True/Falses Flashcards by Peter Turton

Metabolic alkalosis

Results from hypo aldosteronism
Causes muscle cramping
Can result from a large strong ion difference
Can result from excess saline admin
Causes hyperventilation

FTTFF

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VAP

if undertreated is associated with increased mortality

If diagnosed more than 5 days after admission to unlikely to be due to multi resistant organisms

Can be treated with beta lactams vancomycin or aminoglyc

Is better treated with aminoglycosides compared to beta lactamse inhibitors as they have enhanced activity in hypoxia and acidosis

In immunosuppressed pts is associated with herpes simplex

TFTFT

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Warfarin is adequate for initial anticoagulant

D dimmer is up

ECG has right axis deviation

Jaundice has been described

Trop is likely to be normal

FTTTF

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Brain stem death

Temp must be greater than 35c
3rd CN response must be absent
Knee and ankle jerks must be absent
Platers must be extensor
Serum sodium must be within 5 of normal

TTFFF

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Perc Trachy

Can be safely done in the morbidly obese
Has a lower risk of stoma infection compared to surgical
Reduces time of mech ventilation
Serial dilators have a reduced risk of tracheal tear compared to forceps
Is more expensive due to kit cost

TTFFF

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In RIFLE, a patient in group I

Oligure is always present 
Loop discretions improve outcome
Volume resus with isotonic bicarb may help
Protein restriction is needed
Consider HF at exchange of 20-25ml/kg/hr

FFTFT

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Sengstaken blakemore

Gastric balloon always inflates before oesophageal
100 mls is needed to inflate the balloon
Traction is applied to proximal end to stop gastric bleed
Associated with oesophageal ulcerrarion and aspiration in 20%
They control bleeds in 90%

TFTTT

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Sodium bicarb In barbiturate overdose is indicated to:

Increase renal blood flow
Increase tubular reabsorption
Increase glomerular filtration
Promote barbiturate dissociation in alkaline urine
Bind excess barbituate

FFFTF

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DKA

Can only occur in type I DM
Ketoamia of greater than 2mmol/L is needed for diagnosis
Blood glucose greater than 11 is needed
Bicarb less than 10 or venous pH less than 7.3 or both is needed
Predominant ketone is 3-beta-hydroxybutyrate

FFTFT

Ketones are greater than 3 not 2
Bicarb is less than 15, not 10

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DKA

Blood glucose should be used as marker of resolution
Fixed rate inuslin at 0.1 units/kg/hr
Blood ketones should fall by 0.5/hr
Glucose should fall by 1 mmol/hr
Insulin may be increased by 1 unit/hr until targets reached

FTTFT

glucose can be used but it’s third line
Ketones should fall by 0.5
Glucose should fall by 3 not 1
You can increase by 1 unit per hour if this 3 mmol target isn’t reached

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Rib fractures

Mortality can be as high as 33%
Resp failure is commonly due to pain and damage to tissue
A flail occurs when there is paradoxical movement during chest wall during inspiration
4 or more fractures have the highest mortality
Incubated patients with flail, resp failure or prolonged vent should have operative fixation

TTFFT

A Flail moves inward as the chest moves outward. This depends how the question is worded

4 or more has higher mortality but 7 or more is the highest

Fixate if tubed, resp failure, prolonged vent. Non tubed casn be done for deterioating function

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Acute liver failure;

O Grady classification is not prognostic
Paracetamol is leading cause of ALF in Europe
NAC should be given to all ALF
Coagulopathy should be urgently corrected
They may be pro thrombotic

FTFFT

o Grady is the kings classification, sub acute, acute and hyper acute. It is of prognostic value

Paracetamol is leading in the UK, but Europe….

