MCQ CCMCQs Flashcards
At what point does sugammadex become a viable reversal agent for vecuronium?
Once T2 twitch achieved use 4mg/kg
Reversal dose of sugammadex?
16mg.kg
For how long post insertion is high risk for thromosis in BMS and DES?
4-6/52 in BMS and up to 12/12 in drug eluting
What is the 1 year rate of thrombosis in DES?
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
How long do you anticoagulate BMS?
4-6/52 with DAPT thenaspirin for life
If surgery required in first 4/52 with BMS what do you do about DAPT?
Needs to be bridged by Tirofiban or heparin
What are the risks of DAPT and surgery?
50% increase in bleeding but not mortality
Biocompatible stents like the Genous R-Stent still needs anticoagulation. More or less than DES and BMS?
Less- only need 10 days clopidogrel then life long aspirin
How often do you get CICO?
0-2/10000
Below what diameter of tube do you need to jet ventilate?
2mm
What does a quinine overdose look like?
Low QTc , blindness, VF resistant to cardioversion, hypoglycaemia. CVVH of no use
Maximum score for HIIT score?
8
Where is the basilar in relation to the brainstem?
anterior
Which is the largest cerebellar artery?
post inf cerebellar
What cell mediaed graft vs host?
T cells
What drugs are used in GVHD prophylaxis?
Calcineurin inhibitors eg ciclosporin or tacrolimus
What is the mortality associated with transfusion related GVHD?
almost 100%
Defn anaemia in men and women?
M<130
F<120
In HITT type II what is the typical pattern seen with plt?
Immune mediated falls 30-50% in 5-10 days after starting heparin
Is HITT more common in M or W?
W
What is the immune process of HITT?
A complex between heparin antigen and plt factor 4 (PF4) and the patient develops IgG ab resulting in consumptive coagulopathy
How long after HITT diagnosed do you continue anticoag to prevent thrombosis?
14 days (fondaparinux, danaparoid or argatroban)
Emergency cricothryoidotomy is performed through which structure?
Cricothyroid ligament
What is a standard ECG x and y axis?
x-25mm/s
y- 1mV/cm
Which is the most sensitive lead for detecting ischaemia on ECG?
V5 apparently
What sensitivity does a 5 lead ECG have for detecting inf or ant ischaemia?
90%
Normal cardiac axis?
-30 to +90
Define aortic dissection
Either an intimal tear or intra-murral haematoma
When and who get aortic dissections?
Male 50-70
How many classes of aortic dissection does the European Soc of Cardiology classification have?
5 1- classic intimal flap 2-intra-mural haematoma 3- subtle only bulge at tear site 4- atherosclerotic ulcer with haematoma 5- iatrogenic/trauma
Is there a survival benefit to monophasic vs biphasic defibs?
No though the first shock efficacy for biphasic is 86-98% whereas only 54-91% in monophasic
When does IABP inflate electrically and mech?
On middle T wave electrically or on dichrotic notch
When does IABP deflate?
Just before sstole- peak of R wave or just before upstroke on art line
When is NAC useful apart from in paracetamol OD?
In any ALF when early hepatic enceph showing (grade I/II evidence)
In ALF what bleeding risk does ICP monitoring have?
4-20% though I wonder if that’s becase we put them in rather than neurosurgeons
ALF is characterised by high CO state and low SVR, what contributes to the low SVR?
High NO production and cGMP
What is the mortality risk of variceal bleed?
8% immediately and 20% within 6/52
Define portal HTN
Pressure gradient >5mmHg. At gradients >10mmHg blood flow through portal system is redirected to lower pressure areas
Once Sengstaken Blakemore tube removed how many rebleed?
50%
How far do you put the SBlakemore tube in?
55cm
O’Grady ALF system has hyperacute, acute and subacute, what are their time defn?
Hyper <1/52
Acute <1/12
Subacute <3/12
What is the Bernuau system for ALF?
Fulminant 1-2/52 from jaundice to enceph and subfulminant 2+ weeks from jaundice to enceph
What are the phases of Ethylene glycol toxicity?
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
Causes of HAGMA>
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
Causes NAGMA>
USED PART Urinary diversion Small bowel fistula Extra Cl Diarrhoea Pancreatic fistula Addisons RTA Tenoovir/Topiramate
What are the toxic metabolites of ethylene glycol?
Glycoaldehyde, glycolate (35%), formate oxalate (2.3%) benzoic acid and others
Oxalate binds with Ca and causes hypoCa
What is Fomepizole? Loading dose? When stop?
An alcohol dehydrogenase inhibitor, 15mg/kg loading, stop when eythlene glycol <20mg/dl
In SBP what % of cultures are +ve and what are the most common pathogens?
60% positive with E.Coli, Step and enterococcal species being most common
When are prophylactic abx used in SBP?
If had one prev SBP should have prophylaxis
What is the 1 year risk of HRS if cirrhotic with ascites?
18%
Define Wenicke’s enceph
Nystagmus, Opthalmoplegia, ataxia and confusion secondary thiamine def
What is the role of Infliximab in liver failure?
In ALD TNF-alpha is raised (inflix lowers TNFa) but trials showed it increased mortailty
What TNF-alpha lowering drug is useful in ALD?
Pentoxyphylline is associated with recued HRS and is useful in alcoholic hepatitis when steroid contraindicated
What is baseline O2 delivery requirement?
300ml/min
Normal CI?
2.8-4.2 L/min/m2
Normal SVRI?
1760-2600 dynes.sec/cm5/M2
Normal PVR?
<250dynes.sec/cm5 (PVR=80*MPAP-PAOP/CO)
Normal SVI?
Stroke vol index= CI/HR *1000
35-47ml/m”/beat
When is high risk time for liver transplant? What is 1 and 5 year survival?
first 3 months is when most deaths occur
1yr 79%
5yr 72%
How do liver transplants in ALF and chronic liver failure compare?
Acute failures do worse initially but after 1 year this reverses and the acute failures havea better long erm survival
How is paracetamol broken down?
Mostly by glucoronidation and a small amount by cytochome p450 to NAPQI which itself is conjugate by glutathione to form cysteine and mercapturic acid
What 4 and 15 hr levels of paracetamol require immediate treatment?
At 4 hrs 100mg/L
15mg/L at 15hrs
When is NAC continued after the first 16hr treatment>
If ALT x2 or 2x upper limit of normal or INR>1.3
Triad of seretonin syndrome?
Neuromusc excitability - Termor, stiffness, hyperpyrexia
Autonomic disturbance- mydriasis, tachycardia, flushing, hypertheria
Mental changes- headache, agitiation, coma
A cannabis OD in child presents as?
Dilated pupils, hypotonia and hyporeflexia
What is the FOUR score?
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
Why is DVT 3x likely in spincal cord injury?
Everything dilates reuslting in venous pooling and relative stasis
Steroids in spinal cord injury- discuss
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
Where is a lumbar drain placed?
Into the subarachnoid space
What is found on nerve conduction studies in CC polyneurophathy?
Both motor and sensory conduction is reduced
What is seen on EMG in critical illness myopathy?
See fibrillations. In contrast see denervationin MND
Compression of what structure causes Cushing’s response in about 1/3 cases?
Tonsillar herniation compresses the midbrain
What does a normal ICP trace look like
Like an art line trace
What is P1 P2 and P3 in ICP waveform?
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
What happens to P1,2 and 3 in raised ICP?
P2>P1 and wave becomes broader
What are Lundberg A waves (aka plateau waves)
vasogenic waves seen in critical perfusion and are always pathological…seems they are just high ICP with normal poor compliance waveform
What did the POISE study find?
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!)
How does mannitol help in ICP rise?
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
Mannitol dose for raised ICP?
0.25-1g/kg over 20min repeated 1-2 times after 4-8hrs
What % patients remember pain in ICU?
70%
What level of thiopentone would exclude brainstem testing?
> 5mg/L
What is minimum core temp in brainstem testing?
> 34C (brainstem relfexes lost at 28C)
What is the range of Na allowed in brainstem testing?
> 115, <160 (Large range!)
What is an acceptable PO4 in brainstem testing?
0.5-3mmol/L
What frequencies are used in USS and echo?
USS >20kHz, echo 2-10MHz
area definition of severe AS?
0.6-0.8cm2 (and mean pressure gradient of 40-50)
What is the most prev organisms causing meningitis in a child up to 3/12? It has been sign modified by vaccination
Men B
How do you differentiate between croup and trachiitis?
Trachiitis doesnt respond to croup treatments and progresses requiring intubation. It is caused by S aureus and H influenzae type B
What organism classically causes epiglotitis?
H. influ B
4Ds- drooling, dysphagia, dysphonia, dyspnoea
What is the causative organism in croup?
Parainfluenza virus
What is the dose of HFNO in kids?
Well tolerated and used in RSV use 2L/kg/min
What correlated directly with decline of CD4 function in HIV infection?
HIV RNA levels (viral load) correlated with rate of decline of t-helper cells and progression to AIDS
How is AIDS defined?
AIDS defining illness or CD4 <200cells/microl
What is Zidovudine?
Nucleoside analgue reverse transcriptase inhibitor for HIV treatment
What is Enfuvirtide an example of?
a fusion inhibitor which prevents HIV binding with cell membrane
What are the side effects of NRTI nucleoside reverse transcriptase inhibitors?
