Questions Flashcards
A 34 year old woman with no previous history of cardiac disease has been brought to the A&E department and found to have atrial fibrillation.
Which medication is likely to be the most suitable to cardiovert this patient?
Fleicanide
Digoxin
Amiodarone
Adrenaline
Warfarin
Fleicanide
Atrial fibrillation is rapid, irregular, uncoordinated atrial activity. AF decreases cardiac output by 10-20% regardless of underlying ventricular rate and clinical presentation can vary.
Treatment depends on patient stability, myocardial status and duration of the arrhythmia.
Flecanide is a drug commonly used for chemical cardioversion if the patient is relatively young and they have a structurally normal heart.
An elderly gentleman on the ward is complaining of light-headedness and the feeling that “his heart is thumping out of his chest”. On ECG he is found to have a regular pulse, tachycardic (180bpm) with broad QRS complexes. The gentleman is otherwise currently stable.
What is the correct pharmacological management of this patient?
Adenosine
Amiodarone
Adrenaline
Digoxin
Fleicanide
Amiodarone
Ventricular tachycardia usually results from a single focus of abnormal electrical activity within the ventricles that produces rapid ventricular activation (~180-220bpm).
Patients who are unstable with VT (e.g. hypotensive or have chest pain) require immediate electrical cardioversion.
Patients who are stable may be cardioverted with amiodarone.
A 60-year-old lady attends A&E complaining of palpitations that started whilst she was sat at home 45 minutes ago. On examination her pulse rate is 160bpm. ECG confirms that this lady has a supraventricular tachycardia; a regular tachycardia with a narrow QRS complex.
What is the first-line treatment for this patient?
Adenosine
Amiodarone
Adrenaline
Valsalva Manoeuvre
CPR
Valsalva Manoeuvre
Commonly causing a ventricular rate of 160-180bpm, SVT’s are caused by an abnormal electrical circuit in or near to the AVN.
Treatment aims to break the electrical circuit by reducing transmission in the AVN. This can be achieved by the Valsava Manoeuvre (asking a patient to blow a plunger out of a 10ml syringe whilst head tilted down) or one-sided carotid sinus massage (in a young patient only); that increases the vagal (parasympathetic) drive to the AVN.
If this does not work, the AVN can be pharmacologically blocked using Adenosine which temporarily upsets the adenosine/cAMP balance. Patients may experience a ‘feeling of impending doom’.
A 12-year-old girl was at school playing with her friends when a wasp stung her. She develops shortness of breath, an urticarial rash, and begins feeling generally unwell. The ambulance crew arrives and suspects a diagnosis of anaphylaxis.
What is the most appropriate medication, dose and route for the paramedics to administer?
Adrenaline 500mg IM
Adrenaline 100mg IV
Adrenaline 300mg IM
Hydrocortisone 100mg IM
Hydrocortisone 300mg IV
Adrenaline 300mg IM
Anaphylaxis is a life-threatening reaction to an allergen.
Familiarization with appropriate doses of adrenaline is recommended.
Only intensivists and anaesthetists are trained to give IV adrenaline, so even in the ED adrenaline will always be given intramuscularly.
An 85-year-old gentleman was admitted 10 days ago with increasing shortness of breath, fever and new onset confusion.
His observations at the time were:
RR 29
BP 90/60
Pulse 112
Urea 7.3mmol/L
He was diagnosed with community-acquired pneumonia and his CURB-65 score was calculated to be 4. He has since been in ICU and has received ventilator support, inotropes and filtration.
His family has been counselled about turning off his ventilator. The transplant coordinator has telephoned to discuss this patient as a potential organ donor.
He has a history of hypertension and a Duke’s B colon cancer 3 years ago, which was successfully treated. His colon screening since than has been normal.
What factor would make you decide against this patient donating his organs?
Systemic infection
History of malignancy
Need for filtration
Need for inotropes
His age
History of malignancy
This gentleman’s history of malignancy is a contraindication to organ donation. It is not yet possible to exclude micrometastases, and thus it would be inappropriate for this organ to be donated to a recipient who will be immunosuppressed.
He is an elderly gentleman, although with a long waiting list for transplants this organ would be a good match for an elderly recipient.
Although his creatinine was high on admission, the reassuring normal level now suggests that his baseline renal function is good. Creatinine would rise in the clinical setting of sepsis.
Although he has received intensive intervention, it was in the setting of severe sepsis and septic shock, which would suggest that inotropes were required for acute tubular necrosis, and hence there is the potential for recovery after transplantation.
A two-month-old child is brought to the A&E department by her parents. She was crawling on the sofa and fell off onto her buttocks. As a consequence of her fall, she has severe bruising in this region. The child is otherwise well, and is meeting her developmental milestones. On examination, you also notice a small bruise behind the child’s left ear.
What is the most likely cause of this child’s bruising?
Mongolian spots
Capillary haemangioma
Non-accidental injury
Idiopathic thrombocytopenic purpura
Henoch-Schoen purpura
Non-accidental injury
Healthcare professionals must always consider non-accidental injury if there is any hint of a suspicious injury and/or presentation. In this instance it is concerning that a child of a non-ambulatory age has attained bruising across the buttocks. Bruising behind the ear is concerning as it is often referred to as the “triangle of safety” - accidental injuries in this area are unusual.
Mongolian spots are congenital lesions. They are blue-gray areas of pigmentations most commonly found on the sacral area and buttocks. Mongolian spots do not change colour or fade.
Capillary haemangiomas are a common benign vascular malformations, found in 10% of children during the first weeks of life. They have an erythematous or bruised appearance and most commonly occur on the face, but may be seen elsewhere. These lesions blanch with pressure.
HSP could be mistaken as non-accidental bruising as early on in the disease there are ecchymotic lesions present, particularly across the buttock and extensor surfaces. Thus, a recent history of upper respiratory tract infection should be sought.
In the case of idiopathic thrombocytopenic purpura, the parents may give a history in which the child bruises easily. As part of the initial investigations, a full blood count, prothrombin and activated partial prothrombin time should be requested to exclude this diagnosis.
A 19-year-old woman fell on her outstretched hand and has injured her wrist. She requires a Colles fracture manipulation.
Which of the following analgesics/analgesic techniques would be most appropriate in an Emergency Department setting?
Paracetamol
Propofol
Haematoma block with or without Entonox
Ketamine
Thiopental
Haematoma block with or without Entonox
A haematoma block is an analgesic technique used to allow painless manipulation of fractures while avoiding the need for full anaesthesia. This technique is most commonly used for fractures of the radius and/or ulna.
If displacement occurs when a bone is fractured, the space separating the fragments fills with blood (haematoma). Injection of local anesthetic into this area should provide adequate relief during manipulation. If this is not adequate, Entonox (50% Nitrous Oxide, 50% Oxygen) may also be inhaled by the patient to provide short acting relief. This can, however, make the patient feel nauseous.
Paracetamol would take longer to work and may not provide adequate relief.
Propofol and thiopental are IV anaesthetic induction agents and would not be required in this circumstance.
Ketamine is used less frequently in adults within the ED due to its potential dissociative side effects.
