- CN and other poisons

616
Q

What is the presentation of a porphyric crisis?

A

Poorly defined abdo pain and mood disturbance (inc psychosis) with proximal>distal weakness and up to 20% develop bulbar paresis/ resp failure

617
Q

What bloods would you expect in porphyric crisis?

A

HypoNa (SIADH) and Mg

618
Q

Heparin binds anti-thrombin III, reversibly or irrev?

A

Reversibly

619
Q

What causes HIT?

A

IgG ab to heparin PF4 comlex

620
Q

What is the HIT score called officially?

A

Warkentin criteria

621
Q

Whenare CMV-ve blood product required>

A

If pt cmv-ve before transplant

622
Q

How does Cisplatin work?

A

Alkylating agent preventing DNA cross linking and therefore cell replication

623
Q

Which probe for FAST scan?

A

Curvilinear 2.5-5MHz

624
Q

What targets plt in ITP?

A

IgG ab which then tag them for destruction by monocyte-macrophage system

625
Q

If emergency in ITP with bleeding what can be used in addition to steroid?

A

Immunoglobulin (longer term Rituximab/splenectom)

626
Q

Causes of primary and secondary TTP

A

Primary- Lack of ADAMTS13

Secondary (40%)-drug, radiation, chemo, angioinvasive infections, GVHD and secondary surgery, preg, CMV, HIV, antiplt

627
Q

In plasma exchange how much plasma is typically taken and replaced with what?

A

30-40ml/kg

solvent detergent FFP

628
Q

Max dose levobupivicaine?

A

2mg.kg

629
Q

Initial dose intralipid for LA tox?

A

1.5ml/kg then 15ml/kg/hr

630
Q

How long for troponin to start to leak and how long can it persist?

A

2-4 hrs

If huge infarct can persist for up to 2 weeks

631
Q

Those in ICU with trop rise from being so sick have what mortality compared with others?

A

51% VS 16%

632
Q

What is the mortality profile of NSTEMI and STEMI?

A

NSTEMI is better short term but by 6 months equal. After that STEMI is better

633
Q

When is revascularisation considered in NSTEMI?

A

All are considered based on GRACE score. Very high risk within2 hrs, high risk within 24 hrs (GRACE>140) and low risk should be non-invasively evaluated

634
Q

What are the variables of a GRACEscore?

A

8 variables

age HR SBP Cr, CCF Killip class, arrest at admission, ST change or troponin

635
Q

What does GRACE calculate?

A

in hosp and 6/12 mort

636
Q

What does a CHADVASC score of 2 mean in terms of risk of stroke?

A

2.2% per year stroke risk

637
Q

If you only use aspirin in AF what is the reduction in stroke risk? And with warfarin?

A

22% asp

60% warfarin (ICH risk 0.3%)

638
Q

Why is antithrombotic therpay not recommended for those <65 with only AF?

A

THeir absolute risk is so low the RRR is pointless

639
Q

What is Jervell-Lange-Nielsen syndrome?

A

congen (auto recessive) LQT syndrome

640
Q

How is Romano-Ward inherited? Complication?

A

Auto dom, LQT syndrome

641
Q

What is Brugada syndrome?

A

Na channelopathy, auto dom and family clusters

642
Q

What does Dobutamine stimulate?

A

B1 and B2 in 3:1 ratio, some effect on alpha 1

643
Q

How does Levosimendan work?

A

Ca sensitisation (positive inotrope) and opens K channels (periph vasodilatation). May also have a PDE effect

644
Q

What SAAG suggests ascites from portal HTN? What about Budd-Chiari or HF?

A

SAAG>1.1g/dl is likley from portal HTN

if very high >2.5 the portal HTN is huge hence Budd-Chiari or HF

645
Q

How often are low Na diets and diuretics successful in ascites control?

A

10%

646
Q

How much protamine to 100units heparin?

A

1mg

647
Q

How is mild pre-eclampsia treated?

A

Usually with support and frequent monitoring which may include complete or partial bedrest

648
Q

How long post-partum should Mg be continued in pre-eclampsia?