Lamivudine, zidovudine etc cause lactic acidosis, hepatomeg and statosis. Stop the drug
The HIV drug NNRTs (non-nucleoside reverse transcriptase inhibitors) are effective against what HIV?
HIV 1 only
Pulmonary manifestations of RA?
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
What drugs used in RA are toxic to lungs?
Pretty much all of them
What fibres sense temp?
A-delta and C fibres
How does temp affect iron and in turn what does that do?
High temp decreases iron which reduces bacterial growth
What is the initial dose of Dantrolene?
2.5mg/kg
What happens to cerebral blood flow with reducing temp?
Flow reduced by 7% with each degree C dropped postulated to be due to lower CO and higher viscocity
What is the second leading cause of non-accidental death in UK after RTA?
Drowning
Does aspiration often or rarely occur in drowning?
It was thought that 20% had laryngeal spasm with so called dry drowning but now we think most people aspirate
Is salt water vs fresh water bettwer or worse in drowning?
No difference
What makes normal Hb?
2 alpha and 2beta chains (HbF 2 alpha, 2 gamma)
What is the abnormality in sickle cell disease?
Glutamic acid is replaced by valine in the 6th amino acid position
How is porphyria inherited?
Auto dom
How long into a paeds resus should IO be used if no IV in?
90s
Kings college criteria, what in addition to INR>6.5 and Cr >300 is require to fulful criteria?
Grade III or IV enceph
What lactate at 4 and 12 hrs form part of the modified Kings Criteria?
> 3.5 at 4 hr or >3 after 12 hrs maximum treatment
Where does a pelvic binder of any sort encircle?
Level of greater trochanters
What % trauma patients have a c-spine injury and what % of those are unstable/
12% have injury and 14% are unstable (1.7% of all traumas have unstble c-spine injury)
Whatare the rates of c-spine injury without radiological abnormality in adults and kids?
Adults is rare
Kids 10-20% (!)
commonest cause of c-spine injury is vertebral subluxation
When can ANOVA be used?
If parametric data with more than two groupd
Define standard error of mean
SD/ square root of n and is an indication of how well the mean of a sample represents the true mean
What is alpha error (and beta)
alpha is prob of positive finding in study being wrong
Beta is proab of neg finding being wrong
What did the BALTI-2 trial find?
B2 agonists increased mortality in ARDS
What did the PROSEVA trial find?
Proning improves ARDS mortality by 50%(!)
What is the Paul Bert effect?
CNS toxicity of O2 if delivered at >3atm
What pressures are associated with barotrauma?
PIP>45 and Plat >35 (or less, more recent research makes one wonder inf these figures are too liberal)
What is the difference between intra and extracellular pH?
Intracellular pH is about 0.6 lower than extracellular
Where is the compensatory mechanism of hyperventilation due to low pH arise?
Chemoreceptors in aorta and carotid body
How do you check that there is only one source of acidosis going on?
Calc AG then delta ratio
Delta = AG-normal AG/HCO3 -normal HCO3-
How does methanol poisoning present on blood gases etc?
Initially has a high osmolar gap, then as its metabolised it causes a HAGMA
What can cause a HAGMA and high osmolar gap?
Methanol and Ethylene glycol
Normal osmolar gap?
<10
How do you correct AG for albumin?
Observed anion gap + 0.25(normal alb-measured alb)
Paracetamol OD can cause a HAGMA, what is the uneasured anion?
5-oxoproline
What is leukocyte larceny?
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
What is urine Na in SIADH?
> 20
What do hyaline casts and finely granular casts on urine examination mean?
Pre-renal azoteaemia
What urine findings would make you wonder about ATN?
Tubular epithelial cells and granular casts
How is fractional extraction of Na calculated?
FENa= ([urine Na xPlasma Cr]/[plasma Nax urine Cr])x 100
What does a FENa <1% and >2% suggest?
<1% pre-renal azotemia
>2%parenchymal renal disease of urine obstruction
Where is TRH made and what is its function?
Made in the paraventricular nucleus of hypothalamus and stimulates TSH release and prolactin from ant pit
Where does T3 come from?
80% from T4 convesion and 20% from direct thyroid secretion
Where in the body is T4 converted to T3?
liver and kidney
How does Enalapril alter renal blood flow?
Increases renal blood flow but GFR remains unchanged
Can paracetamol act as a nephrotoxic?
Yes in those who are glutathione deplete presents as an ATN
Is acyclovir a nephrotoxic?
yes
What drugs elevate digoxin levels?
Verapamil, erythromycin, diltiazem, tetracyclines
What happens to K in dig toxicity?
Elevated. Initial K correlates with outcome
Standard dig toxic ECG of downard slope ST and TWI is most likely found when?
Initially. Proper toxicity can have any rhythm
Indications for Digibind?
Arrest due to dig or >12ng/ml serum level
What are the connections between the ventricles and thrid ventricle and the third and fourth ventricle?
Vent->3rd foramen of Munro
3rd-4th-> aqueduct of sylvius
What are the electrolytes in CSF that are different to plasma?
HighCl and low K
What happens to Ca in therapeutic hypothermia?
Reperfusion injury thought ot be reduced by reducing calcium flux
What groups of HEV are there?
Two genotypes 1 (water bourne) and 2(faeco-oral) infect humans. Genotypes 3 and 4 come from pigs and are accidental carriers.
HEV may masquerade as DILI. Which genotype is worst for hepatitis in preg women?
Genotype 1
What is the complication rate in cricothyroidotomies?
20%
Where is CSF produced?
Choroid plexus in lateral and 3rd ventricles
What is a normal rate of production of CSF?
0.4ml/min (576ml/day)
What is the volume of CSF around the spinal cord?
35ml
If a normal ICP and you remove CSF what happens to ICP?
Under normal circumstances, taking a bit of fluid has no effect on ICP
What % of those with neut sepsis need ICU?
5%
What is defn of neut sepsis?
Neut <0.5 and T>38 or other signs of infection
What blood abnormalities in DIC?
Thrombocytopenia, hypofibrinogenaemia, high fibrin degredation products, long APTT and PT and TCT
What does chronic DIC look like?
compenstaed state with increased turnover of haemostatic components eg malignancy
How does type 1 DIC present on TEG initially?
hypercoagulable state with decreased R time and K time and inc MA.
Type II DIC can prsent with long R time
Did TTM trial find a difference in harm between 33 and 36C?
No
What does hypothermia do to insulin?
Inc resistance
What happens to myocardial contraction with hypothermia?
It increases but some pts do get dysfn
What is Rasburicase mechanism?
urate oxidase catalyst and oxidises uric acid to allantoin
Define MAP
DBP + 1/3(SBP-DBP)
What are the most common cardiac abnormalities?
ASD 17%
VSD 14%
ToF 11%
Coarc 10%
What is the relative rates of DU and PU bleeds?
PU 35-85%
DU 8-15%
What does the Rockall score predict?
Re-intervention and mortality postOGD
What does the glasgow Blatchford score?
Predicts outcome of someone in need of OGD for bleed and if have a score of 0-2 can be managed as OP
Is CT required for diagnosis of pancreatitis?
No, scan should only be if there’s uncertainty
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?
End diastolic pressure
What does global end diastolic volume index mean and what is a normal value?
GEDVI represents the blood in the heart chambres and is normally 650-800ml
What is intra-throacic blood volume index?
It is the amount of blood in the thorax. Can be calculated from GEDVI (ITBVI=GEDVI x1.25)
What is Reye’s syndrome?
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
What can hapen in the extremes of HELLP and the liver?
Sinusoidal obstruction can result in hepatic necrois, infarction, haemorrahge and rupture (1:40-250k)
Can alpha1 def cause heptaic failure in children?
Yes
What happens to serum Cu and ceruloplasmin in Wilson’s?
Low
What chelates Cu?
Penicillamine
What is Budd-Chiari?
Hepatic vein is occluded by thrombus or tumour
What sort of virus is HBV, HCV and HEV?
HBV- DNA
HC/EV- RNA
What % of HBV causes persistent infection?
5%
What is the first marker of HBV infection?
HBsAg (if persists >6/12 likely chronic infection)
What does interferon alpha and Lamivudine do to HBV?
Int alpha is immunmodulatory impairing HBV replication
Lamivudine directly blocks HBV replication targeting reverse transcriptase
Who with HBV have the highest risk of HCC?
100x more common in HBV patient. Those with HBsAg- and HBeAg +ve most at risk
What does a TIPS connet?
Tract between hepatic vein and intra-hepatic segment of portal vein
TIPS can occlude, what rate of stenosis at 2 years?
40%
If encephalopathy post TIPS how manage?
15% can be managed with drugs but the rest need the TIPS narrowed or occluded
Does HCV cause ALF?
Only 1% of cases get acute hepatic failure
What does Ribavirin do in HCV?
Used synergistically with int alpha
What do Boceprevir or Telaprevir do to HCV?
inhib NS3/4A enzyme with stops HCV polyprotein cleaving during replication
What is standard HCV treatment?
Boceprevir or Telaprevir in combo with peginterferon and Ribavirin for HCV 1. Can cause anaemia
How is a LiDCO setup?
Li transpulmonary dilutiono f 150mM Li into venous circ. An ex-vivo electrode attached to a peripheral art line draws a concentration time graph
What is the LiDCO calibration eqn?
CO=Li dose x 60/area under conc-time graph x (1-packed cell vol)
How measure intra-abdo pressures?