A 5-week-old boy is brought to the ED by his anxious parents who explain that the baby has been projectile vomiting after trying to feed. The vomit doesn’t look like it contains any bile. Their son appears hungry and is keen to feed again but vomits repeatedly after trying. Abdominal palpation reveals an olive sized lump in the epigastrium and confirms the diagnosis of pyloric stenosis.
Which, out of the following blood results would be most expect to find from this child with advanced symptoms?
Normal ranges:
Na+: 135-145mmol/L
K+: 3.5-5.0mmol/L
Cl-:95-105mmol/L
HCO3-: 22-28mmol/L
Mg2+: 1.5-2.0mmol/L
Option B
Hypertrophic pyloric stenosis is relatively common, typically presenting with effortless vomiting between 2-10 weeks. It occurs more frequently in boys than girls and in first-born children.
Vomiting becomes projectile and is not bile stained.
This causes progressive dehydration, a metabolic acidosis and marked electrolyte disturbances, in particular; hyponatraemia, hypochloraemia and hypokalaemia.
Operative treatment must be delayed until electrolyte disturbances are corrected via fluid resuscitation.
Which of the following signs is pathognomonic for measles?
Rose spots
Kernig’s sign
Strawberry tongue
Koplik spots
Murphy’s sign
Koplik spots
A pathognomonic sign is a sign that is diagnostic of a particular disease.
Koplik spots are ulcerated mucosal lesions marked by necrosis, neutrophilic exudate and neovascularisation. They are often described as ‘grains of salt on a wet background’-clustered white lesions on the buccal mucosa opposite the lower 1st and 2nd molars. They often manifest two to three days before the measles rash itself and often fade as the maculopapular rash develops. They are also important if found before a person reaches maximum infectivity, to aid isolation of contacts and greatly aids control of outbreaks.
Rose spots on the abdomen are linked to enteric fever.
Kernig’s sign is linked to meningitis.
Strawberry tongue is linked to scarlet fever.
Murphy’s sign is linked to cholecystitis.
A 31-year-old lady is rushed to the A&E department. She looks shocked; she is tachycardic, hypotensive and appeared confused on the way to the hospital. She has profound muscle weakness, abdominal pain and on arrival she is going in and out of consciousness. It becomes apparent by talking to her husband that she is suffering from an Addisonian crisis due to sudden withdrawal of her chronic steroid therapy for Rheumatoid Arthritis, which has recently worsened, requiring a high dose of steroids.
Her blood tests come back to highlight which of the following results?
Option B
Acute adrenocortical insufficiency (Addisonian crisis) is rare and easily missed. The most common cause is sudden withdrawal of chronic steroid therapy (deliberately or inadvertently). In crisis, the main features may be shock, tachycardia, peripheral vasoconstriction, severe postural hypotension occasionally with syncope, oliguria, profound muscle weakness, confusion and altered consciousness leading to coma. It is a medical emergency.
Hyperkalaemia, hyponatraemia, hypoglycaemia, hypercalcaemia, uraemia, mild acidosis and eosinophilia may be present.
A blood cortisol level should be taken but if an Addisonian crisis is suspected treatment of hydrocortisone sodium succinate (100mg) should be given stat.
Hypoglycaemia should also be treated with glucose to maintain BM.
Mary, a 50-year-old chronic alcoholic who is well known to the A&E department, has been brought in today by her neighbour. She had cut her index finger accidentally at home and requires suturing of the wound. While you are suturing her finger you have a conversation with her and pick up that she seems particularly indifferent to the situation and she can’t remember who brought her into the department.
Mary says that a dog bit her finger and caused the injury, however this is inconsistent with the type of laceration and her neighbour had previously explained to you that she had seen Mary cut herself while trying to pick up a broken glass bottle.
You suspect that Mary may be suffering from a neurological disorder.
Which of the following is the most likely in this instance?
Korsakoff’s Syndrome
Depression with psychosis
Mania with psychosis
Alzheimer’s Disease
Dementia with Lewy Bodies
Korsakoff’s Syndrome
Korsakoff’s syndrome is a neurological disorder caused by a lack of thiamine (vitamin B1) in the brain. Its onset is linked to chronic alcohol abuse or severe malnutrition (which may go hand in hand).
Six major symptoms include anterograde amnesia, retrograde amnesia, confabulation, minimal content in conversation, lack of insight and apathy.
Treatment includes the replacement or supplementation of Thiamine by IV or IM injection, together with adequate nutrition and hydration. Treatment is a long course and if successful, recovery can still be very slow and often incomplete but can help maintain/regain some level of independence.
Mary is unlikely to be suffering from mania because of her apathetic attitude and memory problems.
She is unlikely to be suffering from psychosis as does not seem to have had delusions or hallucinations although she has confabulated a story as to why she injured herself.
Dementia with Lewy bodies is more likely in patients over the age of 65 - patients are likely to experience some hallucinations and day-to-day memory is often affected typically less in the early stages than in Alzheimer’s disease. A
lthough early onset Alzheimer’s disease may form part of your differential diagnosis, the history is more suggestive of Korsakoff’s in this instance.
A 45-year-old man presents to the A&E with unsteadiness and double vision. He had been previously well apart from a sore throat, cough and rhinorrhea last week. On examination, he had complete ophthalmoplegia and bilateral facial weakness. He had full strength in all limbs but had difficulty performing finger-nose and heel-shin testing. He was areflexic.
Which of the following is the most likely diagnosis?
Polymyositis
Multiple Sclerosis
Guillain-Barre Syndrome
Myaesthenia Gravis
Miller Fischer Syndrome
Miller Fischer Syndrome
From the options above, this gentleman is most likely to be suffering from Miller Fischer syndrome. MFS manifests as a descending paralysis in comparison to Guillain-Barre, which is generally an ascending paralysis/weakness.
MFS generally affects the eye muscles first and presents with the triad of ophthalmalgia, ataxia and areflexia. Anti-GQ1b antibodies are present in 90% of cases. As in Gullain-Barre syndrome it is often preceded by a viral (respiratory or GI) infection. Treatment as in Guillain-Barre syndrome is by IV Ig antibodies and (generally) complete recovery should be between 2 to 4 weeks.
You are first on the scene to see an 18-year-old man, Harry, who has just started at University. You find that he has spent the day watching rugby with a group of people he met last week. The group he is with are intoxicated and explain that they didn’t really know much about Harry before drinking with him since 13:00 this afternoon. They describe that he had become very aggressive and tried to start a fight with another man in the pub for no apparent reason. The group said when they tried to calm him down he looked pale, sweaty and then collapsed and seemed to have a fit, which is when someone called for help. On arrival you check his blood glucose level as you have a suspicion he may be diabetic.
From the answers below, which is the most likely to be his current BM?
- 0mmol/L
- 0mmol/L
- 0mmol/L
- 0mmol/L
- 0mmol/L
2.0mmol/L
Hypoglycaemia must always be excluded in any patient with coma, altered behaviour, neurological symptoms or signs. In diabetics the commonest cause of hypoglycaemia is a relative imbalance of administered versus required insulin. This may results from unforeseen exertion, insufficient or delayed food intake and excessive insulin administration. Another common cause, especially in younger adults, is alcohol intoxication that masks features of hypoglycaemia or by directly causing a low BM.