NAC, growing evidence but not universal

Do not correct coag, treat the cause

Yes they may be thrombotic

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Upper GI bleed

Rockall determines if endoscopy is needed
Glasgow should be used after endoscopy
Restrictive transfusion strategy improves outcomes
Hct is part of Glasgow score
Age is part of Rockall

FFTFT

Rockall is done post endo
Glasgow is a risk stratified before
Yes sprestrict to 70
Hb is Glasgow. Also urea, systolic bp and systemic disease features
Age is Rockall, as is, shock, Comorbid state, diagnosis and evidence of bleeding

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Chest pain, vomiting, hr 120, t wave inversion

Oesophageal rupture can by excluded by normal cxr
Ct with contrast is most useful investigation
NSTEMI is a differential
Mortality Rupture is 35%
Mackler triad is vomiting, short of breath and subcut emhysema

FTTFF

Rupture can have a normal x ray
Ct with contrast is useful
MI is a differential
Mortality can be anywhere from 20-70

Mackler is vomiting, subcut emphysema AND thoracic pain NOT breathlessness

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Hypertension

Arterial pressure can be lowered by reducing cardiac output alone
NICE recommends angiotensin blockers in over 55
NICE recommends ca blockers in over 55
ACE is found mainly in the pulmonary vascular use
Aliskiren is a direct angiotensin inhibitor

TFTTF

MAP= CO x PVR there reduced CO would reduce MAP

ACEi to the under 55s, Ca blocker to the overs
ACE Is in the pulmonary vasculature
Alisa Erin is a DIRECT RENIN INHIBITOR

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Beta blockers

All purely block beta receptors
B-adrenoreceptors are G.S. type of GPCR
Metoprolol acts by blocking sodium channels
increase insensitive of diabetic patients to hypos
POISE showed beta blocker on days of surgery increases risk of mortality

FTFFT

labetalol alpha
They are G.S.
Metro pro lol has no effect on Na. propranolol does
Risk of hyper
Poise increased with of death

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Which of these cause raised lactate without tissue hypoxia

G6PD
renal failure
Leukaemia
Biguanides
Monoxide poisoning

FTTTT

G6PD deficiency causes raised LDH
Renal failure clears lactate in extreme cases..
Cancer, metformin etc

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Dexmeditomidine

Is a GABA agonist
Is more selective for a2 than a1
Inhibits norad at the locus coeruleus
Has analgesic properties
As an infusion reduced the median time to extubation compared to Midas

FTTTT

a2:a1 is 1600:1, 8x more than clonidine
Inhibits norad, but at the locus?
Is an analgesic
MIDEX study, but not proprioception

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Consequences of near drowning in warm water

Hypotension
Haemolytic
Cardiac arrest
Alveolar oedema
Seizures

TTTTF

not sure about hypotension

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Anaemia of the critically ill is characterised by

Low ferritin
Low red cell folate
Low serum iron
Low transferrin 
High reticulocyte

FFTTF

Ferritin increases white transferrin reduces
Folate stays normal
Iron does drop
No change or possibly even a drop in reitculocytes

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REM sleep

Occurs every 60 minutes
Associated with MI
normal patterns are abolished for several weeks following surgery
Melatonin restores normal sleep architecture in critical care
Benzos abolish REM

FTFFT

Every 90 minutes
Yes through increase myocardial o2 demand
REM is abolished 2-5 days after surgery
Melatonin does not restore sleep
Benzos do abolish

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Drainage of ascites

FFP should be given if coagulopathic
Go below the umbilicus
PMN leukocyte count more then 100 is diagnostic of SBP
Paarecentesis is complicated by haemoperitoneum in greater than 5%
Hyponatramiea may result from large volume

FTFFT

No need to reverse coag

White cell greater than 250
Bleeding is very rare
There is an known hyponatraemic complication

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Perc trachy

Improved cosmetic appearance compared to surgery
Increased infection risk compared to surgery
Increased bleeding risk
Early trachy is associated with reduced VAP
Minimum of 4 people are needed