A

24hrs at least

649
Q

How does lactate alter if splanchnic ischaemia/infarction?

A

Is usually a alate sign, espcially if the blood supply is completely compromised

650
Q

Whatdoes NA do to splanchnic circulation?

A

no evidence it has any effect, there is evidence adrenaline and dopamine do

651
Q

BNP is not specific and so can be raised in many patients, what non-HF causes are there?

A

High PA pressure if GFR<60(excreted by kidney), sepsis, DM, age>70, liver cirrhosis

652
Q

What can reduce BNP levels?

A

Normal heart or resolution of issue but also obesity, BB, ACEi, aldosterone antag

653
Q

In non-paracetamol liver failure what are the criteria for transplant?

A 
PT>100s or 
three of :
age<10 or >40
INR >3.5 (PT>50)
Bili>300
Jaundice->enceph >7days
unfav aeitiology like seroneg hepatitis, Wilson's idiosynchratic
654
Q

Hep A virus is faeco-oral or eaten in food, what sort of virus is it and if you’ve had it once can you get it again?

A

Once you’ve had it you have lifelong immunity
SS-RNA
0.1% mortality

655
Q

How effecive is HAV vaccine?

A

80-100%

656
Q

What are the withdrawal symtpmos of Dexmet? and when do they present?

A

24-48hrs after stopping if used for 7 days or more

Agitation, nausea and vomiting

657
Q

When should nicotine replacement be carefully considered?

A

If someone has arrhythmia, MI, stroke, uncontrolled HTN, renal or hepatic impairment

658
Q

Who shoud get hyperbaric O2 in CO poisoning?

A

Preg, coma or HbCO >40%

659
Q

What sort of acidosis does CN produce?

A

HAGMA and cherry red skin

660
Q

In decomp liver disease 50% of renal failure is due to what?

A

pre-renal frm multiple causes

661
Q

Opening pressure in
Bact/TB
Viral
Fungal

A

Bact/TB- high
viral- normal
fungal- very high

662
Q

Correction for blood in CSF?

A

for every 500-1000RBC reduce WBC by 1

663
Q

What else apart from WBC needs to be corrected if bloody tap on LP?

A

Protein- reduce 0.1g/dl for every 100RBC (or 1g/dl per 1000)

664
Q

Lactate in CSF is useful in ruling out bacterial meningitis under what level?

A

2

If >4 has 88% sens and 98% spec for bacterial meningitis and is found earlier than low glucose

665
Q

If someone may have HSV enceph and first sample-ve what do?

A

Another one in 24-48hrs for HSV PCR again

666
Q

Lymphocytic differential seen in viral mening/enceph andwhat else?

A

TB and fungal

667
Q

What is a ‘gin’ clear CSF associated with?

A

viral

668
Q

What did ALBIOS study find?

A

No benefit of albumin in sepsis on 28 and 90 day mort

669
Q

What did the IVOIRE study find?

A

No evidence that 70ml/kg/hr cf 35 for 96hrs leads to redcued 28day mort, haemodynamic profile or organ fn

670
Q

What did PROWESS-SHOCK find?

A

PROWESS study found a mort benefit for activate protein C so followup study conducted which didn’t show an improvement

671
Q

Is eary goal directed fluid therapy useful in sepsis?

A

PROMISE study 1260 pts no difference between standard care and protocol however not much difference between groups at any stage…are we just doing the protocol already?

672
Q

How do penicillins act?

A

inhibit enzyme transpeptidase that forms lattice cross links of bacerial walls->bacteriocidal

673
Q

Howdoes co-trimox work?

A

Inhib dihydrofolate reductase (DNA/RNA synthesis is distrupted)

674
Q

How does metronidazole work?

A

damages DNA

675
Q

How does Vancomycin work?

A

Inhib cell wall production

676
Q

How does Rifampicin work?

A

prevents RNA transcription and therefore protein synthesis

677
Q

What is IM ketamine GA dose?

A

4-10mg/kg

678
Q

Where is thiopentone metab?

A

99% in liver

679
Q

What are effects of intra art propofol?