Common features include: sweating, pallor, tachycardia, hunger, trembling, altered or loss of consciousness, irritability, irrational or violent behaviour, fitting or focal neurological deficits.
Plasma glucose is normally maintained at 3.6-5.8mmol/L. Cognitive function deteriorates at levels below 3mmol/L but symptoms such as these are uncommon above 2.5mmol/L. However the threshold for symptoms can be very variable for diabetics.
Treatment depends on the situation but 5-15g of fast acting oral carbohydrate should be given as soon as possible, 1mg Glucagon (IM, SC or IV) can also be given. Glucose (10/50%) solutions can be given to those unable to take glucose orally. 90% patients fully recover within 20 minutes. Alcohol/delayed Insulin may delay/complicate treatment.
A 72-year-old women presents with a 4-month history of tiredness. She presents to A&E as she is increasingly becoming very breathless with minimal exertion.
Her FBC results are in the picture.
What initial management is the most appropriate?
Urgent endoscopy
Ferrous sulphate 200mg BD
2 units packed red blood cells
Chest X-ray
Measure ferritin levels
2 units packed red blood cells
This patient’s results show microcytic hypochromic anaemia, consistent with the clinical picture.
The common causes of microcytic hypochromic anemia are iron deficiency and blood loss.
This patient has a very low haemoglobin count, which suggests chronic blood loss. However, she is currently very symptomatic and so resolution of her anemia is priority.
Investigations should then be geared towards investigation of her blood loss, and are likely to start with an endoscopy.
A 42-year-old man is brought to the A&E following significant haematemesis of fresh red blood. The patient has clubbing and palmar erythema. You notice some spider naevi on his chest. You suspect this gentleman has ruptured oesophageal varices secondary to alcoholic liver disease. These patients have a prolonged bleeding time.
Which clotting factor, from the list below, is produced by the liver?
IV
V
VI
VII
All of the above
VII
Factors II, VII, IX and X are produced by the liver. These are also the vitamin K dependent factors, and therefore those depleted by warfarin therapy.
Patients with cirrhosis will therefore have an increase in prothrombin time.
Other findings in alcoholic liver disease will be hypoalbuminaemia, increase in bilirubin, coagulation defects and a rise in transferase enzymes, particularly GGT in alcoholic liver disease.
A 24-year-old woman presents to A&E with intermittent painless vaginal bleeding. The blood is bright red. She is 36 weeks pregnant. She denies abdominal pain and foetal movements are normal. She is praevia 2 gravida 3, and has had no complications during previous deliveries. She is otherwise fit and well.
Her observations are as follows:
HR: 118bpm
BP: 95/58mmHg
Temp: 36.6 degrees C
Urine Dipstick (+5) haematuria
What is the most likely diagnosis?
Premature rupture of membranes
Placenta praevia
Placental abruption
Pre-term birth
Cervical lesion
Placenta praevia
The main differential diagnoses with bleeding in late pregnancy are placenta praevia, placental abruption or a cervical lesion depending on the history provided.
Placenta praevia occurs when all, or part of the placenta implants in the lower uterine segment. The placement of the placenta is made in relation to the cervical OS, grades 1-4. The history here fits well with placenta previa as the bleeding is fresh and is not associated with pain. Placenta praevia is more common in multiparous and multigravida women, particularly with previous C-sections.
Placental abruption presents as haemorrhage resulting from premature separation of the placenta from the decidual interface. This is more frequently associated with a history of abdominal trauma. Further, it is more likely to be darker blood associated with pain, nausea and vomiting. The movements of the foetus would be likely to be absent or reduced. This is an important possibility to rule out especially in multiparous women.
Cervical lesions should be considered (erosions, polyps or tumours). However, in the setting above there were no cardinal features of cancer- fatigue, unexplained weight loss, or loss of appetite. The patients smear history would be important to clarify.
A 26-year-old gentleman is brought into the A&E by ambulance on a Friday night. He was found lying on a pavement outside a nightclub. He smells strongly of alcohol and on first glance appears to have face and head injuries consistent with a fight. When you begin your initial assessment and speak to the gentleman he does not open his eyes and keeps them closed throughout your assessment. When you ask his name he utters a few incomprehensible words in reply. He pulls his hand away when you press on his finger nail bed.
Calculate the Glasgow Coma Scale score for this patient
2
7
11
10
9
7
The Glasgow Coma Scale is used to give an objective and reliable tool to interpret a patient’s neurological status. It is composed of three tests: eyes, verbal and motor response. The three values are considered separately as well as the total. The lowest possible score is 3, which represents deep coma or death; 15 is an alert and conscious person.
The table below demonstrates the scoring system:
You are asked to review a 73-year-old woman who had a laparoscopic procedure performed 24 hours previously for removal of a Sigmoid Carcinoma. The nurses have called you in view of her continuing hypotension, despite 1L 0.9% saline.
When you arrive, the nurses show you her latest observations:
RR 28
SpO2 93%
Pulse 115
BP 90/65
Temp 38.0*C
Her Arterial blood gas results (ABG) are in the pic.
Which of the following fits best with this ladies clinical picture and ABG results?
Sepsis
Bowel ischaemia
Post-operative bleed
Pulmonary embolism
Acute kidney failure
Sepsis
In this scenario, the ABGs show a metabolic acidosis, most likely due to sepsis syndrome in this clinical post-operative setting.
As part of the sepsis 6 bundle the following should be administered:
- Oxygen
- Antibiotics
- IV Fluid challenge
- Plasma Lactate and Hb monitored
- Urine output monitored
- Blood cultures taken
It would also be necessary to refer this patient to senior with review from the critical care outreach team.
Commonly patients who are gasping for breath, or athletes at the end of a race, assume the “tripod position” to engage accessory muscles of respiration.
Which of the options below is not an accessory inspiratory muscle?
Scalene muscles
Sternocleidomastoids
Alae nasi
Pectoralis muscles
Rectus abdominis
Rectus abdominis
In a healthcare setting (where this shortness of breath is not usually preceded by exercise), adopting the tripod position is one sign of respiratory distress.
The accessory muscles of inspiration act by:
- Scalene muscles elevate the first two ribs
- SCM raise the sternum (contract vigorously during exercise)
- When the arms are secure, the Pectoralis muscle also contracts which results in elevation of the anterior wall of the chest
Rectus abdominis is a muscle of expiration, along with other muscles of the abdominal wall (internal/external oblique and transverse abdominis).
An 85-year-old who is known to have atrial fibrillation presents to the A&E. He describes feeling unwell since the morning, before feeling weakness on one side. An immediate CT scan carried out confirms a CVA. The infarct is within the area of the left lenticulostriate branch.
Which of the following symptoms are most likely to be exhibited in this patient?
