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MBChB4 > new things 15/02 > Flashcards

new things 15/02 Flashcards

1
Q

Subdural haematoma features:

A

Elderly
Alcoholic
Head injury
Insidious onset
Fluctuating levels of consciousness

Rupture of bridging veins that cross the subdural space is the common cause.

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2
Q

Investigation of choice for PSC?

A

MRCP/ERCP

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3
Q

Recent chemo + fever >38 management:

A

Immediate prescription of IV tazocin.
Do not wait for wcc, suspect neutropenic sepsis.

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4
Q

Extradural vs subdural haemorrhage:

A

Extradural = lucid period, usually following major head injury.The majority occur in the temporal lobe where the middle meningeal artery is damaged.

Subdural = fluctuating consciousness, often following trivial injury in elderly or alcoholics.
Majority occur in frontal / parietal lobes.

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5
Q

Which artery is most likely to be damaged in an extradural haemorrhage?

A

Middle meningeal artery

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6
Q

How to manage patients with intracranial bleeds that become unresponsive :

A

Urgent CT head to check for hydrocephalus.

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7
Q

What does the Modified Glasgow Score entail and what is it used for?

A

Severity of pancreatitis:

PaO2
Age
Neutrophilia
Calcium
Renal function - Urea
Enzymes - LDH, AST
Albumin
Suagr

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8
Q

Investigations in acute pancreatitis:

A

Serum amylase.
Note a diagnosis can be made without imaging if characteristic pain + Amylase >3x upper limit of normal

Early ultraound imaging for aetiology e.g. gallstones.

Other options would include contrast enhanced CT.

Serum lipase is more sensitive and specific and expensive, but has a longer half life so may be useful in late presentations.

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9
Q

What are the 3 components of the triad of death?

A

Hypothermia
Acidosis
Coagulopathy

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10
Q

Describe the process of tension pneumothorax causing obstructive shock:

A

Air enters the thoracic cavity and punctures the lung but cannot escape.
Its a one way air leak from damaged wall or lung, leading to increase in pressure, collapsing the affected lung.
Mediastinal shift occurs.
Occlusion of the vena cava, reducing venous return to heart, reducing cardiac output and therefore causing obstructive shock.

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11
Q

Clinical signs of tension pneumothorax:

A

Respiratory distress
Absent breath sounds on one side
Tracheal deviation
Hyperresonance on affected side
Tachycardia and hypotension
Minimal chest movement

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12
Q

Management of a tension pneumothorax:

A

Emergency

15L trauma mask
Grey venflon in 2nd intercostal space miclavicular line to buy some time
Chest drain
Check x-ray

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13
Q

Clinical signs of cardiac tamponade:

A

Pulsus paradoxusus
Distended neck veins
Tachycardia
Hypotension
Muffled heart sounds

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14
Q

Complications of chest trauma:

A

Hypovolaemic shock
Obstructive shock
Hypoxic arrest
Cardiac arrest
Empyema
Intrathoracic infection
Death

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15
Q

3 most common organs affected in abdominal trauma:

A

Liver
Kidneys
Spleen

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16
Q

What is management of abdominal trauma based on?

A

Haemodynamic stability of the patient

Specific abdomen pathology

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17
Q

3 types of management in abdominal trauma and indications:

A

Conservative, if haemodynamically stable

IR

Immediate damage control laparotomy if unstable, or evidence of e.g. perforation or mechanism e.g. stabbing through peritoneum

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18
Q

Goals of damage control laparotomy:

A

Stop bleeding
Infection control
Abdominal packing
Temporary closure device e.g. laparostomy

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19
Q

Clinical signs in abdomen trauma:

A

Haematoma, seatbelt sign
Shoulder tip pain due to blood irritating the diaphragm
Hypovolaemic shock
Haematuria
Abdo pain, rigid, distension

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20
Q

How are liver, spleen and kidney injuries classified in trauma:

A

Grade I-V (kidney and spleen) and VI in liver.

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21
Q

Clinical signs of basal skull fractures:

A

Anterior cranial fossa = raccoon eyes, csf leaking from nose (separates on pillow)

Petrous temporal bone: Battle’s sign, mastoid bruising, CSF leaking from eyes, haemotypanum, cranial nerve signs e.g. facial paralysis / hearing loss.