TFFFF

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Myxoedemic coma

Hydrocortisone is used in management
Associated with hyponatramia
Associated with hyperglycaeamia
Hypothermia
Pericardial effusion

TTFTT

Low cortisol causes a hypo

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Perc trachies Can be safely discharged to any ward Ward staff can do the first trachy change Cuff should be inflated when patient is taking fluids Cuff pressure should be 30 Takes 4 days for perc stoma to be established

FFFFF deflate the cuff as it interferes with swallowing and compresses oesophageal Cuff pressure 20-25 Takes 7-10 days

These are part of APACHE II ``` temperature Magnesium Arterial ph Platelets Glucose ```

TFTFF ``` TEMPERATURE MAP RR PH PO2 Na K Creatinine Wcc Hct ```

Lumbar puncture Should be done urgently to diagnose SAH Contrainidcations include plts less than 100 A correctly placed needle will go through dura, arachnoid and pia WCC in CSF can be due to seizures Ulrasound reduces the failure rate

FTFTT should be done 12 hours after symptoms

Decreased nocosomial c diff infections are associated with ``` Alcohol hand gel Avoiding PPI Minimising Abx use Methotrexate therapy High fat enteral feed solution ```

FTTFF Spores aren’t killed by alcohol PPI use was associated with c diff Over use of abx is bad for gut flora Metho is immunosuppressant High fibre feed leads to generation of short chain fatty acids via fibre fermentation. This acidified the GI tract, reducing colonisation. But no evidence that fat reduces it.

In HIT Risk of abnormal coag recedes in 7 days of stopping Non immune HIT, may be mild and rarely associated with plts below 100 Anti coag such as danaparoid can be used safely Unfractionated heparin can be replaced by LMWH thrombocytopenia will not happen after stopping heparin

FTTFF Anitobodies can last 100 days

HIT ``` LMWH has an increased risk compared to UH Most common in females Most common in medical patients Associated with DIC Warfain is safe in acute phase ```

FTFTF UH is 1% risk, LMWH is 0.1 F>M Cardiac surgery the. Surgery, then medicine, then obstetrics DIC in 10% Warfarin reduces production of protein C, which is naturally anti coag, this fuels the fire

Brain stem death ``` Neuro opinion is essential EEG must be isoelectric for 24 hours Convulsions rule out the diagnosis Spinal reflexes rule out the diagnosis A blood screen for drugs must be made ```

FFTTF convulsions so an intact motor path and therefore intact stem Spinal reflexes do not pass through the stem You only do bloods in specific circumstances, usually just wait that they worn off

Features of amniotic fluid embolus ``` Cyanosis Hypofibrinogenaemia Chest pain Hypoventilation Hypertension ```

TTTFF type one failure, DIC, they get a pleuritic pain, they HYPERventilate and get reduced preload to left heart.

Pulmonary vascular resistance is reduced by ``` Hypoxia Hypercapnia Alkalosis Epoprostenol (prostacyclin) Nitric oxide ```

FFTTT

Side effects of aminodarone ``` Peripheral neuropathy Hypothyroidism Corneal microdeposit Photosensitisatiom Bigeminal rhythm ```

TTTTF Also hyperthyroid, Torsades

After a severe burn Enteral nutrition should start ASAP vascular access must never be put through burnt skin Fluid need is maximal in the first 12 hours Tissue swelling is max at 24-48 Prophylactic abx are needed

TFTTF no role for abx, feed early.