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
How much caffeine in can coke? Tea? Red Bull?
Coke 30-40mg
Tea- 20-60mg
Coffee- 60-180mg
Red Bull 80mg
Fatal dose of caffeine?
150-200mg/kg about 5-10g
What occurs if you have a radiation dose of 0.5-1.5Gy >1.5Gy 3-5 >10-20
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
Does a lead apron reduce expousre to zero?
Yes apparently though I’m not sold
What radiation exposure causes skin burns?
> 3 Gy
What is the cancer risk for adults having a CXR and CT?
CXR- 1:1,000,000
CT- 1:2000-1:2500(!)
Normal ICP?
7-15mmHg
How much does cerebral blood flow increase for 1mmHg rise in CO2?
3-4%
What is an EEG energy output?
between 20-200microV
What EEG is seen in status myoclonus?
sharp repetitive spikes or triphasic waves at about 1Hz
What is the Naloxone dose allowed in heroin OD?
0.4-2mg
What does botulism look like?
Afebrile descending symmetrical flaccid paralysis of motor and autonomic nerves
What is the 1 year mortality of critical ilness weaknes?
65%!
What measures of power may indicate need for mechanical vent eg in GBS?
VC <15ml/kg or <1L or reduced by 50% from baseline
negative insp flow <30cmH2O and exp force < 40.
Nocturnal desats
If arrest due to amitriptyline what do?
Prolonged resus at least 1 hr
intralipid 1.5ml/kg over 1min plus infusion if bicarb ineffective.
Dose of glucagon if needing for hypotension?
5-10mg with infusion at 50-150microg/hr
How do phosphodiesterases exert their effect?
Prevent breakdown of cAMP and cGMP therefore increase contractility, chronotropy, dromotropy and reduce SVR
How much of carotid blood flow goes into the MCA?
75-80%
What is the Lindegaard ratio and what is the upper limit of normal?
MCA to ipsilateral carotid flow velocity in TCD. > 3 or over 120cm//s is suggestive of vasospams
Define death
An irreversible loss of consciousness and irreversible capacity to breathe (no legal definition of death in the uk)
No heart sounds or respiration is used to declare death but what other measures are acceptable in hospital?
asystole, no art line trace or standstill on echo
How long should someone be observed if you are confirming death
5min-no pulse, no heart sounds.
After 5min of that check no pupil reflex, no corneal reflex and no movement to supraorbital pressure
Whats a FEEL echo?
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
In a spont breathing patient what sort of IVC collapsibility would you expect?
about 50% given neg pressure allowing greather inflow of blood to thorax in inspiration. Therefore collapsibility loss in spont breathing means high RA pressure
How are pericardial effusions classified?
Small, moderate and large (<0.5cm, 0.5-2cm and >2cm)
Over what altitude is gas expansion an issue for air-evacuation?
2000m, so rarely a problem as helicopters don’t usually go that high.
How much O2 do youn eed for a transfer?
2x transport time x ((MV xFiO2) + driving gas)
What does helicopter vibration do to the body?
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
Febrile convulsions common betwen 6/12 and 5 yrs, are they usually short or long?
Can be prolonged
Doses of benzos in kids?
Loraz- 0.1mg/kg
Diaz 0.5
midaz 0.5
Dose paraldehyde kids?
0.8ml/kg PR
Dose Phenytoin kids
18mg/kg
Can osteonecrosis occur in HAART and HIV?
Yes in advanced disease
What are some metabolic effects of HAART?
fat redistribution, insulin resistance, dyslipidaemia
What are NRTIs, Stavudine in particular, known to cause
Lipodystrophy syndrome
What HAART drugs can cause SJS?
Nevirapine (NRTI) and protease inhibitors
What sort of virus is flu?
RNA
What surface proteins describe different flu strains?
Neurominidase(9), Haemagluttanin (16) and glycoproteins,
What is the role of haemagglutanin in flu?
attachment of virus to host resp epithelium
Can vasculitis, sarcoid, deymatomyositis and PMR cause a CK rise
Yes all autoimmune or rheum disorders can
Can hyer and hypo tyroid cause raised CK?
Yes both
Haemorrhagic fever has how many subtypes?
5- arena-, bunya-, filo-, flavi and rhabdoviruses
How is haemorrhagicfever transmitted?
blood-blood contact or body fluids though mucus membranes/broken skin
What s thetreatment of Lassa fever (memeber of arenaviruses)?
Ribavirin with weak evidene
What is etanercepts action? (same as infliximab)
TNF alpha inhibitor
If someone taking biologic agent come in with meningitis wht bacteriamay be the cause?
All the normal ones but also rarer things like listeriosis
Where do you get Listeria from?
eating contaminated food get fever and diarrhoea
What is the dose of Oseltamivir?
75mg BD PO for 5/7 (or 150mg BD for 10/7 in severe infection)
How does Clostridium Botulinum affect the body?
Creates a neurotoxin that acts on the pre-synaptic terminal of the neuromuscular junction preventing acetylcholine release
How is clostridium botulinum spread?
Person to person trasnmission does not occur. Get it from food/soil and home-made canned foods
The anti-toxin for botulinum toxin is immunoglobulin fragments. Can it be given in pregnancy and paeds?
Yes
What does Sarin do?
Inhib anticholinesterase (like organophosphate) leading to cholinergic crisis- miosis, rhinorrhiti,bronchospasm, weakness, resp arrest
What is the treatment for Sarin?
Atropine antagonises the muscarinic effects (and pralidoxime reactivates anticholinesterases at nicotinic sites
When is a lateral tilt used in pregnancy ALS?
15-30 degrees if known to be above 20/40 or you can see they are pregnant. If no tilt manually displace
How many more failed intubations are there in obstetrics?
about 8x
In maternal arrest, how long for skin incision and how long for delivery?
4min skin, 5min delivery
Delivery within 10min improved maternal outcome
In amniotic fluid embolus what happens to SVR and PVR?
Increased markedly (according to book but Clark in 1995 suggested its more like anaphylaxis)
If you find foetal material on maternal post-mortem can you conclude amniotic fluid embolus?
No, get some materialin normal labour
While waiting for liver what is the 1year mortaliy?
Those on thelist who didn’t get a liver had a 12% 1 year mort
In the anhepatic phase of liver transplant what happens to the LY30 and 60 (measures of % decrease of clot amplitude at 30 and 60min):
May see fibrinolysis in the patients including immediately post reperfusion
Circumstances of arrest is associated but not definitely causative of poor outcome. What is the PAR score?
Prognosis after resus uses seven variables and scores between -2 and 18 invented in Sheffield. Anything over 5 is terrible
Evaluating prognosis at 72 hrs in arrest patients is contentious wh?
one small study showed some who had absent corneal reflex or pupillary reflex on day 3 and myoclonic status regained awareness
Dose of oxytocin in emergency?
Slow push 5units, (rapdi 10 has killed people)
Define primary and secondary PPH
Primary within 24hrs
Secondary 24hr to 6/52
What usually causes PPH?
Uterine atony
Cell salavage in pregnacy?
Can be used but theoretically risk of foetal cells and amniotic fluid infusion
Virchow’s triad of bleeding (hypothermia, consumption products and acidosis) are known to worsen bleeding in trauma, what else?
activation of fibrinolytic pathway and tissue injury related generation of thrombin-thrombomodulin complexes (which convert thrombin from a coagulant to and anticoagulant)
trauma associated severe haemorrhage score uses what parameters?
SBP, Hb, intra-abdo fluid, complex long bone or pelvic fracure, HR, BE and gender
Dose of TXA in CRASH2?
1g then 1g over 8 hrs
Use of factor VIIa in trauma?
Has been shown to reduce transfusion requirements but no mortality benefit
Define a widened mediastinum
> 8cm
What % of trauma deaths are due to thoracic injury?
25%
Can diarrhoea cause a hyperchloraemic acidosis?
Yes, because you lose Na meaning Cl is relatively high
Maximum warm ischaemic time for liver, lung, kidney, pancreas?
Liver- 30min
Lung- 60min and time to re-inflation critical.
panc 30mni
kidney 120min but can be extended to 4hrs if deemed viable
Before DCD should coroner be informed if no concerns?
Yes, all DCDs should be discussed
Burn injury surface area can be simplified using what?
Wallace rule of 9s
What is the Parkland forumula?
4ml x weight x %burn= volume in first 24hrs with first half given over 8hrs then the rst over 16
What trace elements have evidence for them in burns?
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
Would acidificationo f urine be useful in burn?
No, alkalinisation would be if you had haemoglobinuria and or myoglobinuriea though no level 1-3 evidence
In rhabdo what happens to albumin and calcium
hypoalb due to proteinuria
hyperca can be a late complication due to vit D release from damaged muscle but classically low ca
Treatment of myoedema coma?
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
In myoedemea coma what happens to vasoactive?
May be ineffective or cause arrhythmia, drug metab ay be decreased (dig for example)
OSCILLATE and OSCAR studies?
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)
How do B2 agonists lower K+?
cAMP dependent Na/K pumps is promoted
Maximum K infusion rate via CVC?
40mmol
How much more Ca in calcium chloride vs gluconate?
3x 6.8mmol vs 2.325
How is calcium stored in the body?
40% protein bound, 47% ionised and 13% complexed with citrate, sulphate and phosphate
What is Chvostek’s sign?
Trousseau’s sign?
