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FRCEM SBA > Miscellaneous > Flashcards

Miscellaneous Flashcards

1
Q

When should we not offer PEP to a patient who has unprotected sex with a patient who is HIV positive?

A

If partner has been on ART > 6 months and has had an undetectable viral load in last 6 months

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2
Q

When should PEP be offered routinely (4)

A

If unknown or detectable vial load and:
1. Receptive anal sex
2. Receptive vaginal sex
3. Occupational exposure
4. Needle sharing

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3
Q

When should PEP be considered? (2)

A

Unknown or detectable viral and:
1. Insertive vaginal sex
2. Insertive anal sex

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4
Q

When is PEP not recommended? (2)

A
  1. Sex/splash/injection in high risk group but not known HIV
  2. Human bite in HIV positive
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5
Q

What PEP should be offered?

A

Tenovir + emtricitabne (Truvada) combination and raltegravir OD for 28 days

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6
Q

When should PEP be started?

A

ASAP (ideally <24hours)

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7
Q

After what period is PEP not effective?

A

> 72 hours

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8
Q

What is a tetanus prone wound? (5)

A
  1. Puncture wounds occurring in contaminated enviroment
  2. Wounds with foreign body
  3. Compound #s
  4. Wounds/burns with sepsis
  5. Certain animal bites
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9
Q

What are high risk tetanus prone wounds? (3)

A
  1. Heavy contamination with soil containing spores
  2. Wounds/burns with significant devitalised tissues
  3. Wounds/burns requiring surgery that are delayed over 6 hours
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10
Q

What is full tetanus immunisation? (3)

A
  1. > 11 year priming course and last dose < 10 years ago
  2. 5-11 years and priming course pre-school booster
  3. < 5 years and priming course
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11
Q

What is partial tetanus immunisation? (2)

A
  1. Over 11 years, priming course but last dose >10 years
  2. 5-11 years with priming course but no pre-school booster
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12
Q

If fully immunised against tetanus what do you require following a:
1. clean wound
2. tetanus prone wound
3. high risk tetanus prone wound

A

Nothing

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13
Q

If partially immune against tetanus what do you require following a:
1. clean wound
2. tetanus prone wound
3. high risk tetanus prone wound

A

1.Nil
2. Vaccine dose
3. Vaccine and TIG

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14
Q

If no immunisation against tetanus what do you require following a:
1. clean wound
2. tetanus prone wound
3. high risk tetanus prone wound

A
  1. Vaccine
  2. Vaccine and TIG
  3. Vaccine and TIG
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15
Q

What dose of TIG should be given in tetanus? (4)

A
  1. 250 IU IM
  2. 500 IU IM if :
    - heavy contamination
    - burns
    - > 24 hours

NB do not given vaccine and TIG at same site

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16
Q

What is a clean wound re: tetanus risk?

A

< 6 hours
non-penetrating

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17
Q

What values are considered mild/mod/severe hypercalcaemia?

A
  1. <3
  2. 3-3.5
  3. > 3.5
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18
Q

What ECG changes do you see in hypercalcaemia? (4)

A
  1. Short QTc
  2. Bradycardia
  3. 1st degree HB
  4. Broad T waves
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19
Q

What is first line treatment for hypercalcaemia?

A
  1. 4-6 L of IVI over 24 hours
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20
Q

What is second line tx for hypercalcaemia?

A
  1. Zolendronic acid 4mg
  2. Pomidronate 30-90mg
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21
Q

What is third line for hypercalcaemia?

A
  1. Steroids
  2. Parathyroidectomy
  3. Dialysis or diuresis
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22
Q

What is pituitary apoplexy?

A

Haemorrhage +/- infarction of a tumour within the pitiutary gland

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23
Q

What are the features of pituitary apoplexy? (4)

A

Acute severe headache
Ocular palsy
Bitemporal hemianopia
Meningism

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24
Q

What is the management of pituitary apoplexy? (2)

A
  1. Steroids +/- neurosurgery
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25
Q

What clotting factors are in the intrinsic pathway?

A

IX
X
XI
XII

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26
Q

What clotting factors are in the extrinsic pathway?

A

II, VII, X

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27
Q

What is the final pathway of the clotting cascade?

A

Prothrombin (II) - Thrombin (IIa) - Fibrinogen (I) soluble - Fibrin mesh (insoluble)

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28
Q

What are the vitamin K dependent factors?

A

II
VII
IX
X
Protein C + S

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29
Q

What is the mechanism of action of UFH and LMWH?

A

Indirect thrombin inhibitors

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30
Q

What are the factor Xa inhibitors? (4)

A

Fondaparinox
-bans
Rivoroxaban
Apixiban
Edoxaban

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31
Q

What is a direct thromin inhibitor

A

Dabigatran

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32
Q

If minor bleeding how long should UFH be observed for?