A

Delayed induction but nothing else

680
Q

How long can PRIS take to start>

A

24-48hrs can see CK rise

681
Q

Define bioavailability

A

the proportion of oral drug reaching circulation compared with the same dose given IV

682
Q

What do competitive antagonists do to the dose response curve?

A

Shift to right (non-competitive dont move to right simply reduce amplitude=)

683
Q

Define therapeutic index

A

median lethal dose/median effective dose

684
Q

Clonidindoes what?

A

alpha 2 agonist reducing NA release

685
Q

At what pH does midazolam’s imidaole ring close?

A

pH>4 resulting in better lipid solubility

686
Q

What are the cardiovasc parameters we aim for in a DBD donor?

A

HR 60-120
BP>100
MAP>70

687
Q

What ABG would be minimum in DBD?

pH, PaCO2 and PaO2

A

pH 7.35-7.45
pCO2 4.7-6
PaO2 >10.7

688
Q

What serum Na should DBD donors have?

A

Ideally 140-160 but can be from 115-160

689
Q

What are the Maastricht organ donation classification categories?

A 
I- dead on arrival
II- unsuccessful resus
III- anicipated death (most DCD)
IV-- cardiac arrest in DBD
V- unexpected arrest in ICU
690
Q

What is consent rate for DBD and DCD>

A

DBD 63%

DCD 57%

691
Q

Where is the legislation for donation written?

A

mental capacity act 2004

692
Q

Absolute contra to TOE?

A

bleeding, stricure, tumour, diverticula, scleroderma, perf

693
Q

When is intubation due to haemodynamic compromise warranted in kid?

A

if 60ml/kg fluid given intubate child as up to 40% of their energy expenditure can be due to breathing

694
Q

Extremis IM RSI for kid?

A

5-10mg/kg ketamine and 3-4mg/kg sux

695
Q

asymptomatic candiuria how treat?

A

Can be colonisation, change catheter and see. If neutoropenic etc then be more worried

696
Q

How does amphotericin B work?

A

Binds to ergosterol causing cell death

697
Q

How does fluconazole work?

A

Inhib C-14 alph demethylase which is needed to make ergosterol (which makes up cell wall)

698
Q

How does Caspofungin work

A

targets proteins responsible for cell wall synthesis

699
Q

What classically causes a false positive VDRL, prolonged viper venom time and APTT?

A

Anti-phospholipid syndorome

700
Q

What can have its first presentation with diffuse alveolar haemorrhage?

A

GPA (wegners), SLE, goodpastures, Scleroderma ad RA

701
Q

How long after scleroderma renal crisis does it take for renal fn to improve?

A

3years!

702
Q

What is the first step of viral ingress in HIV?

A

ENV protein binds with CD4

703
Q

What causes secondary and tertiary blast injury?

A

2ry- flying debris

3ry- person thrown across room/etc

704
Q

In blast injury contusions over what size should be resected in bowel/

A

20mm

705
Q

What is an appropriate abx for gun shot?

A

Usually clostridia and beta haem strep so Ben-pen ok

706
Q

What is CO poisoning mech?

A

Not clear, obviousl anaemic hypoxia but also histotoxic is thought to play a role

707
Q

Is PaO2 affected by CO?

A

No

708
Q

How many births in 2018? Still births? neonatal deaths?

A

740K
2500 still
1200 neonatal all improving

709
Q

What population is most likely to have a still birth?

A

white 1:295
Asian 1:188
Black 1:136 (depreivation)

710
Q

Cause of preg women deaths?

A 
in 2015-17 209 women died (2.2million preg)
23% heart disease
16% clots
13% stroke/epilepsy
Asian or black more likely
711
Q

Define PPH

A

loss 500ml in first 24hrs (minor 500-1000, major >1000)

712
Q

What happens to PR interval in hyperK

A

PR longer

713
Q

HyperK and QTc?

A

Shorter

714
Q

HyperMg and HR/BP?

A

bradycardia, hypotension (inc PR and QRS)

715
Q

After liver transplant what sort of reduction in AST is expected each day?

A

50%

716
Q

What vessel is not seen on USS of liver and so should be CT if concerned?