Chvostek-Twitch of facial muscle when tapping facial nerve
Trousseau- carpopedal spasm following inflating blood pressure cuff for >3min
How is Ca corrected for albumin?
0.02mmol/L for each g below 40g/L albumin
Where is calcitonin secreted?
Parafolicular cells of thyroid
How do allopurinol and rasburicase differ?
Allopurinol decreases formation of uric acid where rasburicase promotes its breakdown
What did the CALORIES study find?
No difference in outcome or infection in enteral vs TPN but no advantage of TPN
What did EDEN study find?
1000 pts with acute lung injury got small amount of feed or full enteral feed. No difference
Selinium in septic patients?
May be of use from meta-analysis in 2013
What was the MELD score initially developed for?
Survival after TIPS
Lots of cardiac workup before liver transplant. Sometimes get HF post transplant why?
Relvatievly higher SVR can unmask cardiac dysfn
What sort of fever would you expct in thyroid storm?
> 38.8
Apart from high T4/T3 and no TSH what else would you see in thyroid storm on bloods?
high ALT, hyperCa, Hypergly and leucocytosis
What drugs for thyroid storm?
Propranolol- 60-80mg 4 hrly
Esmolol B1 selective as the absolute number of B1 receptors are markedly increased
and hydrocortisone coutner intuitively
In thyroid storm should you use meds that inhibit T4 secretion or those that reduce its synthesis?
Both sodium iodide inhibits release and propylthiouracil decreases synthesis
Contents Hartmans
Na 131, K 5, Cl 111, Ca 2, lactate 29
Advantage of Int care deliurum screening checlist over CAM-ICU?
CAM-ICU gives a dichotomous assessment at a certain point in time, ICDSC observes over time
What eqn is used to predict calorie requirement?
Harris-Benedict
Daily Ca requirement?
0.1mmo/kg/day
How many variables in APACHE II?
12
Over what time period is APACHE calculated?
from worst measure in first 24hrs
Can APACHE II be used in kids?
No
RDA vit C?
700-900microg
Can Mg be used as a tocolytic?
yes
Where is Clichy criteria for liver transplant used?
Northern Europe-interestingly uses age, enceph, coagulopathy and factor V levels- Kings is better it would seem
How is pyruvate converted to lactic acid?
By lactate dehydrogenase
What does research suggest we aim for in terms of lactate reduction in septic shock/
If lactate >3 decreasing by 20% over 2 hours period is associated with a reduction in mortality
When is there good evidence for RBC transfusion>
Post renal liver and cardiac transplant
Define TRALI
new acute lung injury characterised by acute dyspnoea with hypoxia and bilateral pulmonary infiltrates with non-cardiogenic pulm oedema within 6 hrs of transfusion
What stratgergies have been employed to reduce TRALI?
leucocyte deplete, men only, pooled (to dilute ab) and screening for people with anti-leucocyte antigen antibodies
over what time frame does a necrosed pancreas organise a wall?
After 4 weeks
If you have pancreatic necrosis, do infections make the systemic effects worseor better?
systemic effects and MOF are no different in steril vs infected necrosis
If you have pancreatic necrosis is surgery or endoscopic drainage superior?
Endoscopic drainage due to less morbidity and cost
If adenosine contraindictaed what drug and dose?
Verapamil, 2.5-5mg
If in third degree HB and awaiting temp pacing wire, what drugs can be used to get your through?
Atropine and glyco but also isopren and adren
When should verapamil be avoided in VT?
VT with severe LV failure
What sort of HME filters bacteria?
Hydrophobic
Whatrelative humidity can nose achieve?
80%
With chest drain insertion should prophylactic abx be used?
Yes, less chance of empyema and all infections
What level of suction should be applied to a chest drain?
Book says 10-20cmH2O
Why is ketamine contra in preg?
Increases uterine pressure and cause foetal asphyxia, most evident in third trimester
Does sux cross the placenta? Is its action prolonged?
No, relative reduction in plasma cholinesterases means it last longer
What are category A and B biological weapons?
A- easy to distribute- anthra, smallpox, botulism
B- moderately easy- Q fever, Typhus
What sort of bacterium is Antrax
Bascillus
How treat Antrax?
60 day post exposure prophylaxis, penicillin is effective in natural variety but with genetic engineering there are concerns over resistance
what is the incubation for Anthrax?
2-60days
Survival of Anthrax?
10-15% naturally, 55%with treatment
Most common cause of VAP?
Aerobic gram -ve (E.Coli, Klebsiella, Proteus)
How long after fondaparinux can you put in an epidural?
42 hrs for removal, 36 hrs for insertion
Define TEG R value
Time from initiation to fibrin formation (15-30mm) Prolonged in anticoag use and haemophillia
Define TEG K value
Time measured from end of R time (clot formation starts) until amplitude of 20mm (normal 6-12mm). Prolonged in antiplt
What is a normal MA in TEG?
50-60mm
What is a normal LY30?
<7.5% degredation at 30min
What is alpha-angle in TEG?
measures the acceleration of fibrin buildup and cross-linkage.
Is NIV allowed in bowel obstruction?
Book says no because risk of aspiration…is this true in large bowel obstruction without nausea too??
What % of phaeos are malig?
10%
What are lab findings in phaeo?
Hypergly, hyperCa and erythrocytosis
Why is beta bloackade only started after 2 days of alpha blockade in phaeo?
Unopposed alpha may give rise to a hypertensive crisis
What tumours in MEN I?
Pituitary, parathyroid and pancreas
MEN IIa and IIb?
2A- Para, medullary thyroid, phaeo
2B- Mucosal neuroma, marfanoid habitus, meduallry thyroid, phaeo
Addison’s causes distributive shock with low SVR, what is Waterhouse-Friderichsen syndrome?
adrenal gland failuredue to bleeding into glands seen in meningococcaemia
What deficiency does acute steroid withdrawal cause?
Acte glucocorticoid def
If Addisons and want to do a short synacthen later what drug can you use?
Dex
What is a rare finding in Addison’s?
1/3 have hyperCa
Which Candida have natural resistance to fluconazole?
Krusei and glabrata, though the latter is dose dep resistance
Risk of AAA rupture follows the law of LaPlace, what is the annual risk of ruputre for a 6-7cm and 5.5cm?
6-7cm 6.6%
5.5cm 0.5-1%
Blood products are first line in AAA rupture. How does GI haemorrhage occur?
Can rupture into the duodenum or colon in their retroperitoneal portions
How many umbilical veins are there?
One (two arteries)
What is the umbilical vein sats?
80%
What % of blood in foetal circulation enters the RV?
1/3
What did PAC-man find?
PAC- no evidence harm or benefit but the FACCT trial showed no mort benefit but more complications with PAC
How is the AUCon thermodilution related to CO?
it is inversely related, if low CO the area is large because it takes more time to warm up the thermistor with blood again
How does Ticagrelor work?
ADP receptor blocker
How long after STEMI do you have to get PCI according to the guidelines?
90min if in a PCI hospital
120min if in a non-PCI hospital
What anticoagulant is best given in PCI lab in addition to aspirin and ticag?
Bivalirudin is preferred over heparin with a mortality benefit seen
Dose of Bivalirudin?
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
What do if PCI not available in 120min?
Fibrinolysis within 12 hrs
When is fibrinolysis considered to have failed in ACS?
If there is on-going inschaemia, evidence of re-occlusion or <50% ST resolution at 60min…if occurs PCI.
What is dumping syndrome
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
What are the preservatives in RBC and how long can they be stored?
SAGM- saline, adenine, glucose, mannitol-35 days
ACPD- adenine, citrate, phosphate and dextrose- 42days
What temp are plt stored at and how long before bacterial contamination a concern?
20-24C 5 days
How do you ABO match platelets?
Compatible are preferable but incompatible can be used in emergency as the plasma content is so small
What temp is FFP and Cryo stored at?
FFP -20
Cryo -30
How do you ABO match FFP?
Must be used immediately after thawing and must be ABO matched. Contains clotting factors, fibrinogen and plasma proteins
How many donors for one cryo?
1
How is cryo made?
Precipitate from FFP
How long can you store cryo?
12/12
Cryo needs to be ABO compat, what does it contain?
High levels factor VIII and fibrinogen
What does the posterior column transmit?
Fine touch, vibration and proprioception and two-point discrimination
What is transmitted in the spinothalamic tract?
Pain and temp in the lateral column
What attache to the coccyx at the end of the spinal cord?
Filum terminale
What is the arteria radicularis magna? Where does it arise and what does it supply?
Artery of Adamkiewicz
Arises from L post intercostal artery supplying the lower two thirds of the spinal cord via ant spinal art
How can protamine cause RV failure?
the proamine heparin complexes stimulate complement and produce thromboxane which leads to high PVR (bit of stretch if you ask me)
Is albumin a good marker of liver synthetic fn?
Not acutely but chronically yes
ALT is more liver specific than AST, why?
AST in skeletal muscle and myocardium along with others.
AST up in renal/bowel infarction, pancreatitis and hypothyroid
What do raised ammonia levels imply?
reduced liver synthetic fn
INR goes up in liver disease and is a good measure of synthetic dysfn (when no vit K def), what factor is most affected?
VII low levels
Official dose range of NA?
0.1-2microg/kg/min
Where does NA mostly act?
alpha 1 in vascular smooth muscle promoting vasoconstriction, at high doses get beta effects
What % of NA is metabolised in lung?