In primary adrenocoritcal failure ``` Blood cortisol is low ACTH is unchanged Potassium is low Sodium is low Glucose is high ```

TFFTF No steroid so ACTH raises to stimulate production. No steroid so sodium is lost and k retained. Without steroid glucose drops

Metabolic response to surgery is Increased utilisation of glucose so reduced fasting BM Reduced sodium in the urine Decreased circulating fatty acid Descreased excretion of potassium in urine Moderate increase in o2 consumption

FTFFT Surgery stimulates cortisol, so you hold onto sodium and lose potassium, causes a rise in glucose

Conditions are matched to the antidote ``` Bretylium, LA toxicity Intralipid, LA toxicity Dantrolene and MH Serotonin syndrome and cyproheptadine Aspirin and NAC ```

FTTTTF

Ethylene glycol poisoning Causes a metabolic alkalosis Co poisoning with ethanol may be protective Typically causes renal and liver failure Has a normal osmolar gap Folinic acid may be used in the treatment

FTFFT It’s an acidosis, ethanol can be the treatment, renal failure is common, liver is not, the osmolar gap increases

Absolute contraindications to DCD donation ``` Age more than 75 Recent sepsis Cjd Active harm cancer HIV ```

FFTTF ``` age is relative and depends on the organ Sepsis is only absolute if it hasn’t been treated Cjd is absolute As is haem malig HIV disease is, but infection is not ```

Risks for VAP ``` NG tube Increased gastric residual volume Gastric acid suppression Previous abx use Muscle relaxants ```

TFTTT

HIT Argatroban, danaparoid and fondaparinux can be safely used Platelets typically fall in the first 3 days after exposure to heparin Is due to heparin dependent IgM antibodies binding to heparin/platelet factor 4 The warkentin probability scale is used to estimate the probability of HIT Functional assays such as serotonin release assay, have 95% sense/spec for HIT

TFFTT occurs later than 3 days IgG not IgM

Atrial flutter Type I drugs (flecanide, lidocaine, propafenone) can be used Digoxin can be used Sotalol can be used in recurrence AV block rarely occurs Atrial rate is usually 300

FTTFT some such as 1a flecanide will not work Dig has been described

Elderly patients Over 80s have an APACHE of at least 6 Mortality for emergency laparotomy in older patients over 70 is 30% Mortality for NOF is 10% at one month Elderly patients are less responsive to catechilamines Benzos, cyclising and atropine increase risk of delirium

TFTTT You get 6 points for being over 75 NELA says mortality is 20

DKA in children Cerebral oedema has a mortality of 40% Dry membranes, sunken eyes, reduced skin turgor, and poor cap refill suggests 3% dehydration Replace the fluid deficit over 48 hours Shocked child should be given 10mls/kg fluid bolus A fixed rate insulin infusion should be delayed by one after after fluid

FFTTT Some say 20% others 60% It’s about 9% dehydration Shocked should get 10-20 Replace fluid over 48 hours and delay insulin one hour

AKI defined as 1.5x creatinine increase in 48 hours Furosemide may cause acute interstitial nephritis Protein intake should be reduced IV NAC should be given with iv fluid to prevent CIN in high risk pts Use of low dose hyper osmolar contrast reduces the risk of AKI

FTFTF 1.5x in the preceding 7 days, or an absolute rise on 0.3 over 48 hours NAC is recommended in high risk but evidence poor It is ISO or HYPO OSMOLAR solutions

High flow oscillator Increasing the frequency increases the CO2 clearance Bias flow should be reduced in BPF mean airway pressure is lower than conventional ventilation BP may fall on commencement HFOV is associated with decreased mortality in ARDS

FFFTF decreasing the frequency aids clearance, the opposite of normal vent MUST BE HIGHER TO COPE WITH LEAK Mean airway pressure is higher Haemodynamic instability occurs No evidence of mortality outcome OSCAR/OSCILLATE

Child protection All clinical staff with contact with children young people and parents/careers need to be level 2 safeguarding trained Learning difficulties are at increased risk Low birth weight is an increased risk Neglect is the commonest form of abuse A SAH is associated with abuse

TTTFF Climical in level 2 Physical abuse is most common 7%, neglect is 6% Sub Dural is concerning for abuse not SAH

Statistics Null hypothesis is that a difference exists Type I error rejects the null when it was true Increasing the power reduces risk of type I Increasing the expected difference will decrease number of participants needed A cross over study should be assessed by a paired t test