A

6 hours

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33
Q

If minor bleeding only how long should LMWH be observed for?

A

24 hours

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34
Q

In significant bleeding what should be given to reverse UFH?

A

Protamine

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35
Q

What is the reversal agent for fondaparinox?

A

Recombinant factor VIIa

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36
Q

With LWMH (dalteparin/tinzaparin/enoxaparin) and bleeding what needs to done? (2)

A
  1. Anti Xa assays
  2. Protamine
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37
Q

How effective is protamine with LMWH?

A

60%

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38
Q

What makes a patient on warfarin high risk? (7)

A
  1. > 65
  2. HTN
  3. Diabetes
  4. Renal failure
  5. Hepatic failure
  6. Anti-plts concurrently
  7. Surgery/trauma
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39
Q

If there is no bleeding, how should high INR be managed in patients taking warfarin? (2)

A

INR <8 in low risk or <6 in high risk withold warfarin 24 hours and recheck
INR >8 in low risk of >6 in high risk then 1-2.5mg PO vit K and consider admission

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40
Q

When is it acceptable to simply withold warfarin and recheck in 24 hours?

A
  1. No bleeding
  2. INR <6 in high risk or < 8 in low risk
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41
Q

In minor bleeding on warfarin what tx should be given? (2)

A
  1. 2mg vit k orally
  2. 1mg vit K IV
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42
Q

In severe bleeding on patients on warfarin what tx should be given? (3)

A
  1. 5-10mg vit K IV
  2. PCC 30-50units/kg over 10mins
  3. Recheck clotting after 20 mins
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43
Q

What is the specific assay for dabigatran?

A

ECT + HDTI

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44
Q

What is the specific assay for factor Xa inhibitors?

A

CAX

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45
Q

What is the antidote for dabigatran?

A

Idarucizumab

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46
Q

What is the antidote for rixoroxaban/apixaban?

A

Andexanet

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47
Q

What is the reversal for edoxaban?

A

PCC + vit K

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48
Q

What assessment tool do NICE recommend for identification of those at risk of alcohol dependence?

A

AUDIT

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49
Q

What assessment tool does NICE recommend for severity of dependnce?

A

SADQ

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50
Q

When should inpatient alcohol detox be considered? (4)

A
  1. SADQ >30
  2. Hx of epilepsy
  3. Hx of withdrawal seizures or DTs
  4. Previous assisted withdrawal programmes
51
Q

If benzos are being used in patients with liver impairment what should be used?

A

Lorazepam and go slowly

52
Q

What is first line for DTs?

A

PO lorazepam

53
Q

What is second line for DTs? (3)

A
  1. IV lorazepam
  2. IV haloperidol
  3. IV clozapine
54
Q

In adrenal crisis what is the initial bolus of hydrocortisone dose?

A

100mg IV

55
Q

What is the maintenance hydrocortisone give in adrenal crisis?

A

200mg infusion/24 hours
or
50mg QDS

56
Q

How much IVI should be given over 24 hours to rehydrate a patient with adrenal crisis?

A

3-4 L

57
Q

What are the severe features of hyponatreamia? (4)

A
  1. Vomiting
  2. Arrest
  3. Seizures
  4. Reduced GCS
58
Q

In presence of severe symptomatic hyponatreamia what is the initial treatment?

A
  1. 150ml 3% normal saline or equivalent over 20mins
  2. Repeat twice or until sodium increases by >5mmo/L
59
Q

What is the follow up management of severe hyponatreamia following initial management?

A
  1. Stop hypertonic but continue normal saline
  2. Limit sodium increase to 10mmol/l over 24 hours
60
Q

How is osmsolality calculated?

A

2 (Na + K) + urea + gluc

61
Q

How should we manage HHS?

A

-Fluids until glucose not dropping by 5units/hour, then fixed rate insulin
-Unless significant ketonuria then start insulin after a period of rehydration, never straight away - can lead to circulatory collapse)

62
Q

What is first and second line for complicated/severe malaria in UK?

A

IV artesunate first
IV quinine second

63
Q

What is first and second line for uncomplicated malaria in UK?

A

Artemisinin combination therapy (ACT) first
Atovaquone-praguanil second

64
Q

How does infantile botulism present?

A

Constipation is often the first sign, along with a dry mouth. Then facial palsy can occur.

Following this, there is a worsening weakness with poor suck, poor head control, hypotonia, hyporeflexia, and a weak cry.

65
Q

Why does botulism infect <1 year olds more than older children

A

Spores can germinate in stomach and produces toxin, older children would need to ingest the actual toxin

66
Q

How to infants normal contract infantile botulism?