25% (adrenaline and dopamine no)
What did the VASST study find>
low dose vasopressin did not reduce mortality
How many strokes are haemorrhagic?
10-30%
ICH may expand by up to 33% in the first hours, when do you treat BP?
If >180/105 but is risk/benefit, BP>90 to prevent infarction due to pressure effects
Urine acid or alkalinisation in aspirin OD?
Alkalinisation to between 7.5 and 8.5
Why may aspirin OD look like a NAGMA?
The salicylate acid is mistaken for chloride by the ABG machine and therefore you calculate a NAGMA
What is a bezoar?
a mass trapped in the GI tract (drug mule)
What is the target pH in aspirin OD?
7.5-7.6 which should be rememered when ventilating! oOtherwise the profound acid can be deadly
In pregnancy plasma expands by how much?
45%
If a term preg woman lies flat what happens to IVC and SV?
in 90% IVC will be completely occluded
CV dec by 30%
How much is CO inreased in third trimester?
50%
How much does FRC reduce at term?
20% or more when supine
What happens in hypovolaemia in hearttransplant?
Delayed response due to denervation
Can you use adenosine in heart transplant?
No, has an exaggerated response
What views in FAST scan?
Subcostal, right upper quad, LUQ, suprapubic
What volumes can FAST find?
100-250ml minimumm
What is Pendelluft effect?
Exchange of gas betwen adjacnet lung units due to their differing time constants. Insp fast filling fill first, exp opposite
What is the principle mechanism of gas transport in the terminal airways?
Molecular diffusion
Can ECMO be used in DCD?
yes
Can normal saline cause abdo discomford?
Apparently…how the hell you work that out I dont know
Where is K stored in body?
98% intracelular in particular skeletal muscle
What % potassium absorbed by body is ultimately excreted by kidney?
90%
The Na/K pump transporthow many of each cation?
2K for 3Na
How much hospital AKI is due to contrast?
About 12.5%
Is fluid loading or bicarb more useful in protecting against contrast neph?
bicarb is better
theophylline has been proposed as a way to prevent contrast neph, by what mechanism?
Inhibition of adenoseine A1 receptor which mediates afferent renal vasoconstriction
What does the trochlear nerve innervate?
IV SO4 superior oblique
What nerve for muscles of mastication?
Trigeminal
Where does the abducent arise? Where does it classically get compressed?
Lower pons (VI), if ICA aneurysm get palsy
How does tongue get its sensation?
post 1/3 glossopharyngeal, ant 2/3 facial nerve
AF affects about 1.5-2% pop. By how much does it increase stroke risk?
5x and 3x risk of HF
What is Vernakalant and when should it be used and not used?
It is superior to amiodarone in cardioverting AF in stable patients but should be avoided in HF, hypotension, ACS, severe AS and prolonged QTc
When is dronedarone given?
maintains SR in those with PAF but should be avoided in mod/severe HF and avoided in mild HF if an alternative exists
How does acute acalculous cholecystitis occur?
uncommon but secondary opportunistic infection, iscahemia and hypoperfusion and also in immunocomp
When does acute acalc cholecystitis occur?
Men post trauma or surgery
Who should get USS monitoring for acute acalc cholecystitis?
Trauma pt with ISS>12 who are tachy and getting blood
What are non trauma causes of acute acalc cholecystitis?
Vasculitidies can cause it inc antiphosphlipid syndrome (give anticoag rather than cholecystectomy) others like SLE and Henoch-Schonlein purpura may need steroid
What is mort of acute acalc chole without treatment?
50-85%
Is RRT any good for diltiazem and metformin OD?
Diltiazem too large , relatively ineffecive
Metformin very soluble and readily removed by RRT. Start if severe lactic acidosis
What is the upper limit of normal FTc in anaesthetised pt and why higher than normal?
400ms due to low SVR under GA
What is FTc
Forward flow in aorta corrected for HR
Initial antiplt in ichaemic stroke?
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
Why are statins not given immeditely post stroke?
Higher levels of haemorrhagic transformation reported so start at 48hrs
If you knock out the artery of Adamkiewicz what happens?
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
What is Conus Medullaris syndrome?
Injury at T12/L1 with damage to lumbar and sacral cord leads to extensive paralysis in legs
How does central cord syndrome present?
UL>LL and bladder dysfn
How does Brown-Sequard present?
Ipsilateral motor and prop, contra pain and temp equal ‘loss’ on both sides
How are starch based fluids made?
Hydrolysed maize
With albumin as 1, what is the relative rate of anaphylactoid reactions to HES, dextran and gelatin?
HES-4.5
Dextran -2.3
Gelatin 12.4
Why is starch not recommenede in ICU?
MAy lead to higher need for RRT and death
What side effect of starch do 13% people get?
Itch
What % of post liver resection pts have a major complication( bleeding, liver dysfn, resp failure, sepsis, infection)
30%
Seems high to me
Liver resection pts kept dry but what may make them even more deplete?
Self limiting ascites in first 48hrs which may be helped by HAS in immediate post op
When can paracetamol be used post liver resection?
Usually avoided immediately post op but once LFTs normal can be used
What does hypoPO4 mean in liver resection pt?
PO4 rapidly consumed in liver regeneration via high ATP production so can be low when regenerating
Is PTX frequent in VILI?
Apparently so
What is thought to be the initial mechanism in barotrauma?
Development of extra-alveolar air due to perivascular alveoli disruption
What cytokines are important in lung biotrauma?
TNF Il 6 and 8
How many grades of encephalopathy are there?
5 with grade 0 being normal ! FFS
What levels of ammonia are associated with cerebral oedema?
> 200g/dl
Is Rifaximin NICE approved?
No
What current flow across chest is needed to induce VF?
100mA
What radiation exposure is needed to alter blood counts?
1Gy
MH is auto dom or recessive?
Auto dom
What receptors are involved in MH?
dihydropyridine receptor and ryanodine receptor (Ca efflux) on SR
Dose of Dantrolene for MH?
2.5mg/kg up to 10mg/kg
Normal CSF osmo specific grav gluc Cl Protein?
280mOsm/kg 1.005 1.5-4 Cl 120-130 HCO3 25-30 Pro 0.15-0.3g/L
What are the boundaries of the thoracic inlet?
1st T vertebra, manubrium and first rib and costal cartilage
What separates the subclavian vein and artery?
Scalenus anterior
What goes through thoracic inlet?
Trache oesoph, large vasc trunks, vagi, thoracic duct, phrenics, cervical sympathetic chain
Where is the cricothyroid cartliage?
Between thyroid cartilage and cricoid cartilage
What is the space overlying the cricothyroid muscles that allows access to the cricothyroid membrane?
9mm
Is the cricothyroid avascular?
Not completeley, have branches from sup thyroid
Are bypass and RRT acceptable to jehovah witnesses?
Yes as is EPO, VIIa and Fe and TXA
Indications for RRT?
AEIOU acidosis electrolyte (usually K) Ingestion of toxins (ffs) overload uraemia with complications
What physical principle does haemofiltration use?
Convection for small and middle size molecules
What physical principle does haeodialysis use?
diffusion
Where is the mutaton in Sickle cell disease?
Chrom 11 causing amino acid substitution i beta globin subunit
What causes thalassaemia?
Defective synthesis of alpha and beta globin subunits
Does vit K def result in prolonged bleeding time?
No
Does aspirin and uraemia lengthen APTT/PT?
No only bleeding time
What is the M:F ration in IE?
2:1
What species should be considered in culture negative IE?
Coxiella burnetti, Legionella, Brucella, Bartonella, Chlamydia
What, using Duke is confirmed IE
2x major
1 major, 3 minor
5minor
Cure rate of abx in IE?
50% the remaining require surgery
Define HRS
Cr >133micromol/L in cirrhosis and ascites where no other diagnosis found
What is the pathophysiology of HRS?
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
Which of type I and II HRS is worse?
type 1 (cr>221)- occurs in 2 weeks usually secondary bacterial infection that decomp liver.
When should surgery for AS be considered?
When symptomatic and those who are not with low risk
How is mitral stenosis usually treated?
Most with good anatomy have a perc mitral commussurotomy
How long after bioprosthetic AV do you take aspirin?
3 months
In hypertesnive crisis how muc do you lower BP?
10-20%
GTN dose IV?
0.5-20mg/hr
SHOT reports divide reactions into what?
acute (<24hrs)
Delayed(3-10/7 post)
Blood product reaction may be subtle inder GA, what may be the only signs?
urticria and hypotension
Can Coombs test be used to check for ABO incompatibility (along with others) resulting in haemolysis?
Yes
What is the risk of bacterial contamination in plt and RBC?
Plt 1:2000
RBC 1:500,000
Bazzett’s formula is what?
QTc=QT/square root RR
How does pulmonary fibrosis give a reading for PCWP not close to LVEDP?
The venous obstruction
How does Mg affect Ca?
If low or very high can cause hypoCa
Pseudohypoparathyroid is primarily a function of what and what subtypes?
PTH resistnace
1a,1b and 2
Outline pseudohypoparathyroid 1a,b and 2
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
what can pseudopseudohypoparathyrodism be considered?
A variant of Albright 1a pseudohypoparathyroidism, have the short fingers and round faces but normal gland function
After NSTEMI how long until angio +/-PCI/
72 hrs unless high risk (ongoing pain, arrhyth etc)
What is the ARR of PCI in STEMI?