A

Hepatic artery

717
Q

What conclusion would you draw from infiltrates on day 1 post lung transplant? Day 2/3?

A

Day 1 result from implantation response but if cont for 2/3 days with worsening O2 rejection should be considered

718
Q

In heart-lung transplant which is more likely to reject?

A

Lungs

719
Q

When is fasciotomy indicated in rhabdo?

A

pressure >30mmHg

720
Q

What is the classical CXR finding of fat embolus though it is far from a sensitive investigation

A

Snow storm

721
Q

How is ISS calculated?

A

6 areas with score 1-6 where 6 is incompat with life. The three highest scores are then squared and added together

722
Q

What are the six areas covered by the ISS?

A

head, face, chest, abdo, extermity and external

723
Q

What is the maximum scare in ISS if you’re still alive?

A

75 (5^2+5^2+5^2) if you get a 6anywhere youre dead

724
Q

Is there an equal chance of the ISS hvaing any number between 0 and 75?

A

No, because the numbers are squared some are impossible and othrs less probably

725
Q

What does SIADH do to urine Na?

A

raised (normal na but low water content)

726
Q

What does CSW do to kidney?

A

raised urine Na with plasma hypoNa due to renal Na transport abnormality

727
Q

What are the three mechanisms of pelvic trauma ?

A

ant-post compression, vertical compression or lateral compression

728
Q

What artery is the most likley to be damaged in pelvic trauma

A

superior gluteal

729
Q

What does an open book fracture do to the retroperitoneal space?

A

Can quadruple itssize

730
Q

How long do you give someone a spont breathing test before you know what is the likely outcome of extubation?

A

30min

731
Q

What rapid shallow breathing index means likely to succeed in extubation?

A

<105

732
Q

Where is Na reabsorbed in kidney?

A

25% loop of henle

65% prox tubule

733
Q

WHat is absorbed in prox tubule?

A

70% of Na, H2O and Cl
90% bicarb
100% glucose and alb

734
Q

Where is Na and Cl passive and active transport in loop Henle?

A

Active in thick

Passive in thin

735
Q

Cause of death i DKA most likley?

A

Cerebral oedema

736
Q

Why bicarb not good idea in DKA?

A

Can cause cererbal oedema, delays lactate and ketone clearance and raises CO2

737
Q

Define HHS?

A

pH>7.3, gluc >30, ketone<3, osm >320

738
Q

What sort of water deficit does an HHS patient have?

A

100-220ml/kg!

739
Q

What rate of fall of Na and glucose is acceptble in HHS?

A

10mmol Na, 5mmol glucose

740
Q

When do you get insulin in HHS?

A

If sig ketones or if glucose no longer falling with fluids

741
Q

What is the RRR of perinatal asphyxia cooling?

A

15% NNT 9 within 6hrs

742
Q

Define acute profound hypoNa

A

Na<125 for less than 48hrs

743
Q

What is the differential for hypotonic hypoNa with urine osmo < 100

A

Beer potomania, polydipsia and low solute intake

744
Q

What is the differential for hypotonic hypoNa with urine Na>100 and urine Na >30

A

SIADH and CSW

745
Q

What is the emergency treatment for hypoNa?

A

150ml 3%

746
Q

What head up is required to reduce VAP?

A

30-45degrees

747
Q

What chlorhex soln for skin asepsis?

A

2% (0.5% is used to steralise prior to neuroaxial bloackade)

748
Q

Define transpulmonary pressure/

A

alv pressure - pleural pressure

749
Q

Are femoral lines dirtier than others?

A

Initially we thought so but newer evidence suggests no

750
Q

What is filtration ratio and what is targetted?

A

is a measure of haemoconc in the filter (or the ratio of filtrate removed as a percentage of blood flow)Target 25-30%

751
Q

What ar pros and cons of lactate and bicarb RRT replacement fluid?

A

Bicarb are more preferred as they are more reliable at buffering capacity but they are more unstable

752
Q

If develop HIT on heparin RRT without citrate available what do you do?

A

1A recommendation to start argatroban (direct thrombin inhib) as long as no liver failure. If there is then consider another antcoag

753
Q

What does fat and water look like in T1 weighted MRI?