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22
Q

Describe the aetiology of diffuse axonal injury:

A

Rapid aceleration/ deceleration causes shearing of axons diffusely - can cause persistent vegetative state after trauma.

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23
Q

Traumatic brain injury can be permanent. Describe the relationship between grade of TBI and GCS:

A

GCS 13-15 = mild
GCS 9-12 = moderate
GCS 3-8 = severe, can’t protect airway, need to be intubated.

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24
Q

Describe Cushing’s reflex:

A

Hypertension and bradycardia, a pre-terminal sign as brain is herniating through foramen magnum.

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25
Investigations in head trauma:
Full neuro exam if possible Neuro obs every 30-60 mins Blood gas for gas exchange CT Trauma or head and neck MRI/EEG later on
26
What are 2 factors that contribute to poor prognosis in a head injury?
Hypotension Hypoxia
27
Initial management in head trauma:
Stop / reverse blood thinners Resus CT scan Neurosurgery review Consider transfer depending on site
28
2 types of surgical management in head trauma:
Burr hole decompression Trauma craniectomy
29
Complications of head trauma:
TBI Disability CND infection Coning - herniation of cerbellar tonsils through foramen magnum, causing compression of the brainstem and respiratory arrest.
30
What is a complication of all types of trauma:
Death
31
What is the role of a pelvic binder?
Tamponades bleeding, a factor in C of A-E. Stabilises fracture. Should only be taken off by orthopaedic surgeons.
32
Discuss initial assessment of a patient presenting with trauma / shock:
Hx and AMPLE if possible. A-E assessment with c-spine control in A and haemorrahge contorl in C. Resuscitation is included in the A-E in trauma e.g. control of bleed. Secondary survery, looking for other injuries / wounds etc. Trauma series CXR and pelvic xr FAST Trauma CT (head neck CAP) if stable enough Intervention e.g. theatre, IR, ICU Tertiary survey 24 hours later once distracting injuries have been dealt with.
33
Describe the 4 types of shock and causes of each:
Hypovolaemic - haemorrhage, burns, other fluid loss Obstructive - cardiac tamponade, tension pneumothorax, PE Cardiogenic - heart pump failure Distributive - septic, anaphylaxis, neurogenic
34
Patients who's vital signs / response may be abnormal in shock:
Young patient e.g. athlete with very low HR to start with, may not detect he is tachycardic until later. Drugs e.g. BB, patients may not be able to amount an appropriate tachy response. Elderly - e.g. polypharmacy, depressed response.
35
What do you get when you put out a major haemorrhage 2222 call?
6U prcs 4U FFP that needs defrosted +/- platelets. No doctors will come to a major haemorrhage call.
36
Methods for stopping bleeding during major haemorrhage:
Direct pressure and elevation Adrenaline soaked gauze / haemostatic dressing Reduce and splint long bone and pelvic fractures using pelvic binder. + Suture, tamponade with foley catheter, tie off vessels.
37
Goals of resuscitation in haemorrhage:
Maintaining circulating volume. Stop bleeding. Avoid the triad of death.
38
What constitutes the triad of death?
Hypothermia Acidosis Coagulopathy
39
3 categories of patients when it comes to fluid response, and what this indicates.
Fluid responders - estimated loss <15%. Transient fluid responders - estimated loss 15-40%. Minimal / no response - estimated loss >40%. Transient and no responders will generally require blood products.
40
What is the leading cause of death for under 45s?
Trauma
41
General investigations in trauma:
Blood gas, looks at gas exchange and fast Hb Trauma series = cxr and pelvic xr FAST scan to look at free fluid, bleeding etc, effusion, tamponade etc. (Focused assessment with sonography in trauma) Trauma CT = head, neck, CAP
42
Specific investigations in pelvic trauma:
CTA if worried about bleeding. CT cystogram if bladder injury suspected - dye injects into bladder and seeing if urine in intra-peritoneal.
43
Urine in intraperitoneal cavity management:
Emergency laparotomy
44
4 commonly used IV induction agents for anaesthesia:
Propofol = MOST COMMON Thiopental Etomidate = RARE Ketamine
45
Triad of general anaesthesia:
Loss of awareness / hypnosis Analgesia Optimized surgical conditions / mmuscle relaxant.
46
4 inhaled options for GA:
sevoflurane - only this one is really used. desflurane isoflurane NO
47
2 drugs that cause muscle relaxation and their mechanism:
Suxamethonium - depolaring Rocuronium - non depolarising They block the NMJ from working by blocking Ach.
48
Reversal agents of neuromuscular blocking agents:
Neostigmine Sugammadex is used specifically with rocuronium, non-depolarising muscle relaxants.
49
Features of malignant hyperthermia:
Hypermetabolic response to anaesthesia. Risk is mainly iwth volatile anaesthetics (sevoflurane) and suxamethonium (NMJ blocker). AD genetic mutation - important aspect of anaesthetic pre-op assessment. Signs and symptoms: Increased body temp Increased CO2 production Tachycardia Muscle rigidity Acidosis Hyperkalaemia Treated with Dantrolene.
50
List 3 common anti-emetics and their receptor targets:
Cyclizine = H1 antagonist Ondansetron = 5HT3 antagonist Metoclopramide = D2 receptor antagonist
51
Patient risk factors for PONV:
Age <50 Female Non-smoker Previous PONV or motion sickness
52
Surgical and anaesthetic risk factors for PONV:
prolonged surgery inner ear / intracranial / gynae / laparoscopic surgery inhaled anaesthetic prolonged surgery insufficient analgesia intra-op Prolonged BVM use (gastric dilation) Opiate or spinal anaesthesia Intra-op bleeding or dehydration.
53
Factors to decrease baseline risk of PONV:
Limit opioid analgesia Use local / regional anaesthetic vs GA if possible Avoid volatile anaesthetic and NO
54
Side effects of ondansetron:
5HT3 antagonist. Reduces peristalsis and cause significant constipation if taken long term.
55
Classically used d2 antagonist in anaesthesia PONV, and side effect:
Droperidol, prolongs QTc Metoclopramide is a second line agent.
56
Common side effects of opioids:
Constipation Drowsiness N+V common when starting or increasing Dry mouth Flushing Hallucinations Headache Dependence and addiction risk Longer term side effects include risk of falls, ED, amenorrhoea, infertility, depression and hyperalgesia.
57
Which animal is yersinia enterocolitica associated with?
pigs + can cause reactive arthritis + can be mistaken for appendicitis due to right mesenteric lymphadenitis
58
Which cause of gastroenteritis is a cause of GBS?
Campylobacter
59
Which cause of gastroenteritis causes a recognisable biphasic presentation?
Bacillus cereus. From rice. Cereulide toxin first causes vomiting and abdo cramps, and then further toxins are produced in the intestines causing diarrhoea +8hrs later.
60
Which 2 bacteria cause HUS in gastroenteritis, and describe the presentation:
E.coli 0157 Shigella From Shiga toxin production. Triad of HUS: AKI Microangiopathic haemolytic anaemia Thrombocytopenia
61
Causes of HUS:
E.coli + Shigella Pneumococcal infection HIV Rare = SLE, antiphospholipid, drugs, cancer
62
Common infections in HIV patients with CD4 count 200-500:
Shingles HZV Oral thrush Candida albicans Hairy leukoplakia - EBV Kaposi sarcoma HHV-8
63
Common infections in HIV patients with CD4 count 100-200:
Cerebral toxoplasmosis PML PJP Cryptosporidium HIV dementia
64
Common infection in HIV patients with CD4 count 50-100:
Oesophageal candidiasis Cryptococcal meningitis Aspergillosis Primary CND lymphoma
65
What virus is associated with hairy leukoplakia and primary CNS lymphoma?
EBV
66
Differences between cerebral toxoplasmosis and primary CNS lymphoma:
TP has multiple ring enhancing lesions, PCL has homogenous enhancement, usually one lesion. Toxoplasmosis is associated with cats, thallium spect -ve.
67
What is the most common opportunistic infection in HIV and how does it present?