Left pure upper motor hemiparesis
Right pure upper motor hemiparesis
Left hemianopia
Right hemianopia
Behavioural changes
Right pure upper motor hemiparesis
The lenticulostriate branch supplies the basal ganglia (globus pallidus and striatum) and thus an infarct of the left lenticulostriate branch would cause a right pure upper-motor hemiparesis. In larger infarcts of this area, which extend to the cortex, the patient may also exhibit cortical deficits such as aphasia.
Posterior circulation infarcts would produce contralateral homonymous hemianopia due to damage to the visual cortex in the occipital lope. Larger infarcts in the posterior circulation may cause hemisensory loss and hemiparesis due to disruption of the ascending and descending information passing through the internal capsule and thalamus.
Behavioral abnormalities are most commonly associated with injuries to the frontal lobe (for instance: anterior circulation infarcts).
Depolarisation during phase 0 of a cardiac action potential is caused by which of the following changes?
Calcium channels opening
Potassium channels opening
Potassium channels closing
Sodium channels opening
Sodium channels closing
Sodium channels opening
A cardiac action potential is split into four phases.
Phase 0- Depolarisation mediated by fast Na+ channels opening and an influx of Na+ ions into the cell.
Phase 1- Initial repolarization is caused by fast Na+ channels closing
Phase 2- Plateau: K+ and Ca2+ channels open, Calcium enters the cell and is balanced by Potassium leaving the cell.
Phase 3- Repolarisation is caused by Ca2+ channel closure, causing a net negative current as K+ ions continue to leave the cell.
Phase 4- Resting membrane potential (unable to fire action potentials).
A 4-year-old boy is brought to the A&E by his mother. The child has fallen off a step in the garden and hit his head. On examination, the child has a superficial laceration on the scalp that does not breach the aponeurotic layer and measures about 2cm in length. You gently clean the wound; it is linear with regular edges and there has been no loss of tissue.
What is the best method for wound closure?
Staple
Steri-strip
Adhesive glue
Simple interrupted stitch
Vertical mattress stitch
Adhesive glue
This question refers to methods of healing by primary intention. This is a small lesion (<5cm) with clean edges and no loss of tissue and should be a simple wound to manage. Adhesive glue is used most commonly in the under 10s due to generally better cosmetic outcomes.
Steri-strips would be appropriate for a lesion of this size in non-hair bearing areas. However, due to the site of injury, the child’s hair would likely prevent adequate adhesion of the strips.
Staples are a fast method for wound closure, and have been associated with decreased wound infection rates. However, it is not suitable for a child.
Suturing in this setting would also be less appealing to the child - the technique includes needles and local anesthesia; unless necessary due to the type of injury.
A nervous 45 year-old woman is admitted to the A&E with palpitations. She reports that her heartbeat feels fast, although she denies chest pain
On examination, you notice some discoloration of the legs bilaterally.
Her observations are as follows:
Temperature: 37.3°C
Respiratory rate: 16/min
Pulse: 150bpm, irregular
Blood pressure: 125/80
What is the most likely diagnosis from the following?
Thyrotoxicosis
Anxiety
Deep Vein Thrombosis
Cellulitis
Myocardial Infarction
Thyrotoxicosis
This lady is mostly likely to be suffering from thyrotoxicosis. The key clinical features of thyrotoxicosis are graves ophthalmopathy, goitre, and pretibial myxoedema (as shown in the picture above). Graves’ is an autoimmune condition, and can be diagnosed with a test for antibodies to thyroid stimulating hormone receptor.
The treatment of thyrotoxicosis is propranolol, for symptomatic control of the tremor and atrial fibrillation and rule out/correct any underlying thyroid pathology.
Anxiety could cause palpitations and tachycardia, but would not account for the ankle discoloration. Cellulitis is an infection of the skin, and thus, you would expect an increased temperature. Further, you would expect a history classically of fluid retention.
A 21-year-old man is brought into A&E at 13:00. He has overdosed on an unknown quantity of Paracetamol at around 11am today. He weighs 70kg. His housemates say he has never done anything like this before.
What result below is the most concerning?
Ingestion of 6g paracetamol
Ingestion of 10g paracetamol
2 hour plasma paracetamol level of 200mg/L
4 hour plasma paracetamol level of 200ml/L
Clinically jaundiced and evidence of hepatic tenderness
4 hour plasma paracetamol level of 200ml/L
You should only ever test plasma levels 4 hours after ingestion. This is because plasma levels before this time will not be accurate or reliable. The graph to show concerning levels has two curves. One for high-risk patients and one for normal risk patients.
For this young man, he has no risk factors that would cause him to become high risk (malnourishment or ongoing liver injury). We therefore follow the “normal risk” curve. At 4hrs a level of 200mg/litre or above is concerning and we would need to start treatment with Acetylcysteine.
Overdose Paracetamol levels:
* High risk > 75mg/Kg
* Normal risk: 150mg/kg.
This young man weighs 70kg. A level of >10.5g would be classed as an “overdose.” We would still want to assess him clinically and it is likely we would still perform Plasma levels at 4 hours.
A 5 year old is brought into the Emergency Department. Her father says she suddenly developed a high temperature and has now started to become very distressed. She has obvious stridor and you note that she is drooling.
What is the most likely diagnosis?
Croup
Anaphylaxis
Peritonsillar Abscess
Pharyngitis
Epiglottitis
Epiglottitis
Epiglottitis is inflammation above the glottis. It is most often bacterial and presents with an abrupt onset of symptoms.
They typically present with a fever followed by Drooling, Distress, Dysphonia and Dysphagia. The child would also have a fever. It is a medical emergency and requires urgent assessment form a paediatric anaesthesiologist to control the airway. If not treated quickly it can progress to respiratory arrest and death within a matter of hours.
You are asked to see Sophie, a 2 year old who has taken multiple antidepressants. It happened about 20 minutes ago. Her mother says she left her for a couple of minutes and then found her next to her bottle of antidepressants. She is stable however it is unclear how many tablets she has taken.
Which database would you use to ensure this patient was treated effectively?
DRUGDATABASE
BNF
P.O.I.S.O.N.
TOXBASE
TOXINZ
TOXBASE
Toxbase is a widely used Internet resource (provided by the National Poisons Information Service (NPIS)) particularly in Emergency Departments across the UK.
It is the primary clinical toxicology database and first line information resource for guidance in managing and treating any poisoning (accidental, overdose, child-related). Toxbase also provides a 24-hour telephone service for further clinical toxicological enquires.
A 3 year old is rushed into the ED. His mother says she was in the kitchen preparing dinner when she suddenly heard him coughing and spluttering. He is struggling to breath and his lips are starting to become cyanosed.
Where is the foreign object most likely lodged?
Left mainstem bronchus
Larynx
Right mainstem bronchus
Trachea
Soft palate
Right mainstem bronchus
This is a very typical history for inhalation of a foreign object.
This can quite quickly lead to death if the object is not removed.
The right main bronchus enters the right lung at approximately the 5th Thoracic Vertebra and lies more vertically than the left.
(The left main Bronchus enters the lung slightly lower down, approximately the 6th thoracic Vertebra).
This anatomy predisposes the right lung to several problems including the above.
A mother brings her 7 year old son into the Children’s assessment unit; he has had a wheeze throughout the morning which does not seem to be improving despite 6 puffs of his inhaler.