A

Fat bright, water dark

754
Q

What noise level can you expect when switching gradient fields in MRI?

A

85dB which can damage hearing

755
Q

Current guidance is to measure ICP in all patients with abnormal CT and are salvageable but what happens if you have a normal scan with a TBI?

A

should have ICP if more than two of >40, motor posturing, SBP<90

756
Q

What happens to SID in RTA?

A

urine SID is high but plasma is low due to Cl loss in kidney

757
Q

What characterises RTA types 1,2 and 4?

A

1- reduced ammonium production distally
2- increased prox tubular Cl resorption
3- reduced ammonium production proximally

758
Q

What doe acetazolamide do to SID?

A

It increased Na:Cl extraction meadning serum chloride is relatively higher than Na meaning SID is low

759
Q

What can a metabolic alkalsis cause?

A

Seizure, confusion, drowsiness and cerebral vasospasm

760
Q

In overt hyperthyroid what patterns of T3 and T4 can be seen?

A

Both high classically but can have isolated T3 or T4

761
Q

What is primary hypothyroid?

A

Normal T4 but high TSH

762
Q

How is sick euthyroid distinguished from primary hypothyroid?

A

in sick T3 decreased more than T4 whereas in primary T4 is dec more than T3
In sick TSH normal or low but primary TSH high
Reverse T3 high in sick and low in primary
T4 usually normal in sick and low in primary

763
Q

What the hell is reverse T3?

A

Is were the iodine atom has been removed from the inner ring of T4 rather than the outer which would make T3

764
Q

What activator is used in ROTEM EXTEM and INTEM?

A

EXTEM- tissue factor

INTEM0 contact actiator

765
Q

What does FIBTEM look at?

A

When compred with EXTEM gives you the fibrin component of clot

766
Q

Where does Ricin come from?

A

Castor oil beans

767
Q

How does ricin kill you?

A

Inhibits protein synthesis only 5-10microg/kg is fatal

768
Q

What does VX nerve gas do?

A

Inhibits ACh esterase causing cholinergic crisis

769
Q

Whats another name for variola major?

A

smallpox

770
Q

how are the pox different in chick and small pox?

A

Small pox mostly on body with relative limb sparing (centrifugal) whereas chickenpox is on limbs

771
Q

What factors are in the Child-Pugh scoring system?

A 
TB
ALb
PT
Ascites
Enceph
772
Q

What scores do you get from each of the five factors that make up Child Pugh?

A

A TAPE

Ascites= None, mild, mod
TB- <34 =1, 34-50=2, >50 =3
Alb >35 =1, 28-35 = 2, <28 = 3
PT/INR <1.7=1, 1.7-2.3=2, >2.3=3
Enceph - none, I/II, III,IV
773
Q

What are the CP classes? What score puts you in each category?

A

A, B and C

5-6=A, 7-9=B, 10-15=C

774
Q

4Ts of HIT score are made up of Thrombocytopenia, Timing of platelet fall, Thrombus and other cause what changes of each variable get you what score?

A

Thrombocytopenia- <30% or plts <10, 30-50% or plt 10-19 = 1, >50% or plt >20=2
Timing- <4/7=0, 5-10 but not clear or <1 day with prev heparin=1, 5-10 clearly or <1day if prev exposure
Thombus- None-0, suspect or non necrotizing-1, new thrombus or skin necrosis
Other cause - definite-0, maybe -1, none -2

775
Q

What are low medium and high risk HIT scores?

A

Low <4, medium 4-5, high >5

776
Q

Risk (stage 1 of AKIN)of RIFLE define

A

1.5x Cr/ >26.5micromol/L inc

or <0.5ml/kg/hr for 6 hours

777
Q

Injury (stage 2 of AKIN) of RIFLE define

A

Cr x2-3 or u/o <0.5ml/kg/hr for 12 hrs

778
Q

Failure (stage 3 of AKIN) in RIFLE define

A

Cr x3 or Cr> 353.6
or
U/O <0.3ml/kg/hr for 24hrs or auria for 12hrs

FFICM (4 decks)

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