A

Ingesting honey

67
Q

Which type of electrical current causes:
1. Tetany
2. Forceful ‘jolt’ that can throw a patient a distance from power source

A
  1. AC (usually higher voltage)
  2. DC
68
Q

Which type of electrical current causes
1 VT/VF
2. Asytole

A
  1. AC (70ma or higher)
  2. DC
69
Q

What 3 things make up a diagnosis of HHS?

A
  1. Hypovolaemia
  2. Marked hyperglycaemia without significant ketonaemia or acidosis
  3. Osmolality >320 mosmol/kg
70
Q

What makes up the FeverPAIN score?

A

Fever in last 24hours
Purulent tonsilts
Attends within 3 days
Inflamed tonsils (Severe)
No cough or coryza

71
Q

What is qSOFA made up of?

A

BP <100mmHg
RR over 22
Altered mental state

1 for each
2 or more suggests greater risk of death

72
Q

What abx do NICE not recommend giving empirically for neutropenic sepsis?

A

Aminoglycosides

73
Q

What does the road traffic act say about doctors taking blood samples for alcohol and drug testing?

A

Lawful - regardless of patients consent and has to be given to constable

74
Q

Describe the serious incident framework?

A
  1. Confirm serious incident -report to commissioners (2 days)
  2. Confirm level of investigation required (3 days)
  3. Investigation - root cause analysis ( 60 days)
  4. Final report and action plan (20 days)
74
Q

Describe the serious incident framework?

A
  1. Confirm serious incident -report to commissioners (2 days)
  2. Confirm level of investigation required (3 days)
  3. Investigation - root cause analysis ( 60 days)
  4. Final report and action plan (20 days)
75
Q

What is MHA section 4?

A

Emergency holding powers (72 hours)

76
Q

What is MHA section 5 (2)

A

Doctors holding powers (only a ward)

77
Q

What is MHA section 5 (4)

A

Nurse holding powers

78
Q

What is section 2 MHA?

A

Nature of illness unclear

79
Q

What is section 3 MHA?

A

Nature of illness clear

80
Q

What condition is non IgE mediated but can can lead to angio-oedema and GI symtoms?

A

C1 esterate deficiency

81
Q

What is the treatment for CI esterase deficiency? (3)

A
  1. Berinert (c1 esterase inhibitor)
  2. Icatibant (bradykinin receptor blocker)
  3. FFP contains C1 esterase

NB: adrenaline/anti-histamines will not work

82
Q

What is the cause of Scromboid?

A
  • histamine poisoning from unrefrigerated fish (esp dark-flesh)
  • Cooking does not kill the histamine
83
Q

What are the features of Scromboid poisoning and when do they present/relieve?

A
  • Sx within 10-30 minutes after eating fish + resolved within 12 hours
  • Symptoms = pruritis, skin flushing, peppery taste, headache, palpitations, D+V
  • Rare to have A/B/C involvement
84
Q

What is the management of Scromboid poisoning? (2)

A
  • Mx = supportive care, antihistamines
    -can eat fish in future, inform PHE as case of food poisoning
85
Q

Describe the 4 types of immunological skin reactions?

A
  • Type 1 reaction (IgE mediated) = anaphylaxis
  • Type 2 reaction = cytotoxic
  • Type 3 reaction = immune complex
  • Type 4 reaction = delayed, cell mediated e.g. contact dermatitis
86
Q

What is steven-johnson syndrome?

A

Severe erythema multiform >10% TBSA.

Vesicles in mucous membranes of eyes and mouth.

-

87
Q

What is toxic epidermal necrolysis (TEN)

A

Severe erythema multiform >30% TBSA. Painful rash and fever.

Widespread desquamation.

7-14 days after 1st drug exposure

88
Q

What does DRESS stand for?

A

DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms; also called drug
hypersensitivity syndrome).

89
Q

What are the signs/symptoms of DRESS/drug hypersensitivity syndrome? (5)

A

2-6 weeks after 1st drug exposure -
Maculopapular rash
Fever
Abnormal LFTs
Lymphadenopathy
Eosinophilia

90
Q

What is erythroderma?

A

> 90% TBSA erythema

91
Q

What is the management for erythroderma?

A
  1. Bed rest
  2. IVI
  3. Emollients
92
Q

What is erysipelas?

A

Skin infection distinct from cellulitis
Only superficial dermis so distinct borders
Painful, red and raised

93
Q

What are the causes of a bitemporal hemianopia? (3)

A
  1. Pituitary adenoma
  2. Glioma
  3. Carotid artery aneurysms

Act on the optic chiasm

94
Q

What is the predominant cause of a homonymous hemianopia?