FTFTT Null, no difference Type one is declaring a difference exists when there wasn’t one. Increasing power reduced risk of type II error If the expected difference is large you need less people to prove it Cross overs use themselves as a control

ECMO AV uses a pump CO2 is exchanged more efficiently than o2 AV needs a cardiac index of at least 2.5 SIRS may happen in decanulation VA is contraindicated in severe aortic regurgitate

FTTTT AV uses its own arterial pressure CO2 is many times more diffusion-y than o2 SIRS on decannulation has been reported

The icnarc 2009 model ``` Physiology score is from 0-10 Source of admission is used Physiology score has 10 parameters Uses Hct Burns are excluded ```

FTFFT Scored to 100 12 parameters in 2009 and 15 in 2017 Burns are included Hct is from the Apache

Traumatic rib fractures Contusions lead to ventilation perfusion mismatch and therefore type II failure Increasing age is associated with morbidity and mortality Opioids should be first line for all fractures Flail chest is an indication for fixation FVC is reduced a year later when comparing control to fixation

FTFTF Its a type I failure Opioids are not first line Flail chest should be operated FVC is increased after fixation compared to control

Statistics Ordinal data is continuous R=0 means a no correlation between two sets of paired data Mode is the central datum when arranged in order Negatively skewed data has a longer upper tail Positive skewed data, mode is, less than median less than mean

FTFFT The lower tail is longest Positive skew mode is smallest, then median, then mean is furthest right

In ECGs ``` ST elevation in V5-6, III and aVL Is a lateral MI in chest pain Normal PR interval is 120-200ms P Pulmonale is a bifid p wave Peaked t waves show Hyperlactatemia Hypokalaemia is associated with U waves ```

FTFTT lead I not III for lateral Bifid p waves are mitrale not pulmonale PR interval is 120-200

Acid base balance Kidneys excretes most acid Pancreatic fistula can cause a normal anion gap acidosis Low albumin lead to retention of sodium bicarbonate Bartters disease is associated with met acidosis Uretric diversion causes a raised anion gap acidosis

FTTFF lungs excrete most acid through CO2 Fistula loses bicarb Bicarb is maintained in albumin loss Bartters is an alkalosis due to renal acid loss, they have hypokalemia, and hyperalodostronism Uretric diversion is acidosis but the gap is normal

Levosimendan ``` Is an inodilator Is a calcium channel activator Causes vasodilation by opening ATP dependent K channels in vascular smooth muscle Increases coronary blood flow Cleared by kidneys unchanged ```

TFTTF DOES IMPROVE CORONARY FLOW WHILST DILATING SYSTEMIC PULMONARY VESSELS It is an inodilator, but sensitises calcium rather than activating the channel Promotes K opening Is handled by the liver

ACS grace score estimates 3/12 mortality risk Grace score should be used in patients with NSTEMI Primary PCI is recommended for all STEMI within 6 hours of chest pain Uncocniousness after cardiac arrest due to stemi is a contraindication to PCI If pci cannot be done within 180 minutes of the time fibrinolytic could be given then they should get fibrinolytic

FTFFF 6 month mortality Can be used in NSTEMI Within 12 hours of chest pain Within 120 minutes of fibrinolytic

Cardiovascular system in sepsis AF is commonest tachyarrhythmia in sepsis Loss of HRV in respiration is early sign Pulmonary hypertension is a significant cause of right heart failure Excess NO is produced by cNOS Diastolic dysfunction occurs in less than.a quarter of patients with severe septic shock

TTTFF it’s iNOS not cNOS Diastolic dysfunction is in more than a quarter 37%, not less

Crucial illness with haem malignancy Survival is based by the underlying haem cancer NIV should not be used outside Crit care A large ICNARC study found in hospital mortality for icu to be 60% It is recommended that patients appropriate for further life extending treatment should be considered for an unrestricted trial of icu In septic patients, in dwelling catheters should only be removed if there is a positive culture from the line