3% (8->5% mortality)
Ifyou have left main or three vessel disease is CABG or PCI better?
CABG
Can Neostigmine be used in pseudo-bstruction?
Not first line but if conservative measures failed can with cardiac monitoring
Is fluid and eletrolyte replacement wiith NG decompression useful in adhesional bowel obstruction?
Yes apparently though I think time is the most therapeutic component
Is CT helpful pre-laparotomy?
If peritonitis CT and USS have limited yield and increase time. CT with contrast however is useuful in finding leaks and collection
cellurlar prion protein occurs natually in humans and animals where is the gene located?
Chrom 20
What happens if there is a mutation in the prion protein gene?
Accumulation of abnormal proteins and death ensues
What is the scarpic isoform of prion protein
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
What is the best way to test for prion disease?
Tonsillar biopsy 100% sens (bloods 70%)
What is the WHO defn of CJD?
progressive psych disorder of less than 6/12 with no alternative diagnosis
What is the M:F split in gastroparesis?
1:4
What are risk factors for secondary gastroparesis?
T1DM, abdo surgey- vagotomy, fundoplications, bariatric surgery, HypoT4, rheum conditions
What scores do albumin get in Child-Pugh?
> 35=1
28-35= 2
<28=3
What is the 1 year survival for C-P A, B, C cirrhosis?
A- (5-6)=100%
B- (7-9) =80%
C-(10-15)=45%
Is Child-Pugh better or worse than APACHEII at predicting prognosis of critically ill patients with liver disease?
Worse (SOFA is better than CP too)
What do people with paraquat poisonoing die from?
Fibrosis (O2 during resus probably makes them worse)
How does strychnine work?
antagonist of glycine->inc muscle toe, twitch, seizures
What are the symptoms of organophosphate OD?
DUMBBBELS Diarrhoea URination Miosis Bronchorrhoea Bronchoconstriction Bradycardia (but tachy can also occur) Emesis Lcrimaion Salivation 'everything comes out of you'
How does short bowel syndrome cause lactaemia?
Raised D-lactate causing type B hyperlact
What does baclofen OD look like?
Can mimic brainstem death with fixed pupils for days to weeks. Intubation is needed in all but the most minor intrathecal OD
What does baclofen toxicity often present with?
hypotension and hypothermia with reboudn hypertension, hyperthermia and hallucinations on withrawal
Is RRT any good in baclofen OD?
yes
How does baclofen work?
GABA(b) agonist so down regulates everthing
Whats the difference between hyperthermia and hyperpyrexia?
Hyperthermia is fever, hyperpyrexia is where the set point for temp is raised
How does ecstasy give sympathetic over activity?
dopamine release
NMS results in true hyperpyrexia, how?
antagof D2 receptors in hypothalamus and spinal cord. This increases the temp set point and impairs heat dissipating mechanisms
Why does bromocriptine sometimes work in NMS?
It is a D2 agonist (antipsych are D2 antag)
Whats the danger with phenytoin and status?
Extravasation can cause nasty burns and necrosis
How does keppra work?
Nobody knows but its not Na+ cannels, GABA or glutamate. ? works on synaptic vesicle protein 2 influencing Ca signalling
What are the 4 mechanisms of diarrhoea?
Osmotic, secretory,inflamm and dysmotility
Define osmotic and secretory diarrhoa
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)
Define inflamm and dysmotility diarrhoea
Inflamm- loss of mucosal integ
dysmotility- fluid/electrolyte stay in SB which then overwhelms the large bowel ability to absorb
HSV is most common cause of enceph in developed countries, which one?
90% HSV1
10% HSV2 (more immunocomp and kids)
Treatment for VZV enceph?
Limited evidence but given aciclovir for 14/7 and shot course steroids to reduce inflamm
What do 20% of those who are receiving aciclovir get?
reversible obstructive neph secondary crystalluria (usually after about 4days)
What % enceph is unknown cause and what % VGKC/NMDA ab?
50% uknown
8% voltage gated K channel and NMDA ab
Define delirium
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
What % patients ahve hyperactive delirium and hypoactive?
2% have hyperactive
Lidocaine Vaughan williams class?
Propranolol?
Flecanide?
Verap?
Lido- Ib (Na blocker)
Prop- II
Flec Ic
Verap- IV
Which is faster midaz or loraz?
Midaz (2-5) vs loraz 5-10
Half life of midaz and loraz?
Loraz 8-15hrs
Midaz- 3-11
What are phase 1 reactions?
All oxidative
Zero order and 1st order kinetics?
zero- contatnt amount of drug removed per unit time
1st- amount drug removed prop to concentation
Which of alkali vs acid ingestion cause liquefactive necrosis?
Alkali
Rates of c-spine injury and TBI in paeds?
2% c-spine but 75%TBI
What agents are approrpiate and in what dose for Paed RSI?
Ketamine 1-2mg/kg
Thiopental 2-5mg/kg
Sux 1-2mg/kg
Etomidate 0.3mg/kg
What malarial species causes the most deaths?
P.Falciparum
In P. Falciparum where does infecrion initialy develop?
Liver then RBC (incubation 9-14 days)
Whatis gold standard for malaria diagnossi?
Thick and thin blood films
TB causes 3million deaths annually, how oes primary and secondary TB present?
Primary asymp usualy. Over 90% of TB is secondary in non-HIV group
How does Botulism present?
Acute descending motor paralysis (cranial resp and autonomic nerves0
What does botulinum toxin do?
Bloacks acetylcholine release fro presynapse
How is botulinium toxin tested for?
ELISA and electrochemicaluminecent test or tissue culture
How does tetanus cause its effects?
Inhibits presynaptic GABA
Treatment for tetanus?
Metronidazole to kill clostridium tetani, immunoglobulin sedation, muscle relaxants, benzos and management of autonomic dysfn
C. diff is what sortof bacteria?
G+ve anaerobic bacillus
What do c.diff enterotoxin A and cytotoxin B target>
Rho proteins are target within colonic cells leading to diarrhoea
Where may the future issues be in drug resistnace?
G -vebascilli as no new drugs for years
What has VRE evolved?
mutated penicillin binding protein
In addition to b-lactams what else are ESBLs usually resistant to?
Aminoglycosides and quinolones
in preg what happens to clotting factors?
Increase except XI and XIII
What happens to platelet function in preg?
Remains normal, there is a relative low count given plasma expansion
Risk of VTE in preg? And post partum?
10x throughout and 25x post partum
Is thrombolysis allowed in pregnancy?
Yes
What is Mendelson’s syndrome?
Aspiration pneumonitis
What are the common casues of infectionin preg?
Chorioamnionitis, post partum endometritis, UTI, pyelo, septic abortions
How long should empiric abx be used for according to surviving sepsis?
3-5 days
Glucocorticoids synthesised where>
zona fasiculata or cortex
Where are
aldosterone
androgen sex hormones and catecholamines secreted?
Aldost-zona glomerulosis
sex-zona reticularis
catecholamines- adrenal medulla
Where is glucagon made?how does it act?
Alpha cells in islet of Langerhans, opposes insulin via second messenger cAMP
What size ETT for neonate at term?
3.5mm
What do you assess in neonatal resus?
colour, tone, RR, HR
Without antiviral prophylaxis what rate of CMV infection post solid organ trans?
23-85%
What are predictors of re-admission to ICU post discharge with liver transplant?
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
How many ant and post spinal arteries?
Two post, one ant
What % of spinal column fractures lead to cord injury?
14%
In spinal cord injury what % develop VTE and PE?
90% VTE, 10% PE
How good is ciclosporin’s PO availability?
Uncertain gut absorption and bioavailability is poor
What sort of anion gap acidosis does acetazolamide cause?
NAGMA
What tests can be used in non-parametric data?
Mann-Whitney U tests, Wilcoxon matched pairs and Spearman’s rank co-efficients
Well’s criteria for PE?
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%
What is the maximum time an inner tube should be in a trache without cleaning?
7-14 days…I’d be amazed if anyone has ever reached that
What is the upper limit of pressure for hyperinflation physio techniques?
40cmH2O
Sedation slows mucocillary clearance,whenuse cough assist?
When pt has exp muscle weakness
What is Bartter’s sndrome?
Inherited defect in thick ascnding limb, K loss and high aldosteronewith normotension. If low HCO3 could be an RTA
Whatis the Fowler method utilised for?
Measureanatomical dead space
Howcan resp drive be measured?
airway pressure 0.1s after occluding airway against insp effort
Where’s calcium found in body?
> 98% in bones
ECG changes in hyperCa?
wide T wave, short QT
What does secondary hyperparathyroidism look like?
appropriate hyperPTH due to low Ca so normally have normal Ca but canbe hyper or hypo
What do thiazides do to Ca?
HyperCa
What are recognised treatments for hyperCa?
Mithramycin, steroids, calcitonin, bisphos
incidence of prop infusion synd?
1.1%
What ppt the metb acidosis in PRIS?
Renal failure and lactic acidosis
What ECG changes in PRIS?
Brugada-like changes also AT, bradys, BBB and eventually asystole
Risk factors for PRIS?
head injury, sepsis, high catecholamines and glucocort levels, low carbs:lipid ratio and inborn errors
2g Mg is how many mmol?
8
What can cause hypoMg?
diuretics, ACEi, aminoglyc, amphotericin, cyclsporin, cisplatin
ECG findinds inhyperMg?
long PR, QRS and QT
What is the Ostrosky-Zeichner rule used for?