A

CVA

95
Q

What acts on the optic nerve directly causing loss of vision?(2)

A
  1. MS
  2. Ethylene glycol
96
Q

What does a complete 3rd nerve palsy looks like? (3)

A
  1. Down and out pupil
  2. Proptosis
  3. Dilated pupil
97
Q

What does on differentiate between compressive and medical causes of third nerve palsy?

A

Pupillary involvement - compressive/surgical (bleed/aneurysm/SOL) usually cause pupillary dilatation as the parasympathetic fibres are on the outside of the nerve and are compressed.

98
Q

What do patients with a CN IV (trochlear) present with?

A
  1. Weakness of downward gaze - difficulty walking downstairs or reading
  2. Vertical diplopia
99
Q

Which muscle does CN IV (trochlear) innervate?

A

Superior oblique

100
Q

What muscle does CN VI (abducens) innvervate?

A

Lateral rectus

101
Q

What will patients suffering from CN VI palsy present with?

A
  1. Convergent squint at rest (pupil moves towards nose)
  2. If complete palsy will be unable to abduct eye past midline
  3. Horizontal diplopia on affected eye
102
Q

What does vitreous haemorrhage present like?

A

Painless visual changes - from floaters/black spots to light perception only

103
Q

What is the hx for CRAO and CRVO?

A

Sudden, painless visual loss

104
Q

What does this suggest and describe the findings?

A
  1. CRAO
  2. Pale optic disc / retina with ‘cherry red spot’ of the macula
105
Q

What does this finding suggest?

A

CRVO

106
Q

What is the ED management for CRAO?(2)

A

Digital massage of eye in supine position (patient should do to themselves)
IV acetazolamide

107
Q

What laboratory criteria are needed to confirm tumour lysis syndrome? (4)

A

2 or more of:
1. Hyperkalaemia
2. Hyperphosphataemia
3. Hyperuricaemia
4. Hypocalcaemia

108
Q

How long after a dive do the bends normally present?

A

< 6 hours (90%)

109
Q

What increases your risk of the bends? (7)

A

1.Deep dive, long dive, missed decompression stops, multiple dives
2. Age
3. Exercise during or after a dive
4. Flying/ ascending to altitude after diving
5. Obesity
6. Dehydration
7. Alcohol use prior to dive

110
Q

What are is mainstay of treatment for the bends?

A
  1. High flow oxygen
  2. Rehydration

Decompression chamber gold standard - obvious practical issues

111
Q

What should be avoided in in the bends? (2)

A

Analgesia - oxygen normally enough and risks with opiates and NSAIDs

No entonox!

112
Q

What distinguishes keratitis/keratoconjunctivitis from conjunctivities?

A
  1. Pain worse
  2. Photophobia
  3. Worsening visual acuity

More likely if contact lens wearer

113
Q

How does acute angle glaucoma present in terms of the eye?

A
  1. Painful + red
  2. Decreased visual acuity
  3. Mid-dilated pupil
  4. Non-responsive pupil
114
Q

How should acute closed angle glaucoma be managed? (3)

A
  1. 500mg IV acetazolamide
  2. Opiates/analgesia
  3. After one hour of treatment topical miotic such a pilocarpine every 5 mins (pupil unlikely to respond until this point)
115
Q

What is episcleritis? (3)

A

1.Engorgement of the superficial episcleral plexus
2. More irritating than painful
3.Self limiting

116
Q

Describe the features of scleritis?

A
  1. Either localised of generalised blue-ish/violet discolouration
  2. Deep, dull ocular pain
  3. Pain worse on movement of eye

Associated with rheumatological diseases

117
Q

What serotype is anterior uveitis associated with?

A

HLA-B27

118
Q

How does anterior uveitis present? (4)

A
  1. Painful red eye, worse on accomodation
  2. Photophobia, can be consensual
  3. Pupil maybe an unusual shape
  4. Can have keratitic precipitates
119
Q

Which commonly used drugs can precipitate acute closed angle glaucoma?

A
  1. Anticholinergics
  2. Chlorphenamine (has some anticholinergic propertis)
  3. Salbutamol
  4. SSRIs
120
Q

Who is more prone to getting acute closed angle glaucoma?

A

Elderly and far sighted

121
Q

What is the difference between monocular and binocular diplopia?

A

Mononuclear diplopia does not resolve when one eye closed, binocular is present with both eyes open and resolves when either eye is closed.

Binocular suggests concerning pathology, monocular suggests issue with eye

122
Q

How does acetazolamide help treat acute closed angle glaucoma?

A

It decreases the production of aqueous humour

FRCEM SBA (12 decks)

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