His RR is now 33, SpO2 is 91% on air, HR 135.
What is your first line management?
O2 via face mask
B2 agonist 2-10 puffs via spacer
Nebulised salbutamol 5mg and soluble prednisolone 30-40mg
B2 agonist 2-10 puffs via spacer and soluble prednisolone 30-40mg
Nebulised salbutamol 5mg
Nebulised salbutamol 5mg and soluble prednisolone 30-40mg
The SIGN guidelines state that the above treatment is essential in a child >5 with a severe exacerbation of asthma (as above).
O2 must always be given but on its own would not relieve the exacerbation.
Puffs of a B2 agonist are given to children with a moderate exacerbation of asthma – SpO2 >92%, PEF >50% best or predicted, No clinical features of severe asthma.
Prednisolone is a glucocorticoid, similar to cortisol. Anti-inflammatory.
You are the F2 on a night shift in the ED. It is 1 in the morning and a young mother comes running in with her child in her arms. Her 3 year old daughter woke up half an hour ago struggling to breath and had developed a barking cough. She has no other symptoms. From your initial assessment she has obvious stridor and an inspiratory wheeze.
What is the most likely diagnosis?
Epiglottitis
Croup
Inhaled foreign body
Anaphylaxis
Severe asthma
Croup
Croup is common and primarily found in children. It is a viral respiratory tract illness which typically affects the larynx and the trachea. It is the most common cause of acute stridor in febrile children.
Stridor is an audible harsh, high-pitched, musical sound on inspiration produced by turbulent airflow through a partially obstructed upper airway.
Mr. Harding, a 77 year-old man, is brought to the Accident and Emergency Department by ambulance. He started to have a nose bleed at home three hours ago and this is still going on arrival, despite applying continuous pressure and attempting to pack it himself.
Mr. Harding is on Simvastatin, Warfarin, Bendroflumethiazide and Sertraline. On examination his heart rate was 62bpm and blood pressure; 102/76mmHg. Mr. Harding’s INR is 6.
Which one of the following drugs should be given to this patient as soon as possible?
Vitamin K
Aspirin
Atorvastatin
Magnesium
Paracetamol
Vitamin K
Epistaxis can be idiopathic or follow minor/major trauma. When it occurs in patients with hypertension and coagulation disorders, haemorrhage can be severe with significant mortality. Check current medications, full blood count and clotting in older patients.
INR or International Normalised Ratio is regularly measured in patients on Warfarin to ensure they are within the therapeutic window and determine the next dose. The target INR is usually 2.0-3.0, a range of factors can cause the INR to become unstable, for example missed doses or illness. If the INR becomes higher than the target range, coagulation is significantly slowed which can increase a patient’s risk of haemorrhage/prolonged bleeding. If major bleeding occurs at any time whilst on Warfarin, the patient should stop taking Warfarin and should be given Vitamin K 10mg via a slow IV and be referred to secondary care for factor replacement. Without major bleeding, if the current INR is between 5 and 9, guidelines indicate Warfarin should be stopped, INR tested daily until it has returned to therapeutic range and restart Warfarin with a reduced dose when INR is <5. Give Vitamin K 1.0-2.5mg orally if INR fails to reduce or patient is at high bleeding/re-bleeding risk
A 63 year-old woman is brought to the Accident and Emergency Department by her husband after complaining of a two day history of general malaise, a unilateral headache, noticeable pain when brushing her hair as well as right sided jaw pain. She is worried because vision in her right eye seems to be diminished.
Which of the following would you do immediately?
Visual Acuity Test
Lumbar Puncture
Start Prednisolone 40-60mg
Temporal Artery Biopsy
Start patient on 4-hourly paracetamol
Start Prednisolone 40-60mg
This patient has classical symptoms of Giant Cell Arteritis. This diagnosis must be considered in all patients over the age of 50 that present with a unilateral headache, jaw claudication, scalp/temporal tenderness, amaurosis fugax or sudden blindness, typically in one eye.
ESR should be carried out (will appear raised) and if GCA is suspected, 40-60mg Prednisolone should be started orally, immediately. The risk is irreversible bilateral visual loss which can occur suddenly if not treated rapidly. A temporal artery biopsy should be carried out within three days of starting steroids. Pain relief is important and should be considered but will not stop progressive blindness. Visual test should also be carried out to clarify the extent of damage, but can be done after starting steroid treatment.
A 53 year-old male comes to the Accident and Emergency Department describing eight days of gradually worsening scrotal pain and pain on urination. His temperature is 37.7 °C, heart rate 86bpm and blood pressure 130/70mmHg. He is still sexually active with his wife. On physical examination his scrotal skin is warm and erythematous, the patient’s left testicle is swollen and tender to touch. A cremastic reflex is present.
What is the most likely diagnosis from the options below?
Testicular Torsion
Epididymitis
Urinary Tract Infection
Testicular Tumour
Varicocele
Epididymitis
This patient has epididymitis. It is often difficult to distinguish epididymitis from testicular torsion. Testicular torsion is a surgical emergency and therefore should be on the differential for a patient with scrotal pain and should be ruled out first. Testicular torsion is rare above the age of 25 and is caused by twisting of the spermatic cord, causing testicular ischaemia. Pain is often an acute onset and the whole testes may present as tender.
Epididymitis in those above 35 years old is usually secondary to a UTI and can be associated with an underlying urinary tract pathology. Typically there is a gradual onset of progressive testicular ache with subsequent swelling. The patient may be pyrexic and may have a history of dysuria. The epididymis is acutely tender with the testis lying low in the scrotum. Treatment includes antibiotics, analgesia and rest.
Testicular tumours can be mistakenly diagnosed as epididymitis.
A Varicocele is a painless scrotal swelling that is caused by dilation of the veins in the pampiniform plexus. These individuals may be asymptomatic or complain of a scrotal pain or heaviness.
A 23 year-old woman has come into A&E explaining that she has had a burning sensation on urinating and suprapubic pain for the past five days. This morning she began vomiting and has lower back pain. Her temperature is 37.9°C.
It is decided that she is likely to have acute pyelonephritis.
Which is the most likely organism to have caused this patient’s symptoms?
Klebsiella
Candida Albicans
Enterococcus Faecalis
Staphylococcus Aureus
Escherichia Coli
Escherichia Coli
Females are more prone to Urinary Tract Infections due to the short urethra. Acute pyelonephritis occurs when a UTI ascends to the kidney(s).
The patient is systemically unwell with fever, loin/back pain (as the kidneys are retroperitoneal), rigors, headache, nausea and vomiting. The kidney(s) are tender on palpation.
E.Coli is the most common causative organism (>70% in the community but <40% in hospital).
Treatment of lower UTI includes antibiotics such as Trimethoprim or Nitrofurantoin. Patients with acute pyelonephritis usually require admission for IV antibiotics (broad spectrum-specific after causative organism is identified by blood cultures), fluid replacement and analgesia. Assess and treat for severe sepsis when appropriate.
A 15 year-old boy is brought into the Accident and Emergency Department from the school playing fields where he had become acutely short of breath. On arrival he struggles to tell the Emergency team his name and how old he is within one breath.