Had a high negative predictive value of those who will not develop invasive candida
normal daily GFR?
180L
5mg pred = ?hydrocort
20mg
Prednisolone is equal to prednisone in potency but how much methypred =5mg Pred?
4mg
Dex and Betamethasone have the same conversion from pred, 5mg pred =?
0.75mg
GI bleed in HIV, mostly HIV or something else?
70% lower GI bleed is HIV related eg CMV colitis.
Most common causative organism in HIV meningitis
cryptococcus neoformans
If have cANCA and PR3 ANCA what is 99% likely?
GPA
If you have CF what ANCA are you likely to have?
cANCA with MPO -ve
What drugs can cause ANCA vasculitis?
minocycline, hydralazine and propythiouracil
what is the calorific value of propofol?
1kcal/ml
What are the effects of adrenalin?
Beta at low dose, alpha at high
What Ig is responsible for anaphylaxis?
IgE though in some it may be IgG
How does adrenalin help in anaphylaxis?
It increases cAMP in leukocytes and mast cells therefore inhibiting further histamine release and improves cardiac contractility and SVR and bronchial smooth muscle tone.
Risk factor for latex allergy?
Healthcare worker, strawberry/kiwi allergy and spina bifida
60% of all anaphylaxis is from muscle relaxants, which is the most likely to cause anaphylaxis?
Sux
What WBC abnormalities are diagnostic of sepsis?
> 12, <4 or normal count with >10% immature forms
What mixed venous sats would suggest sepsis?
> 70% due to microvascular shunt
If someone has drowned how many rescue breaths?
5
In drowning what immersion time indicated prolonged asphyxia?
10min
If inadvert intra art thio what do?
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
How many panels are there on a CPET?
9 panels (2,3,5 CV, 1,4,7 vent and 6,8,9 VQ)
What does peak VO2 correlate with although under the control of the pt at testing
Cardiopulm complications after oesophgectomy and AAA
Define anaerobic threshold
The point at which the rate of increase of CO2 exceeds the rate of increase of VO2
What should happen to a patient with an AT<11ml/kg/min?
Admit ICU post op
In TURP syndrome what fluid is used?
glycine 1.5%, mannitor5% or sorbitol 3.5%
All are non-conductive and non-haemolytic
Where does the RCA arise?
anterior aortic sinus or right coronoary sinus
Wheredoes the LCA arise?
Posterior aortic sinus dividing into LAD and circ
Which cardiac veins drain into the LA via the coronary sinus?
All of them except the anterior cardiac veins which directly flow into the LA
What is the PDA a branch of? And the anterior ventricular art?
PDA is a branch of RCA, ADA is from LCA
What determines coronary art dominance? Which is more prevelent? What happens whenthe unusual setup occurs?
PDA, R dom in 80%
If not the PDA arises from the LCx
What types of hypoxia are there?
Hypoxic, anaemic, stagnant, histotoxic
What are the causes of hypoxic, anaemic, stagnant and histotoxic hypoxia?
Hypoxic- low O2 eg VQ mismatch of high altitude
Anaemic- anaemia, blood loss, CO poisoning
Stagnant- HF, Shock, ischaemia
Histotoxic- CN and other poisons
What is the presentation of a porphyric crisis?
Poorly defined abdo pain and mood disturbance (inc psychosis) with proximal>distal weakness and up to 20% develop bulbar paresis/ resp failure
What bloods would you expect in porphyric crisis?
HypoNa (SIADH) and Mg
Heparin binds anti-thrombin III, reversibly or irrev?
Reversibly
What causes HIT?
IgG ab to heparin PF4 comlex
What is the HIT score called officially?
Warkentin criteria
Whenare CMV-ve blood product required>
If pt cmv-ve before transplant
How does Cisplatin work?
Alkylating agent preventing DNA cross linking and therefore cell replication
Which probe for FAST scan?
Curvilinear 2.5-5MHz
What targets plt in ITP?
IgG ab which then tag them for destruction by monocyte-macrophage system
If emergency in ITP with bleeding what can be used in addition to steroid?
Immunoglobulin (longer term Rituximab/splenectom)
Causes of primary and secondary TTP
Primary- Lack of ADAMTS13
Secondary (40%)-drug, radiation, chemo, angioinvasive infections, GVHD and secondary surgery, preg, CMV, HIV, antiplt
In plasma exchange how much plasma is typically taken and replaced with what?
30-40ml/kg
solvent detergent FFP
Max dose levobupivicaine?
2mg.kg
Initial dose intralipid for LA tox?
1.5ml/kg then 15ml/kg/hr
How long for troponin to start to leak and how long can it persist?
2-4 hrs
If huge infarct can persist for up to 2 weeks
Those in ICU with trop rise from being so sick have what mortality compared with others?
51% VS 16%
What is the mortality profile of NSTEMI and STEMI?
NSTEMI is better short term but by 6 months equal. After that STEMI is better
When is revascularisation considered in NSTEMI?
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
What are the variables of a GRACEscore?
8 variables
age HR SBP Cr, CCF Killip class, arrest at admission, ST change or troponin
What does GRACE calculate?
in hosp and 6/12 mort
What does a CHADVASC score of 2 mean in terms of risk of stroke?
2.2% per year stroke risk
If you only use aspirin in AF what is the reduction in stroke risk? And with warfarin?
22% asp
60% warfarin (ICH risk 0.3%)
Why is antithrombotic therpay not recommended for those <65 with only AF?
THeir absolute risk is so low the RRR is pointless
What is Jervell-Lange-Nielsen syndrome?
congen (auto recessive) LQT syndrome
How is Romano-Ward inherited? Complication?
Auto dom, LQT syndrome
What is Brugada syndrome?
Na channelopathy, auto dom and family clusters
What does Dobutamine stimulate?
B1 and B2 in 3:1 ratio, some effect on alpha 1
How does Levosimendan work?
Ca sensitisation (positive inotrope) and opens K channels (periph vasodilatation). May also have a PDE effect
What SAAG suggests ascites from portal HTN? What about Budd-Chiari or HF?
SAAG>1.1g/dl is likley from portal HTN
if very high >2.5 the portal HTN is huge hence Budd-Chiari or HF
How often are low Na diets and diuretics successful in ascites control?
10%
How much protamine to 100units heparin?
1mg
How is mild pre-eclampsia treated?
Usually with support and frequent monitoring which may include complete or partial bedrest
How long post-partum should Mg be continued in pre-eclampsia?
24hrs at least
How does lactate alter if splanchnic ischaemia/infarction?
Is usually a alate sign, espcially if the blood supply is completely compromised
Whatdoes NA do to splanchnic circulation?
no evidence it has any effect, there is evidence adrenaline and dopamine do
BNP is not specific and so can be raised in many patients, what non-HF causes are there?
High PA pressure if GFR<60(excreted by kidney), sepsis, DM, age>70, liver cirrhosis
What can reduce BNP levels?
Normal heart or resolution of issue but also obesity, BB, ACEi, aldosterone antag
In non-paracetamol liver failure what are the criteria for transplant?
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
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?
Once you’ve had it you have lifelong immunity
SS-RNA
0.1% mortality
How effecive is HAV vaccine?
80-100%
What are the withdrawal symtpmos of Dexmet? and when do they present?
24-48hrs after stopping if used for 7 days or more
Agitation, nausea and vomiting
When should nicotine replacement be carefully considered?
If someone has arrhythmia, MI, stroke, uncontrolled HTN, renal or hepatic impairment
Who shoud get hyperbaric O2 in CO poisoning?
Preg, coma or HbCO >40%
What sort of acidosis does CN produce?
HAGMA and cherry red skin
In decomp liver disease 50% of renal failure is due to what?
pre-renal frm multiple causes
Opening pressure in
Bact/TB
Viral
Fungal
Bact/TB- high
viral- normal
fungal- very high
Correction for blood in CSF?
for every 500-1000RBC reduce WBC by 1
What else apart from WBC needs to be corrected if bloody tap on LP?
Protein- reduce 0.1g/dl for every 100RBC (or 1g/dl per 1000)
Lactate in CSF is useful in ruling out bacterial meningitis under what level?
2
If >4 has 88% sens and 98% spec for bacterial meningitis and is found earlier than low glucose
If someone may have HSV enceph and first sample-ve what do?
Another one in 24-48hrs for HSV PCR again
Lymphocytic differential seen in viral mening/enceph andwhat else?
TB and fungal
What is a ‘gin’ clear CSF associated with?
viral
What did ALBIOS study find?
No benefit of albumin in sepsis on 28 and 90 day mort
What did the IVOIRE study find?
No evidence that 70ml/kg/hr cf 35 for 96hrs leads to redcued 28day mort, haemodynamic profile or organ fn
What did PROWESS-SHOCK find?
PROWESS study found a mort benefit for activate protein C so followup study conducted which didn’t show an improvement
Is eary goal directed fluid therapy useful in sepsis?
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?
How do penicillins act?
inhibit enzyme transpeptidase that forms lattice cross links of bacerial walls->bacteriocidal
Howdoes co-trimox work?
Inhib dihydrofolate reductase (DNA/RNA synthesis is distrupted)
How does metronidazole work?
damages DNA
How does Vancomycin work?
Inhib cell wall production
How does Rifampicin work?
prevents RNA transcription and therefore protein synthesis
What is IM ketamine GA dose?