PJP pneumonia. Few chest signs, sob, dry cough etc. Exercise induced desaturation. Pneumothorax is a common complication. Often can't be shown on a sputum, so BAL with silver staining is required. CXR typically shows bilateral interstitial pulmonary infiltrates.
68
Which opportunistic infection presents with red cysts on Ziehl-Neelsen stain?
Ziehl-Neelsen is an acid-fast stain. Reveals red cysts of cryptosporidium. Can affect the whole GI tract resulting in sclerosing cholangitis and pancreatitis. Watery diarrhoea. abdo cramps and fever.
69
Protective factors for malaria:
Sickle cell disease G6PD deficiency HLA-B53 Absence of Duffy antigens
70
4 types of Plasmodium protozoa:
Falciparum Vivax Ovale Malariae
71
Criteria for uncomplicated malaria:
Parasitaemia <2% Temp <39 Ambulatory patient No complications
72
Crtieria for complicated / severe malaria:
Parasitaemia >2% Complications present Schizonts seen in peripheral blood smear Non ambulatory All patients will >2% will require IV antimalarials.
73
Complications of malaria:
AKI Hypovolaemia DIC ARDS Severe anaemia Jaundice Pulmonary oedema Cerebral involvement
74
Pathophysiology of the complications of severe malaria:
Adherence of schizonts and sequestration of rbcs to vascular endothelium
75
How do you exclude a diagnosis of malaria?
3 negative samples taken over 3 consecutive days to exclude it, as the parasites are released from the rbcs cyclically every 48-72 hours. Gold standard is thick and thin blood films, and antigen detection test.
76
What information will a malaria blood film show?
The type of Plasmodium and the concentration / parasitaemia.
77
Incubation period of malaria:
P.falciparum is usually 1-4 weeks. Other types e.g. ovale and vivax can lay dormant for years though, so if very characteristic they can be asked about any travel history.
78
Endemic areas to each type of Plasmodium:
Falciparum - Sub Saharan Africa Ovale - Africa Vivax - Central America and Indian Subcontinent Knowlesi - South East Asia
79
Infectious mononucleosis triad:
Sore throat, pyrexia and lymphadenopathy.
80
Features of infectious mononucleosis and diagnosis:
Monospot test and FBC in 2nd week of illness. Petechiae on the palate. Malaise, anorexia, headache. Splenomegaly Transient rise in ALT Lymphocytosis Maculopapular / pruritic rash if you take ampicillin / amoxicllin Resolves after 2-4 weeks.
81
Define pyrexia of unknown origin:
Prolonged fever >38 persisting for >3 weeks without an obvious cause despite >1 week of inpatient investigation.
82
Different diagnosis of pyrexia of unknown origin (that are already in ILOs) :
Vasculitides Cryptococcus TB HIV CMV/EBV Toxoplasmosis Lymphoma Liver / CNS mets Pancreatic carcinoma Atrial myxoma Endocarditis - culture for 21 days to detect slow growing organism
83
Top causes of pyrexia of unknown origin (4):
Abscess Lymphoma TB Preleukaemia
84
Investigations in pyrexia of unknown origin:
Initial: bloods, urine dipstick +/- MSSU, cultures, imaging (plain film CXR) Further investigations depending on specific history points: Malaria? repeated bloods films IVDU - hepatitis serology +HIV CTD? ANA, anti-dna, CRP Look for other random causes etc.
85
Symptoms of staph aureus bacteraemia:
perisistent high fever shock common cause of death in people with severe burns
86
What investigation should all patient with S.aureus bacteraemia have?
ECHO to evaluate presence of endocarditis.
87
A patient has been found to have S.aureus bacteraemia. What are important features of the history / examination that will ensue?
Recent skin / soft tissue infections. Hardware / iatrogenic equipment in the patient. Symptoms and signs of endocarditis, or osteomyelitis. Beside infectious diseases consultation.
88
Borders of the triangle of safety:
Sup = base of axilla Ant = lateral border of pec major Inf = 5th intercostal space Lat = edge of latissimus dorsi

MBChB4 (15 decks)

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