FTTTF It’s determined by the severity of acute illness Mortality is 43.1 Indwelling catheters should be removed and replaced

Chemotherapy Bleomycin are at lifelong risk of belomycin induced lung injury Short periods of high concentration oxygen are safe in patients previously exposed to bleomycin Anthracyclines such as doxorubicin can cause life threatening cardiac function Patients with chemo in childhood have 8-9 fold increased risk of mortality to cardiovascular disease in later life Cyclophosphamide is associated with renal and hepatic dysfunction

TFTTT even short periods of oxygen can cause rapidly progressive fibrosis Haemorrhaging cystitis and diffuse HC destruction

The unanticipated difficult airway A 4th attempt at direct laryngoscopy by a more experienced colleague is permitted If intubation fails, plan B is bag mask ventilation Cricoid pressure should be applied during insertion of a subglottic airway Scalpel cricothyroidotomy is the front of neck technique of choice Further neuromuscular block should not be administered if front of neck is needed

TFFTF plan b is an LMA Take the cricoid off during LMA You need paralysis to do front of neck

Smoke inhalation It is associated with a two fold increase in mortality after a burn In an RSI, sux should be avoided ET tunes should be cut to an appropriate length to minimise dead space Early bronch is associated with improved outcomes Cyanide poisoning should be suspected if the fire involved synthetics such as plastics

FFFTT 3.6x fold increase Sux CAN be used in the first 24 hours Do not cut a tube, facial swelling

Regarding encephalitis In the uk, 60% of viral cases are due to herpes simplex, varicella zoster, and enteroviruses Time to antiviral treatment is the single most important modifiable risk factor All patients presenting with encephalitis or meningitis should be tested for HIV Clinical examination is not as accurate as CT for predicting risk of brain herniation following an LP MR will demonstrate changes in a minority of cases of herpes enceph

FTTFF 90% Clin exam is at least as accurate as CT Lesions on MRI are found in 90% of cases

Vasopressin Levels demonstrate a biphasic response in septic shock Has been shown to reduce mortality in septic shock comapared to norad Vasoactive effects are on V2 receptor Is an endogenous octapeptide Has been used at a dose of 40 international units in cardiac arrest

TFFFT Levels are elevated for 6 hours then suppressed the VAAST trial compared one to the other, and there was no mortality difference (this is different from adding it in on top of norad in refractory shock) Its the V1 receptor Its a nonapeptide Apparently used in an arrest?!

The enhanced recovery of elective surgical patients NG tubes should not be routinely used Thoracic epidurals are recommended in laparoscopic procedures Multimodal analgesia with the smallest dose of opioid is recommended Early mobilisation is emphasised Patients should be well hydrated post op by iv fluid

TFTTF Maybe an epidural for open procedures Disconitnue iv fluids ASAP

Dexmeitomidine Is twice as selective for a2 receptors than clonidine Associated with less delirium compared to propofol Produces a state of sleep compared to REM Withdrawal after prolonged use can cause a hypertensive crisis Context sensitive half time after 8 hours in 20 minutes

FFFTF 8 times more selective Less delirium compared to midaz (MIDEX study) Sleep is non-REM Half time is 250 minutes

Ventricular arrhythmias Ventricular ectopics are always benign VT is defined as rate > 150 bpm Sustained VT is when its longer than 60 seconds Polymorphic VT is associated with long QT VF can occur without loss of cardiac output

FFFTF Ectopics can be associated with sudden death when there is LVH Rate >100 not 150 Sustained is longer than 30 seconds VF has to occur with loss of cardiac output