4-10mg/kg
Where is thiopentone metab?
99% in liver
What are effects of intra art propofol?
Delayed induction but nothing else
How long can PRIS take to start>
24-48hrs can see CK rise
Define bioavailability
the proportion of oral drug reaching circulation compared with the same dose given IV
What do competitive antagonists do to the dose response curve?
Shift to right (non-competitive dont move to right simply reduce amplitude=)
Define therapeutic index
median lethal dose/median effective dose
Clonidindoes what?
alpha 2 agonist reducing NA release
At what pH does midazolam’s imidaole ring close?
pH>4 resulting in better lipid solubility
What are the cardiovasc parameters we aim for in a DBD donor?
HR 60-120
BP>100
MAP>70
What ABG would be minimum in DBD?
pH, PaCO2 and PaO2
pH 7.35-7.45
pCO2 4.7-6
PaO2 >10.7
What serum Na should DBD donors have?
Ideally 140-160 but can be from 115-160
What are the Maastricht organ donation classification categories?
I- dead on arrival II- unsuccessful resus III- anicipated death (most DCD) IV-- cardiac arrest in DBD V- unexpected arrest in ICU
What is consent rate for DBD and DCD>
DBD 63%
DCD 57%
Where is the legislation for donation written?
mental capacity act 2004
Absolute contra to TOE?
bleeding, stricure, tumour, diverticula, scleroderma, perf
When is intubation due to haemodynamic compromise warranted in kid?
if 60ml/kg fluid given intubate child as up to 40% of their energy expenditure can be due to breathing
Extremis IM RSI for kid?
5-10mg/kg ketamine and 3-4mg/kg sux
asymptomatic candiuria how treat?
Can be colonisation, change catheter and see. If neutoropenic etc then be more worried
How does amphotericin B work?
Binds to ergosterol causing cell death
How does fluconazole work?
Inhib C-14 alph demethylase which is needed to make ergosterol (which makes up cell wall)
How does Caspofungin work
targets proteins responsible for cell wall synthesis
What classically causes a false positive VDRL, prolonged viper venom time and APTT?
Anti-phospholipid syndorome
What can have its first presentation with diffuse alveolar haemorrhage?
GPA (wegners), SLE, goodpastures, Scleroderma ad RA
How long after scleroderma renal crisis does it take for renal fn to improve?
3years!
What is the first step of viral ingress in HIV?
ENV protein binds with CD4
What causes secondary and tertiary blast injury?
2ry- flying debris
3ry- person thrown across room/etc
In blast injury contusions over what size should be resected in bowel/
20mm
What is an appropriate abx for gun shot?
Usually clostridia and beta haem strep so Ben-pen ok
What is CO poisoning mech?
Not clear, obviousl anaemic hypoxia but also histotoxic is thought to play a role
Is PaO2 affected by CO?
No
How many births in 2018? Still births? neonatal deaths?
740K
2500 still
1200 neonatal all improving
What population is most likely to have a still birth?
white 1:295
Asian 1:188
Black 1:136 (depreivation)
Cause of preg women deaths?
in 2015-17 209 women died (2.2million preg) 23% heart disease 16% clots 13% stroke/epilepsy Asian or black more likely
Define PPH
loss 500ml in first 24hrs (minor 500-1000, major >1000)
What happens to PR interval in hyperK
PR longer
HyperK and QTc?
Shorter
HyperMg and HR/BP?
bradycardia, hypotension (inc PR and QRS)
After liver transplant what sort of reduction in AST is expected each day?
50%
What vessel is not seen on USS of liver and so should be CT if concerned?
Hepatic artery
What conclusion would you draw from infiltrates on day 1 post lung transplant? Day 2/3?
Day 1 result from implantation response but if cont for 2/3 days with worsening O2 rejection should be considered
In heart-lung transplant which is more likely to reject?
Lungs
When is fasciotomy indicated in rhabdo?
pressure >30mmHg
What is the classical CXR finding of fat embolus though it is far from a sensitive investigation
Snow storm
How is ISS calculated?
6 areas with score 1-6 where 6 is incompat with life. The three highest scores are then squared and added together
What are the six areas covered by the ISS?
head, face, chest, abdo, extermity and external
What is the maximum scare in ISS if you’re still alive?
75 (5^2+5^2+5^2) if you get a 6anywhere youre dead
Is there an equal chance of the ISS hvaing any number between 0 and 75?
No, because the numbers are squared some are impossible and othrs less probably
What does SIADH do to urine Na?
raised (normal na but low water content)
What does CSW do to kidney?
raised urine Na with plasma hypoNa due to renal Na transport abnormality
What are the three mechanisms of pelvic trauma ?
ant-post compression, vertical compression or lateral compression
What artery is the most likley to be damaged in pelvic trauma
superior gluteal
What does an open book fracture do to the retroperitoneal space?
Can quadruple itssize
How long do you give someone a spont breathing test before you know what is the likely outcome of extubation?
30min
What rapid shallow breathing index means likely to succeed in extubation?
<105
Where is Na reabsorbed in kidney?
25% loop of henle
65% prox tubule
WHat is absorbed in prox tubule?
70% of Na, H2O and Cl
90% bicarb
100% glucose and alb
Where is Na and Cl passive and active transport in loop Henle?
Active in thick
Passive in thin
Cause of death i DKA most likley?
Cerebral oedema
Why bicarb not good idea in DKA?
Can cause cererbal oedema, delays lactate and ketone clearance and raises CO2
Define HHS?
pH>7.3, gluc >30, ketone<3, osm >320
What sort of water deficit does an HHS patient have?
100-220ml/kg!
What rate of fall of Na and glucose is acceptble in HHS?
10mmol Na, 5mmol glucose
When do you get insulin in HHS?
If sig ketones or if glucose no longer falling with fluids
What is the RRR of perinatal asphyxia cooling?
15% NNT 9 within 6hrs
Define acute profound hypoNa
Na<125 for less than 48hrs
What is the differential for hypotonic hypoNa with urine osmo < 100
Beer potomania, polydipsia and low solute intake
What is the differential for hypotonic hypoNa with urine Na>100 and urine Na >30
SIADH and CSW
What is the emergency treatment for hypoNa?
150ml 3%
What head up is required to reduce VAP?
30-45degrees
What chlorhex soln for skin asepsis?
2% (0.5% is used to steralise prior to neuroaxial bloackade)
Define transpulmonary pressure/
alv pressure - pleural pressure
Are femoral lines dirtier than others?
Initially we thought so but newer evidence suggests no
What is filtration ratio and what is targetted?
is a measure of haemoconc in the filter (or the ratio of filtrate removed as a percentage of blood flow)Target 25-30%
What ar pros and cons of lactate and bicarb RRT replacement fluid?
Bicarb are more preferred as they are more reliable at buffering capacity but they are more unstable
If develop HIT on heparin RRT without citrate available what do you do?
1A recommendation to start argatroban (direct thrombin inhib) as long as no liver failure. If there is then consider another antcoag
What does fat and water look like in T1 weighted MRI?
Fat bright, water dark
What noise level can you expect when switching gradient fields in MRI?
85dB which can damage hearing
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?
should have ICP if more than two of >40, motor posturing, SBP<90
What happens to SID in RTA?
urine SID is high but plasma is low due to Cl loss in kidney
What characterises RTA types 1,2 and 4?
1- reduced ammonium production distally
2- increased prox tubular Cl resorption
3- reduced ammonium production proximally
What doe acetazolamide do to SID?
It increased Na:Cl extraction meadning serum chloride is relatively higher than Na meaning SID is low
What can a metabolic alkalsis cause?
Seizure, confusion, drowsiness and cerebral vasospasm
In overt hyperthyroid what patterns of T3 and T4 can be seen?
Both high classically but can have isolated T3 or T4
What is primary hypothyroid?
Normal T4 but high TSH
How is sick euthyroid distinguished from primary hypothyroid?
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
What the hell is reverse T3?
Is were the iodine atom has been removed from the inner ring of T4 rather than the outer which would make T3
What activator is used in ROTEM EXTEM and INTEM?
EXTEM- tissue factor
INTEM0 contact actiator
What does FIBTEM look at?
When compred with EXTEM gives you the fibrin component of clot
Where does Ricin come from?
Castor oil beans
How does ricin kill you?
Inhibits protein synthesis only 5-10microg/kg is fatal
What does VX nerve gas do?
Inhibits ACh esterase causing cholinergic crisis
Whats another name for variola major?
smallpox
how are the pox different in chick and small pox?
Small pox mostly on body with relative limb sparing (centrifugal) whereas chickenpox is on limbs
What factors are in the Child-Pugh scoring system?
TB ALb PT Ascites Enceph
What scores do you get from each of the five factors that make up Child Pugh?
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
What are the CP classes? What score puts you in each category?
A, B and C
5-6=A, 7-9=B, 10-15=C
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?
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
What are low medium and high risk HIT scores?
Low <4, medium 4-5, high >5
Risk (stage 1 of AKIN)of RIFLE define
1.5x Cr/ >26.5micromol/L inc
or <0.5ml/kg/hr for 6 hours
Injury (stage 2 of AKIN) of RIFLE define
Cr x2-3 or u/o <0.5ml/kg/hr for 12 hrs
Failure (stage 3 of AKIN) in RIFLE define
Cr x3 or Cr> 353.6
or
U/O <0.3ml/kg/hr for 24hrs or auria for 12hrs