His respiratory rate is 28 breaths/min, heart rate 60bpm and his SpO2 is found to be 94%. The boy’s lips are tinged blue.
What is the most likely diagnosis?
COPD
Acute severe asthma
Panic attack
Pneumonia
Life threatening asthma
Life threatening asthma
This young man has a life threatening exacerbation of asthma. Asthma can be unpredictable and dangerous for young and otherwise healthy men and women.
A patient has a moderate exacerbation of asthma if they have increasing symptoms of breathlessness, a peak flow of 50-75% and no features of acute severe asthma (see below).
Acute severe asthma (any 1 of):
Inability to complete sentences in one breath
Respiratory rate less than or equal to 25 breaths/min
Heart rate of more than 110bpm
Peak flow 33-50% of best or predicted
Life threatening asthma (A patient with severe asthma with any 1 of):
Cyanosis
Exhaustion, confusion, coma
Feeble respiratory effort SpO2 <92%
Silent Chest Bradycardia, arrhythmia, hypotension
pO2 <8kPa
Normal pCO2 (4.6-6.0kPa)
Peak flow <33% of best or predicted
Treatment is guided by regular Peak Expiratory Flow (PEF) measurements:
Patients are treated with Oxygen and B2 agonist bronchodilators (e.g. Salbutamol) delivered by nebulizer or metered dose inhaler/spacer. Steroids are often also given to reduce small airway inflammation. Anticholinergics are used in severe cases of asthma. Non-invasive ventilation can be used to reduce the work of breathing without intubation where it can be avoided.
A 44 year-old man, who weighs approximately 70kg is brought to the Accident and Emergency department having escaped a house fire by jumping out of a low level window.
On initial assessment he has a patent airway but his voice is slightly hoarse, a respiratory rate of 12 breaths/min and a GCS of 14. He has approximately 27% partial thickness burns across his anterior trunk and right arm.
Use Parkland’s formula to calculate the IV fluids this patient needs in the first eight hours.
Parkland’s formula: 4ml x (% burn) x (bodyweight in kg) over 24 hours. Half given in the first 8 hours, the rest over 16 hours.
7560ml
1890ml
3780ml
2700ml
1680ml
3780ml
Initial assessment and resuscitation of a patient who has been involved in any fire must follow the ABCDE protocol. Indications of airway burns may include carbon/soot in nostrils/mouth/sputum, singed eyelashes/nostril hair, facial burns, oropharyngeal swelling or redness, change in voice or stridor. Upper airway burns require urgent prophylactic intubation as the patient’s upper airway may swell a large amount within a few hours.
Burns can be of varying thickness: superficial epidermal (red and painful but not blistered), partial thickness superficial dermal (pale pink and painful with blistering), partial thickness deep dermal (dry or moist, blotchy and red, and may be painful or painless. There may be blisters) and full thickness (dry, painless, no blisters white/brown/black/leathery/waxy).
The ‘rule of nines’ is a quick way to estimate the relative percentage of the patient’s body surface that is burnt, for example: arm 9%, front of trunk 18%, head and neck 9%, leg 18%.
Parkland’s formula is used to calculate the amount of IV fluid required for the first 24 hours after a patient has suffered burns injuries, to ensure they remain haemodynamically stable. The formula is only a guide and fluids should be adjusted according to urine output and clinical response.
A 24 year-old male is brought to the Emergency Department by air ambulance. A pedestrian, he had been hit by a car travelling at approximately 40mph.
The patient has a heart rate of 110bpm, blood pressure of 90/60mmHg and paramedics on scene explained that the man had excruciating pelvic pain and a pelvic binder had been put on in the field.
A FAST scan was conducted in the Emergency Department that highlighted a significant amount of blood within the pelvis.
What type of pelvic injury has this man sustained in the road traffic accident?
Lateral Compression Injury
Anterior Posterior Compression Injury
Shear Force
Combination
No injury sustained
Anterior Posterior Compression Injury
Anterior Posterior Compression injuries (also known as ‘open book pelvis’ make up 15-20% of pelvic trauma injuries. These injuries are often the result of a RTA (car vs pedestrian/motorcycle accident), direct crush injury or a fall over 12ft. Classically the pubic symphysis is broken and there is a risk of major haemmorhage as the direction of impact may rupture the venous plexus or internal iliac arteries. A large proportion of a person’s entire blood volume can insidiously enter into the pelvic cavity.
A lateral compression injury, or ‘closed pelvis’ is the most common type of traumatic pelvic injury (60-70%). This can also occur as a result of a RTA and make cause damage to genitourinary organs but life threatening haemorrhage is less common.
Shear force injuries are often caused by high energy mechanisms and falls onto one limb, creating major pelvic instability.
A combination injury is where the patient has more than one type of pelvic trauma injury
Rose, a 17 year-old girl, is brought to the Accident and Emergency department complaining of pain that started centrally but is now worse in her right iliac fossa. She hasn’t felt like eating for the last day or so.
On examination Rose shows guarding, her heart rate is 80bpm and she is pyrexic with a temperature of 37.8 °C.
What is the most likely diagnosis?
Cystitis
Appendicitis
Constipation
Dysmenorrhoea
Cholecystitis
Appendicitis
Appendicitis is the most common surgical emergency which classically presents as poorly localized peri-umbilical pain then moves to tenderness and guarding at McBurney’s Point (2/3 of the way from the umbilicus to a point midway along the inguinal ligament) in the right iliac fossa due to peritoneal irritation.
Anorexia is also an important presenting symptom. Rovsing’s sign may also be present; pain that is worse in the right iliac fossa than the left, when the left iliac fossa is palpated.
Treatment should be a prompt appendectomy to avoid perforation.
A 55 year old is rushed into the emergency department. He was out for lunch with friends when he suddenly developed a severe headache that he described as, “the worst headache I’ve ever had”. He was alert when the paramedics got to him however his GCS is now 12.
What is the most likely diagnosis?
Subarachnoid haemorhage
Giant cell arteritis
Migraine
Extradural haemorrhage
Tension headache
Subarachnoid haemorhage
Subarachnoid haemorrhages may be caused by ruptured saccular aneurysms (~80%), arterio-venous malformations, hypertension or trauma. Most commonly occurring between the ages of 40-60 years old, the classic symptom is a sudden ‘thunderclap’ (usually occipital) headache, sometimes described as the most severe headache the person has ever had. Vomiting, collapse, seizures and coma often follow if not treated promptly.
A 24-year-old woman was brought into the Emergency Department after having a seizure at home. Since her arrival she has received two doses of intravenous lorazepam and has subsequently been started on a phenytoin infusion. Her husband says she has now been seizing for about 45 minutes.
What is the most likely cause of this seizure?
Intracranial haemorrhage
Hypoglycaemia
Eclampsia
Status epilepticus
Encephalitis
Status epilepticus
SE means seizures lasting for greater than 30 minutes, or if repeated seizures occur without consciousness returning between seizures.
Management of status epilepticus involves initial treatment with intravenous lorazepam with two boluses given 10 minutes apart.