Ventricular arrhythmias Treatment of polymorphic VT is 4g Mg over 10 minutes B-blockers are CI'd in Brugada syndrome Ca blockers may be used to terminate ventricular arrhythmias of unknown origin Implantable cardiac defibs are recommended in patients who survived a cardiac arrest caused by VT/VF Anti-tachycardia pacing can be used to terminate monomorphic VT

FTFTT Its 2g over 10 minutes B blockers aggravate ion current imbalances Ca channel blockers should never be used to terminate a broad complex tachy of unknown origin as it may cause VF

The CXR can usually differentiate between the following ``` CVC in the SVC or ascending aorta CVC in the SVC or ayzgous vein CVC in the SVC or hemi-azygous vein CVC above or below a pericardial reflection CVC in the SVC or internal mammary vein ```

TFTTT The aortic arch is more medial then the SVC The SVC and azygous are superimposed The hemi azygous vein is in the left chest The pericardial reflection is separated by the R main bronchus The internal mammary is more lateral

The following actions resulting in death, could be considered euthanasia Stopping MV in a competent adult who consents to stopping Not transfusing a competent adult Jehovah's witness Agreeing with the family of a man with LD who is otherwise well, not to have appendectomy Giving a man with MND morphine because "he has had enough" Not admitting a man to ICU with pneumonia and advanced Parkinsons

FFTTF (my opinion, may be wrong) 1) BJA talks of a case of a paralysed woman who consented to her vent being turned off 2) JW's can 3) euthanasia or manslaughter? From BJA: Non-voluntary euthanasia describes the killing of a patient who does not have capacity to request or withhold consent 4) sounds straightforward 5) decision to admit to ICU not the same as not treating

Contraindications to heart beating organ donation include: ``` Heb B Cerebral malignancy in last 12 months Donor not being on the register Continued cranial nerve activity MOF ```

FTFTF Active cancer in the last 3 years?? Continued cranial nerve would mean not BSD Dont need to be on the register

A normal anion gap acidosis is seen in ``` Rental tubular acidosis Type B lactic acidosis Renal Failure Ketoacidosis Biguanide toxicitiy ```

TFFFF RTA is normal acidosis but AKI/CKD is raised Metformin and any lactic acidosis raises it Others that are normal Diarrhoea Ileostomy TPN Ureteric diversion procedures

C diff. Is an anaerobic gram negative bacillus Infection is reduced by washing hands with alcohol Secretes two exotoxins to exert its effects OTHER TWO QUESTIONS MISSING

FFT Its Gram positive Alcohol gel does nothing It does - Toxin A and Toxin B

A thoracic epidural will pass through the followng ``` Ligamentum flavum Arachnoid Mater Posterior longitudinal ligament Supraspinous ligament Interspinous ligament ```

TFFTT Lig flavum is where the resistance is prior to LOR Too far! Sits on the verterbral body Most superficial ligament

Acute liver failure - the Kings transplant criteria ``` pH 7.2 Creatinine 200 Bilirubin >300 PT 6.5 Grade 3 enceph ```

?FTTF So - if the failure is due to paracetamol, a pH of less than 7.3 is a criteria, but in non paracetamol failure, the pH isnt taken into account. A creatinine is not part of the non para criteria, but is part of the paracetamol criteria, but the value is greater than 300. Bili greater than 300 is a criteria in non para but doesnt feautre in para enceph does not feature in either

Diuretics ``` Metolozone works on the DCT Bumetanide works on the DCT Furosemide interferes wit K/Na/Cl pump Mannitol exerts its effect through Mg reabsorption in the DCT FIFTH QUESTION MISSING ```

TFFF? Bumetanide is a loop Na/K/Cl co-transporter, not pump... It works on the PCT and dont think Mg really comes into it

Dilated pupils are caused by ``` Hypothermia Seizures Tropicamide Sarin ? ```

TTTF? Hypothermia causes a fixed dilated pupil Sarin causes a pinpoint pupil (Dilated pupils are a mydriasis)

Delirium Hyperactive nature is >30% cases

F 8-22%