If seizures continue then an intravenous infusion of either phenytoin or diazepam is given. If this does not stop the seizures then patient should be put under general anaesthesia, for paralysis and ventilatory support.
You are called to see a 65-year-old man with dizziness and palpitations. He had open-heart surgery 6 days ago.
His ECG is shown in the picture.
What is the most likely diagnosis?
Atrial flutter
Sinus tachycardia
Sick sinus syndrome
Atrial fibrillation
Wolff-Parkinson-White syndrome
Atrial flutter
The ECG shows a typical saw-tooth appearance of Atrial Flutter in inferior leads II, III and aVF.
Atrial flutter has many similarities to Atrial Fibrillation but is different in terms of mechanism and management.
Some patients have both arrhythmias are associated with increased risk of thromboembolism. Atrial flutter is much less common than atrial fibrillation.
Prevalence increases with age and is more common in men and during the first week after open-heart surgery. Presentation may be asymptomatic but is generally not tolerated as well as AF and most often presents with palpitations.
You are called to review the ECG of a previously well 14-year-old boy. He was brought into the ED after blacking out during a PE class. On arrival he is alert and explains he often feels light headed and has a ‘funny feeling in his chest’.
His ECG is shown in the picture.
What is the most likely diagnosis?
Atrial flutter
Sick sinus syndrome
Atrial fibrillation
Wolff-Parkinson-White syndrome
Ventricular ectopic beats
Wolff-Parkinson-White syndrome
WPW syndrome is the most common ventricular pre-excitation syndrome.
It is important to diagnose because of it’s association with paroxysmal tachycardias that can potentially result in sudden death, in otherwise, healthy young people (more frequently, men). WPW syndrome is a congenital absnormality which can result in SVT by an AV accessory tract.
Classic ECG findings of WPW syndrome include a short PR interval (less than 120ms) and a delta wave.
Asymptomatic patients may just need periodic review. However, symptomatic patients, such as this, may require ablation of the accessory tract.
An 18-year-old woman, Alice, is brought into the ED after becoming extremely anxious during her A-level Chemistry exam. Her teacher explains that he noticed her becoming pale, sweaty and short of breath before ‘passing out’. When you call her mother to come to the ED, she tells you that her nephew died unexpectedly two years ago aged 15. On examination Alice is now alert but is complaining of palpitations and still appears pale and sweaty.
Her ECG is shown in the picture.
What is the most likely diagnosis?
Sinus tachycardia
Atrial fibrillation
Wolff-Parkinson-White syndrome
Ventricular ectopic beats
Torsades de Pointes
Torsades de Pointes
Torsades de Pointes is a ventricular tachycardia in which the QRS amplitude varies and the QRS complexes appear to twist around the baseline. It is a life threatening arrhythmia associated with a congenital (or acquired) long QT interval and may present as sudden cardiac death in patients with structurally normal hearts.
Risk factors include congenital long QT syndromes or acquired long QT syndromes such as; MI, certain drugs (methadone, antipsychotics and erythromycin), electrolyte disturbances, AKI, anorexia etc.
Episodes of torsades de pointes can spontaneously revert to sinus rhythm, to another ventricular tachycardia or ventricular fibrillation.
Episodes may be triggered by stress, fear or physical exertion. Patients can present with recurrent episodes of palpitations, dizziness and syncope, alongside nausea, pallor, SOB and chest pain may also occur.
A 23-year-old man comes to the ED after burning himself with an iron. On examination he has a 4x3cm area of pale pink skin on his forearm. Within the pink area there are two small, fluid filled blisters.
What is the most accurate description for this injury?
Superficial Epidermal Burn
Superficial Partial Thickness (Superficial Dermal) Burn
Deep Partial Thickness (Deep Dermal) Burn
Full Thickness Burn
Circumferential Burn
Superficial Partial Thickness (Superficial Dermal) Burn
A 36-year-old woman is brought to the ED after being involved in a house fire. Whilst running out of the house, she explains that something that was alight had fallen on her leg. On examination a patch of skin on her thigh, 6x4cm appears black and waxy. There are no blisters in this area and she is not complaining of any pain.
What is the most accurate description of this woman’s leg injury?
Superficial Epidermal Burn
Superficial Partial Thickness (Superficial Dermal) Burn
Deep Partial Thickness (Deep Dermal) Burn
Full Thickness Burn
Chemical Burn
Full Thickness Burn
Cross-matched blood is always preferable, but may not always be immediately possible.
Which blood group can be referred to as the ‘Universal donor’ and can be given to any patient in an emergency?
A (Rhesus +ve)
AB (Rhesus +ve)
AB (Rhesus -ve)
O (Rhesus +ve)
O (Rhesus -ve)
O (Rhesus -ve)
Group O-ve is considered the ‘Universal DONOR’ because it has no surface antigens and therefore should not cause a transfusion reaction.
Group AB is considered the ‘Universal RECIPIENT’ because it contains no antibodies to cause a transfusion reaction to any blood type.
A 27-year-old man has been involved in a road traffic accident on his drive home from work. He has suffered a blunt chest trauma and is suspected to have a fractured clavicle and at least two fractured ribs. A short while after he arrives in the department, the patient becomes tachycardic and tachypnoeic. A chest X-ray indicates that he has a large tension pneumothorax.
Which anatomical location is generally considered ‘the safe triangle’ when inserting a chest drain?
5th intercostal space, anterior to mid-axillary line
5th intercostal space, mid-clavicular line
2nd intercostal space, mid-axillary line
2nd intercostal space, mid-clavicular line
3rd intercostal space, mid-axillary line
5th intercostal space, anterior to mid-axillary line
Needle thoracostomy (with a 14-16G intravenous cannula inserted into the second intercostal space, mid clavicular line) can be used to urgently decompress a tension pneumothorax, where there is not enough time to insert a chest drain.
Chest drain placement is the definitive treatment of a tension pneumothorax. The position of the drain is determined by the location and the nature of the collection to be drained; however the 5th intercostal space anterior to the mid-axillary line is generally used for most situations (the long thoracic nerve lies in the mid-axillary line).
This is commonly known as the ‘safe triangle’ bordered by the anterior border of the latissimus dorsi, the lateral border of the pectoralis major, a line superior to the horizontal level of the nipple and an apex below the axilla.
Signs and symptoms of a tension pneumothorax include: tachycardia, tachypnoea, hyperresonance on percussion and tracheal deviation away from the pneumothorax, seen on CXR.
Paramedics suspect that their patient, Roy, a 73-year-old man, is having an MI. He has smoked approximately twenty cigarettes a day since he was 21 and has a history of angina, usually controlled by his GTN spray. He denies chest pain but appears pale, clammy and is clutching a sick bowl. Roy explains his jaw is ‘tight’ and he has pain radiating down his left arm. An ECG is performed which shows ST segment elevation across leads V1 to V6.
Which coronary artery is most likely to be involved?
Left Anterior Descending Artery
Right Coronary Artery
Left Circumflex Artery
Left Marginal Artery
Posterior Descending Artery
Left Anterior Descending Artery
ST elevation across leads V1 to V6 suggests an Anterior MI, which would most likely involve the Left Anterior Descending (LAD) artery.
A 40-year-old woman, Danielle, is brought to the ED, describing her pain as 10/10 in severity and tenderness across the whole of her lower leg and foot. Her left leg is shown below.
Her son explains that she never likes to bother the doctor and is very rarely ill; with only a past medical history of asthma for which she uses a salbutamol inhaler. Danielle is in too much pain to provide an extensive history, but her son suggests that she started complaining of a pain in her left leg two days ago, which has gotten progressively worse. He brought her to the ED because she had become lethargic and had noticed this discolouration that had gotten larger on her leg.
On examination Danielle appears clinically dehydrated, is febrile and tachycardic. Whilst Danielle is in the department awaiting further assessment, you notice the development of some small bullae and her left leg appears to have become more oedematous.
From the following options, which is the most likely diagnosis?
Pyoderma Gangrenosum
Necrotising Fasciitis
Cellulitis
Vasculitis
Deep Vein Thrombosis
Necrotising Fasciitis
Necrotising Fasciitis is an uncommon but life threatening infection, defined as any necrotising infection (polymicrobial, gram-negative monomicrobial, fungal etc.) that involves any layer of the deep soft tissue compartment (dermis, subcutaneous tissue, fascia or muscle).
NF is difficult to diagnose in its early stages as it mimics cellulitis. Important early clues and distinguishing features from cellulitis include: disproportionate pain and tenderness that extend outside the boundary of tissue decolouration. Systemic illness may also be out of proportion to the visible tissue damage. Bullae and ecchymotic skin lesions can also point to NF rather than cellulitis. A high index of suspicion is important.
NF can be caused by Group A Strep, in otherwise fit and healthy individuals. NF signs and symptoms typically develop over a few days but can progress much more rapidly and be fatal within 48 hours for some. Disproportionate pain may be the first symptom with some mild erythema and swelling on one area of the body. The pain is disproportionate because of the extensive deep tissue injury.
Day 2-4 bullae may appear alongside tense oedema. Skin will become discoloured, progressing to necrosis which can rapidly spread along fascia planes.
Day 4-5 is usually when hypotension and septic shock develop. Urgent surgical debridement and often removal of affected areas is essential to survival, alongside high dose IV broad spectrum antibiotics.
Mortality is generally considered to be >25%.
Andrew, a 36-year-old, was involved in a multi-vehicle accident one week ago. Despite suffering massive haemorrhage and multiple lower limb fractures at the time of the accident, he has been stable and gradually improving following his admission to hospital. As the junior doctor on nights, you have been called to assess Andrew after a nurse had raised concerns. He has become increasingly dyspnoeic, tachypnoeic and on respiratory examination you hear some bilateral crackles.
His CXR (below) indicates which of the following diagnoses?
Pneumothorax
SIRS
ARDS
Lobar Pneumonia
Goodpasture Syndrome
ARDS
The CXR shows diffuse bilateral consolidation with a ground glass appearance; suggestive of Adult Respiratory Distress Syndrome (ARDS).
Air bronchograms can also be seen (left and right). This is an (almost always pathological) phenomenon in which air filled bronchi (black) are highlighted by the opacification of surrounding alveoli (grey/white). On this CXR a central venous line and a nasogastric tube can also be seen.
ARDS is a devastating condition which can affect adults as well as children. It occurs when non-cardiogenic pulmonary oedema (secondary to acute damage to the alveoli) leads to acute respiratory failure. Most common risk factors include; massive trauma with shock and multiple transfusions, hypovolemic shock (as was likely to be the case for Andrew), pneumonia or gastric aspiration.
ARDS can be associated with direct or indirect lung injury. Overall mortality is 50-75% and prognosis varies with age and number of organs in failure and immediate admission to ITU to provide supportive care is vital to increase the likelihood of survival.
Which of the following statements regarding the Salter-Harris classification for bone injuries in children is correct?
The classification is for fractures involving the metaphysis and the diaphysis
Growth arrest is common in Salter-Harris type II injury
Growth disturbance is very unlikely in Salter-Harris type III injury
Salter-Harris type V is described as a comminuted fracture of the metaphysis
Salter-Harris fractures account for less than 5% of all fractures in children
Salter-Harris fractures account for less than 5% of all fractures in children
The Salter-Harris classification system is for fractures through the growth plate or the epiphysis (in Salter-Harris types II & IV, the metaphyseal fragment is also involved but the diaphysis is never affected).
Salter- Harris types I & II do not involve the germinal layer and therefore growth disturbance is uncommon.
In Salter-Harris types III & IV, the germinal layer is breached and growth disturbance is likely, although its incidence could be minimised by precise reduction of the fracture.
Although not originally described, a Salter-Harris type V fracture is recognised as a crushing injury of the epiphysis following which growth arrest is common. This fracture is often diagnosed retrospectively, when disturbance of physeal growth is apparent as a limb deformity. Because of the weakness of the growth plate, these injuries are relatively common.
A 24-year-old male involved in a high speed RTA is brought to the Accident and Emergency unit. He is noticed to be bleeding from the nose and he complains of a salty taste in the mouth. There is bruising over his mastoid process and a periorbital haematoma. Examination using an otoscope reveals visible bleeding behind the tympanic membrane.
Which of the following is the most likely diagnosis in this patient?
Open skull fracture
Basal skull fracture
Extradural haematoma
Subarachnoid haemorrhage
Subdural haematoma
Basal skull fracture
This patient is manifesting the classical signs and symptoms of basal skull fracture. Trauma is the commonest cause of such fractures. These fractures commonly involve the roof of the orbits, the sphenoid bone, or portions of the temporal bone.
The commonly found signs and symptoms of basal skull fracture include, Raccoon eyes (periorbital haematoma), subconjunctival haemorrhage where the posterior margins cannot be seen, Battle’s sign (post auricular bruising and blood behind the eardrum; this sign may develop after 24-48 hours of injury) and rhinorrhoea/otorrhoea (blood with CSF & doesn’t clot; this is caused by damage to the cribriform plate).
The management of such patients depends on other associated injuries and the features found from relevant investigations such as a CT or an MRI. Some of the indications for a CT scan include a falling GCS or a GCS <13, depressed skull fracture, lateralising neurological signs and convulsions. Patients with a GCS <8 warrant intubation to protect their airway. With any skull fracture, especially basal fractures, prophylactic antibiotics are indicated to prevent meningitis.
Some recognised complications of basal skull fractures include, high risk of infection (especially following CSF rhinorrhoea), facial palsy (usually responds well to steroids), and isolated VI nerve palsy.
A 9-year-old boy presents to A&E after falling off a trampoline onto his outstretched left hand. He is complaining of pain across all of his wrist and he has limited range of movement. His plain film is below:
He has a fracture to both his ulna and radius, though the radial fracture is a Salter-Harris Fracture because it involves the growth plate - which type of Salter-Harris fracture is this?
I
II
III
IV
V
II
This is Salter-Harris II because the fracture involves the metaphysis only, with no apparent disruption to the epiphysis. These fractures are only found in people with immature bone.
